Hospital Electronic Health Information Exchange Grew Substantially In

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1 doi: /hlthaff HEALTH AFFAIRS 32, NO. 8 (2013): Project HOPE The People-to-People Health Foundation, Inc. By Michael F. Furukawa, Vaishali Patel, Dustin Charles, Matthew Swain, and Farzad Mostashari Hospital Electronic Health Information Exchange Grew Substantially In Michael F. Furukawa (michael.furukawa@hhs.gov) is director of the Office of Economic Analysis, Evaluation, and Modeling, Office of the National Coordinator for Health Information Technology (ONC), Department of Health and Human Services, in Washington, D.C. Vaishali Patel is a senior adviser in the ONC Office of Economic Analysis, Evaluation, and Modeling. Dustin Charles is a public health analyst in the ONC Office of Economic Analysis, Evaluation, and Modeling. Matthew Swain is a public health analyst in the ONC Office of Economic Analysis, Evaluation, and Modeling. Farzad Mostashari is the National Coordinator for Health Information Technology at the ONC. ABSTRACT Electronic health information exchange can improve care coordination for patients by enabling more timely and complete sharing of clinical information among providers and hospitals. Approaches to health information exchange have expanded in recent years with the growth in entities such as regional health information organizations (HIOs) and the increased adoption of electronic health record (EHR) systems. However, little is known about the extent of exchange activity in US hospitals. Using national surveys of hospitals, we found that between 2008 and 2012, hospitals electronic exchange of health information with other providers increased significantly, regardless of provider type, organizational affiliation, or type of clinical information. In 2012 nearly six in ten hospitals actively exchanged electronic health information with providers and hospitals outside their organization, an increase of 41 percent since EHR adoption and HIO participation were associated with significantly greater hospital exchange activity, but exchanges with providers outside the organization and exchanges of clinical care summaries and medication lists remained limited. New and ongoing policy initiatives and payment reforms may accelerate the electronic exchange of health information by creating new data exchange options, defining standards for interoperability, and creating payment incentives for information sharing across organizational boundaries. Clinical information such as laboratory results and medication lists ideally should follow patients as they move across different care settings, even those that do not share an organizational affiliation. However, gaps in communication and poor transmission of information commonly occur during transitions between hospitals and primary care providers, and the sharing of patient data among hospitals is probably even more limited. 1 Addressing these information gaps is critical because the timely sharing of a patient s clinical information can improve the accuracy of diagnoses, reduce the number of duplicative tests, prevent readmissions, and prevent medication errors. 2 4 One way to facilitate the sharing of various types of clinical information among providers and hospitals is electronic health information exchange. Historically, regional health information organizations (HIOs) entities that can connect a myriad of stakeholders, including laboratories, public health departments, hospitals, and providers have served as key facilitators of local exchanges of information. 5 Hospitals and providers can also electronically exchange clinical information via interoperable electronic health record (EHR) systems and patient portals. 6 Federal policies have sought to expand various 1346 Health Affairs AUGUST :8

