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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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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.
Importantly, our estimates are based on the arrangement of organizational membership and EHR adoption in 2017. Three ongoing trends may change the value proposition of proprietary HIE: provider organization market consolidation, increasing control of the EHR market by a few vendors, and broader participation in multivendor alliances. Intentional marketing of proprietary HIE assets may be used to accelerate these trends and create a self-fulfilling cycle of value generation. Relative to open HIE approaches, however, this still maintains siloed environments that limit patients’ freedom as consumers. If information moves among only a specific subset of providers, patients may feel limited to choosing among that subset.26,32

In light of these trends, our findings support targeted policy to maintain and advance open HIE infrastructure and engagement, especially among independent and small integrated systems. If open HIE attains sufficient participation from independent physicians, larger organizations may in turn be motivated to participate so that they are positioned as a referral destination for independent physicians and groups. The success of the Regional Extension Center (REC) program in increasing EHR engagement among independent and rural physicians provides one potential model for how public policy can effectively target and provide information technology (IT) assistance to physicians practicing outside of large integrated health systems.33,34 REC-like entities could coordinate this sizable population of unconnected providers and facilitate collaboration between providers and regional health information organizations or identify proprietary HIEs that could be approached about participation. Entities contracted to provide support to practices engaged in Medicare’s Merit-based Incentive Payment System through the Small, Underserved, and Rural Support initiative are particularly well positioned to serve in this capacity, as participating practices need information exchange capability to perform successfully under value-based payment models. Outside of government support, those involved in governance of active open HIE initiatives also need to think creatively about value creation and financial sustainability. For instance, some state-level HIEs have opted to participate in growing multivendor alliances, which may offer a path to broader connectivity and operational efficiency. In addition, one important and still underused pathway toward financial sustainability is involvement of payers, which can offer unique value to open HIE (beyond just broader patient coverage), such as claims data and advanced analytics that single organizations cannot get with their enterprise HIE solutions.11


Our study is subject to a number of important limitations. Our study focused on the overall number of patient transitions between providers; we are not able to distinguish between transitions where information exchange would impact patient care and those where it might be unnecessary. However, we have no reason to suspect that the proportion of transitions where information sharing would be valuable would systematically vary by HIE approach, thus minimizing potential for biased or misleading results. We also do not know whether HIE-mediated information sharing is actually occurring in situations in places where we designate that it could potentially occur (ie, 2 providers are in the same system or share the same EHR). Therefore, our findings reflect the upper limits of the impact of each approach given current organizational membership and EHR adoption. Further, our estimates are dependent on EHR choice and integration status in 2017; their potential could change as physicians adopt different EHRs or join integrated organizations. Similarly, if new EHR vendors join the growing alliances, their potential coverage could increase. We also chose to retain ancillary providers in our measure of transitions, although, to some extent, a patient is not transitioned to the care of a radiologist or pathologist. Nevertheless, electronically supported communication among these providers could offer value in the timeliness and clarity of reports. Finally, we acknowledge that vendor alliance–based HIE is the most dynamic in terms of participation and breadth of network connectivity. Our measure of coverage for these alliances is based on EHR vendor participation; however, as these approaches have grown, they have increasingly included other healthcare organizations, technology companies, and state-level HIEs. Thus, our estimates are likely to represent a lower bound on the total value of alliance-based HIE.


Growing proprietary approaches to HIE have a substantial but ultimately limited potential to facilitate information exchange as patients move between providers, and these approaches are most useful to large providers using dominant EHR vendors. This dynamic indicates potential challenges for policy makers and providers. As policy makers focus on developing approaches to encourage free information exchange, their strategy should work to limit barriers among the 3 proprietary approaches described here and open HIE infrastructure. Moreover, policy can support innovation and sharing of best practices among community-based health information organizations to encourage broader participation and financial sustainability of open HIE. Providers need to strategically consider how their technology portfolio facilitates exchange with key care partners, keeping in mind that referral patterns and IT use are remarkably disparate despite trends of consolidation and integration. The ultimate goal of comprehensive network coverage still requires active engagement in nonproprietary approaches to information sharing.

Author Affiliations: Department of Health Policy and Department of Biomedical Informatics, Vanderbilt University (JE), Nashville, TN; Division of Health Policy and Management, University of Minnesota School of Public Health (DAC), Minneapolis, MN.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JE, DAC); acquisition of data (JE); analysis and interpretation of data (JE); drafting of the manuscript (JE, DAC); critical revision of the manuscript for important intellectual content (JE, DAC); statistical analysis (JE); administrative, technical, or logistic support (JE); and supervision (JE).

Address Correspondence to: Jordan Everson, PhD, Department of Health Policy and Department of Biomedical Informatics, Vanderbilt University, 2525 West End Ave, Ste 1275, Nashville, TN 37203. Email:

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