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The American Journal of Managed Care January 2019
The Gamification of Healthcare: Emergence of the Digital Practitioner?
Eli G. Phillips Jr, PharmD, JD; Chadi Nabhan, MD, MBA; and Bruce A. Feinberg, DO
From the Editorial Board: Rajesh Balkrishnan, PhD
Rajesh Balkrishnan, PhD
The Health Information Technology Special Issue: New Real-World Evidence and Practical Lessons
Mary E. Reed, DrPH
Inpatient Electronic Health Record Maintenance From 2010 to 2015
Vincent X. Liu, MD, MS; Nimah Haq, MPH; Ignatius C. Chan, MD; and Brian Hoberman, MD, MBA
Impact of Primary and Specialty Care Integration via Asynchronous Communication
Eric D. Newman, MD; Paul F. Simonelli, MD, PhD; Shelly M. Vezendy, BS; Chelsea M. Cedeno, BS; and Daniel D. Maeng, PhD
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Mind the Gap: The Potential of Alternative Health Information Exchange
Jordan Everson, PhD; and Dori A. Cross, PhD
Understanding the Relationship Between Data Breaches and Hospital Advertising Expenditures
Sung J. Choi, PhD; and M. Eric Johnson, PhD
Organizational Influences on Healthcare System Adoption and Use of Advanced Health Information Technology Capabilities
Paul T. Norton, MPH, MBA; Hector P. Rodriguez, PhD, MPH; Stephen M. Shortell, PhD, MPH, MBA; and Valerie A. Lewis, PhD, MA
Alternative Payment Models and Hospital Engagement in Health Information Exchange
Sunny C. Lin, MS; John M. Hollingsworth, MD, MS; and Julia Adler-Milstein, PhD
Drivers of Health Information Exchange Use During Postacute Care Transitions
Dori A. Cross, PhD; Jeffrey S. McCullough, PhD; and Julia Adler-Milstein, PhD

Mind the Gap: The Potential of Alternative Health Information Exchange

Jordan Everson, PhD; and Dori A. Cross, PhD
Proprietary health information exchanges (HIEs) offer significant but uneven opportunities to advance provider connectivity. Open forms of HIE remain critical for comprehensive coverage of patient transitions.

Objectives: To determine the proportion of patient transitions that could be connected through 3 proprietary alternatives to open, community-based health information exchange (HIE): HIE between physicians who are part of the same integrated system, use the same electronic health record (EHR), or use an EHR that participates in an EHR vendor alliance.

Study Design: Cross-sectional analysis of Medicare patient transitions and physician EHR adoption and organizational affiliation from SK&A.

Methods: We characterized the percentage of transitions that could be covered by each HIE approach and the degree of redundancy. We then assessed whether coverage opportunities differed by provider type and used multivariate linear regression to estimate the association between physician characteristics and proportion of transitions uncovered by any proprietary approach (ie, requiring an open HIE approach).

Results: Given current EHR adoption and organizational affiliations, 33% of transitions could be covered by proprietary HIE. For the average physician, open methods of HIE would still be needed for 45% of patients treated by other physicians. Physicians who did not use a market-leading EHR, were not members of a large integrated system, and shared patients with a broader network of physicians have the greatest need for open HIE.

Conclusions: Proprietary approaches to HIE do not eliminate the need for open HIE and may further disadvantage providers in small healthcare organizations using less common EHRs. Ongoing support and innovative value creation within open HIE will likely remain necessary to support HIE by independent physicians. Public efforts to promote interoperability should seek to integrate proprietary models with open HIE.

