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The American Journal of Managed Care January 2019
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Eli G. Phillips Jr, PharmD, JD; Chadi Nabhan, MD, MBA; and Bruce A. Feinberg, DO
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Mind the Gap: The Potential of Alternative Health Information Exchange
Jordan Everson, PhD; and Dori A. Cross, PhD
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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
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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.

Our sample includes 398,485 physicians who shared at least 11 Medicare patients with another physician in 2016. The sample included physicians from 2994 counties in all 50 states and the District of Columbia; see eAppendix Table 1 (eAppendix available at for descriptive characteristics of the sample. There were more than 1 billion Medicare patient transitions among physicians in the sample in 2016.

Summing all coverage offered by proprietary HIE (both exclusive coverage and areas of overlap), 33% of a provider’s patient transitions, on average, could be covered by a combination of the 3 possible restricted HIE mechanisms (Figure 1). Internal transitions within an integrated organization, potentially covered by enterprise HIE, accounted for 22.5% of total patient transitions. Of these transitions, 9.5% were between physicians using the same EHR (indicating potential for vendor-mediated HIE) or between physicians who used an EHR connected through an alliance. The only form of proprietary HIE available to the remaining 13% of internal transitions was enterprise HIE.

EHR vendor–mediated HIE could potentially cover up to 15.6% of total transitions. However, less than one-third of these (4.5% of total transitions) would be uniquely covered through this potential mechanism. Similarly, vendor alliances could cover 12.3% of total transitions, but less than one-third (3.6% of total transitions) are reachable only through this approach. After accounting for each of these forms of HIE, and the 21.6% of transitions that occurred between pairs of physicians in which at least 1 physician did not have an EHR, open HIE remains as the only potential mechanism to cover the remaining 45.4% of all patient transitions.

The potential for proprietary HIE solutions (enterprise, vendor-mediated, or vendor alliance HIE) to cover patient transitions differed notably by physician EHR use and membership in an integrated system (Figure 2). For the average physician using 1 of the 7 most commonly adopted EHR vendors and in an integrated system, these 3 forms of HIE could cover more than half of all transitions (52.6%). More than half of these covered transitions (27.6% of total transitions) could be covered by more than 1 form of HIE. In contrast, the potential value of these HIE tools is less obvious for physicians who neither were integrated nor used one of the largest vendors. Physicians in integrated systems with a less common EHR could have covered 41% of transitions through proprietary forms of HIE. Independent physicians would rely only on the 2 vendor-based solutions, potentially covering 24.9% of transitions for users of the most common EHRs and only 10.3% for users of less common EHR vendors.

When we examined potential coverage from proprietary HIE mechanisms based on the type of provider included in the transition, we found limited differences by provider type (eAppendix Table 2). For instance, whereas 70.1% of transitions involved medical specialists, a larger proportion of transitions (75.2%) potentially covered by vendor alliance included specialists. Across all provider types, the proportion of transitions where open HIE was needed paralleled the proportion of transitions involving that type (for instance, 30.5% of all transitions involved primary care providers and 29.9% of open HIE transitions involved primary care providers).

In multivariate regression analysis (Table), physician membership in a very large integrated system was associated with a decrease of 34.5 percentage points in the transitions for which open HIE was needed, relative to independent physicians. Physicians had reduced need for open HIE (ie, were better served by proprietary HIE mechanisms) when they used Epic or Cerner as their EHR vendor (decrease in need for open HIE of 14.5 and 13.5 percentage points, respectively, relative to use of a vendor other than the top 7), had few exchange partners (decreased need of 3.1 percentage points, relative to many), and concentrated partner relationships (decreased need of 5.0 percentage points, relative to dispersed). Physicians in large practices also had decreased need for open HIE relative to solo physicians, by 9.4 percentage points. All reported results were significant at P ≤.001, and the regression model performed well in regression diagnostics (see eAppendix Figure).


Given the EHR vendor choices and organizational membership of physicians in this large national sample, proprietary forms of HIE had the potential to cover up to one-third of all patient transitions. Of the 3 approaches to HIE, enterprise HIE within integrated care systems had the potential to cover the largest percentage of patient transitions (23%) if fully implemented. Vendor-mediated HIE also had the potential to connect almost 10% of transitions; however, a large portion of this connectivity would also be covered by enterprise HIE. Despite enthusiasm surrounding new alliance-based HIE, we found that the alliance-based approach may offer limited value beyond these 2 alternatives. However, the extent to which these HIE approaches covered a given physician’s transitions differed substantially based on the physician’s choice of EHR vendor and organizational membership, with large organizations that have invested in the most prominent EHR vendors receiving the most coverage from these proprietary HIE approaches.

Despite overlap, these 3 HIE approaches could offer substantial increases in the overall level of HIE—for many providers, far greater connectivity than required by Meaningful Use criteria established for information sharing under the federal EHR incentive programs, under which attesting physicians only need to send a summary of care record for 10% of patients. Further, these approaches, led by technology companies and invested provider organizations, may offer greater usability that motivates physicians to use systems when available. However, our results suggest significant inequality with which different providers could benefit from these proprietary alternatives. Open HIE may offer lower value to physicians in large organizations with advanced EHR systems, who stand to benefit the most from investment in enterprise HIE. This corroborates recent studies’ findings that large systems are less likely to engage in cross-system HIE than are small systems, and that hospital systems’ investments in intersystem HIE are lower when they invest in intrasystem HIE.25,27 These value dynamics could incentivize leading healthcare organizations to reduce their commitment and resources to open HIE approaches like community HIEs, the Direct Trust, and Nationwide Health Information Network.29-31 To the extent that broad community support for open HIE falters, independent physicians and less-resourced providers are most likely to be left out of proprietary sharing networks; this may further exacerbate disparities in quality of care for patients served by these providers.

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