Am J Manag Care. 2019;25(1):32-38
Takeaway Points
  • Forms of health information exchange (HIE) that restrict participation based on organizational affiliation and/or electronic health record vendor could cover up to one-third of all patient transitions that occur annually, based on descriptive national provider data.
  • These approaches are redundant with each other in terms of network coverage.
  • These approaches would disproportionately benefit physicians in large, integrated provider organizations with dominant vendor systems.
  • A significant need for open methods of HIE remains; even with consolidating provider referral patterns, the majority of an average physician’s patients would not be covered by any of these potential proprietary coverage options.
Open and accessible approaches to health information exchange (HIE) have been pursued for nearly 3 decades to address information silos that hamper effective coordination and transitions of care.1-4 HIE has been shown to make information more available and accessible across provider organizations, resulting in reduced redundant testing, increased identification of medication errors, and reduced discrepancies in diagnoses, among other benefits.5,6 State, regional, and even national HIE infrastructures have had public political and financial support but have struggled to grow rapidly and function independently and sustainably.4,7-11 Because of this, alternative proprietary approaches to exchanging information have emerged in the market.12,13 These approaches are fundamentally different from open HIE networks because they are designed to support HIE within a specific group of providers.14 Enterprise HIE facilitates information exchange within an integrated delivery system or set of close partners.12,15 Similarly, electronic health record (EHR) vendor–mediated HIE, such as Epic’s Care Everywhere network, is aimed at facilitating exchange among providers using the same EHR.16,17 Most recently, cooperative engagement in HIE networks, such as the CommonWell Health Alliance and Carequality, has promised to connect providers using any of several vendors that participate in the alliances.18-20 These vendor networks emerged to offer solutions to common HIE issues around data governance, data standards, common contracting, and transaction credentialing.21,22

These proprietary approaches are supported by more obvious business cases than are open HIEs. Enterprise HIE can help integrated health systems increase capacity for continuity and care coordination within organizations, mitigating the risk of organizations losing patients who might otherwise opt for treatment outside the system.23-26 For vendors, a developed intravendor HIE network may be a selling point for new customers, especially when those potential customers’ key partners already use the EHR. Similarly, vendor participation in alliances can increase their appeal relative to those vendors that do not or cannot join the alliance. Although these approaches appear to be becoming more widely used, there is concern that their growth will exclude certain providers and that care will continue to be fragmented so long as exchange is limited by EHR vendor or organizational affiliation.27,28

Our objectives in this work are to measure the extent to which these proprietary HIE approaches can meet patient and provider needs for information exchange and to determine who is best served by these proprietary forms of HIE and which providers (and patients) are left behind. By doing so, we intend to estimate the continued value in pursuing open HIE as proprietary approaches become more widely available. One intuitive way to capture the relative value of different HIE approaches is to consider the proportion of patient transitions nationwide that these proprietary HIE approaches could potentially cover independently and in combination. To do so, we combined national physician survey data, from which we derived potential to engage in enterprise or vendor-based EHR solutions, with a comprehensive provider-to-provider database of shared Medicare patients. We then addressed 3 important research questions. First, what proportion of patient transitions occur between providers who could be connected by enterprise HIE, vendor-mediated HIE, and/or vendor alliance HIE? Second, does the potential for connectivity through these mechanisms differ across physician types (primary care vs specialty or surgical providers)? And finally, what organizational characteristics of physicians’ practice locations are associated with being “left out” by proprietary HIE and therefore likely to remain most reliant on open HIE?



Our primary data sets were the 2017 SK&A Physician Survey and the 2016 CareSet Labs DocGraph Hop Teaming Dataset. The SK&A Physician Survey is a nationwide survey of office-based physicians that contains information on provider and organizational characteristics. The DocGraph Hop Teaming Dataset is a relational data set that captures the “sharing” of patients, in which each observation represents a pair of healthcare providers and the number of fee-for-service (FFS) Medicare patients for whom both providers in the pair appear on claims using a transaction-based approach. Pairs of providers that shared fewer than 11 patients are censored from these data following Medicare minimum cell size rules for publicly available data. This results in an inclusive measure of patient transitions defined by the number of times that patients switch providers, which reflects both intentional referrals and happenstance. Therefore, the volume of transitions provides a broad sense of the need for information exchange to support coordinated care.

In combination, these data sets allowed us to develop a large national sample of physicians, the other physicians they share patients with, and their organizational and EHR characteristics. Our population of interest was all office-based physicians in the United States who treated FFS Medicare patients in 2016.

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