2 options available to providers for exchanging health information electronically, particularly via interoperable EHR systems. 7 The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorized the Centers for Medicare and Medicaid Services to provide incentive payments to eligible hospitals that adopt and meaningfully use certified EHR technology. 8 As of April 2013 more than 3,800 hospitals, representing about 80 percent of eligible hospitals, had received incentive payments through EHR Incentive Programs in Medicare and Medicaid. 9 HITECH also established the State Health Information Exchange Cooperative Agreement Program, which awarded more than $540 million to states and designated entities to ensure that mechanisms are in place to enable providers to exchange clinical information. 10 Through this program, states are using a variety of approaches to make it possible to exchange health information, including funding regional HIOs and other private entities to provide information exchange services to hospitals and other providers. 11 Recent data show substantial growth in both hospitals adoption of EHR systems and the number of operational public and private HIOs Additionally, in 2012, 71 percent of hospitals reported that they planned to invest in the electronic exchange of health information. 15 Despite substantial growth in EHR adoption and the availability of regional HIOs, exchange activity has been relatively limited in hospital settings. 13,16 In general, limited interoperability across vendors, low motivation to share information in a fee-for-service payment environment, and the high cost of interfaces remain substantial barriers to widespread health information sharing. In many cases, hospitals lack the means to share patient information electronically with other hospitals or providers. Limited incentives and competition may further hinder exchanges between hospitals and outside organizations. 17,18 Beyond the recent expansion in approaches to health information exchange, little is known about the extent of exchange activity in hospitals. In particular, research to date has not focused on the roles of interoperable EHR systems and regional HIOs in facilitating exchange activity among hospitals, nor has it examined variations in the types of exchange among providers and hospitals. In this study we used national surveys of hospitals conducted between 2008 and 2012 to examine the following three questions. First, to what extent has hospitals exchange activity increased since the enactment of HITECH? Second, how does hospitals exchange activity vary by type and organizational affiliation of provider and by type of clinical information? And third, how were EHR adoption, HIO participation, and other hospital and area characteristics associated with hospitals exchange activity in 2012? We hypothesized that exchange activity overall had increased since HITECH s enactment but that the amount of increase had varied depending on the type of health information exchange and on the approach to that exchange. We also hypothesized that more hospitals were exchanging information with ambulatory providers than with other hospitals and that exchanges were more likely to occur among affiliated entities than between entities that were not part of the same organization. Furthermore, we hypothesized that hospitals that adopted EHR systems and participated in HIOs were more active in exchanging information than hospitals that did not meet both of these criteria. Prior studies have characterized health information exchange as a function of HIO participation. 16,19 In contrast, we assessed the extent of exchange activity based on the reported exchange of clinical information with other providers, including exchanges that occurred through an HIO. Building on another study that examined exchange activity by organizational affiliation, 18 our study focused on the association between hospitals EHR adoption and HIO participation, on the one hand, and their exchange activity, on the other hand. In addition to affiliation, we assessed the variation in exchange activity by type of provider and type of clinical information. Our findings have important policy implications. Assessing hospitals approaches to health information exchange and their exchange activity in 2012 indicates how much progress has been made since the enactment of HITECH. It also establishes a baseline in anticipation of new policies to accelerate the exchange of health information, including subsequent stages of the EHR Incentive Programs and new payment models established by the Affordable Care Act, which rely on care coordination. Study Data And Methods Data Source And Collection We analyzed the health information technology (IT) supplements to the American Hospital Association s Annual Survey of Hospitals. The surveys were administered to all hospitals located in the fifty states and the District of Columbia and collected information on the adoption and use of health IT, including exchange activity. The surveys were sent to all hospitals, whether or not they were members of the American Hospital AUGUST :8 Health Affairs 1347

3 Association. The instructions requested the recipient the hospital s CEO to ask the person most knowledgeable about the hospital s health IT (typically the chief information officer) to complete the IT supplement and return his or her responses via mail or a secure website. Nonrespondents received follow-up mailings and phone calls. The response rates were 63 percent at both the beginning and the end of our study period, in 2008 and We limited our analyses to nonfederal acute care hospitals, including children s and cancer hospitals, which were eligible for federal meaningful-use incentives. The analytical sample included 2,805 hospitals in 2008 and 2,836 hospitals in Hospital Exchange Activity We analyzed hospital exchange activity using survey questions that asked respondents whether their hospital electronically exchanged or shared the following four types of clinical information: radiology reports, laboratory results, clinical care summaries, and medication lists. For each type of information, the survey asked about exchange activity by organizational affiliation (exchanges inside versus outside the organization) and by provider type (ambulatory care providers versus other hospitals). To measure the extent of exchange activity, we calculated the proportion of hospitals that actively exchanged clinical information with other providers. We created an overall measure of exchange activity that captured whether the hospital reported exchanging any type of information with any providers (ambulatory care providers, hospitals, or both) outside the organization. To examine variation by provider type and organizational affiliation, we created measures of the proportion of hospitals that reported exchanging any type of information with other hospitals outside their organization, other hospitals inside their organization, and ambulatory care providers outside their organization. To examine variation by type of clinical information, we created measures for the proportion of hospitals that reported exchanging each type of clinical information (radiology reports, laboratory results, clinical care summaries, and medication lists) with any provider (ambulatory care provider, hospital, or both) outside the organization. EHR Adoption And HIO Participation We used survey items to measure EHR adoption and HIO participation for each hospital. We defined EHR adoption as a hospital s adoption of at least a basic EHR system. A basic system requires advanced capabilities such as viewing imaging results, 20 and this measure has been used to monitor hospitals EHR adoption in a number of national studies. 14,21 HIO participation was determined using a survey question about participation and active exchange in an HIO, either regional or some other type. For both 2008 and 2012 we calculated the proportion of hospitals in one of the four following mutually exclusive categories: having adopted less than a basic EHR system and not participating in an HIO, participating in an HIO without having adopted an EHR system, having adopted at least a basic EHR system but not participating in an HIO, and both having adopted at least a basic EHR system and participating in an HIO. We also analyzed the change between 2008 and 2012 across these four categories. Other Hospital And Area Characteristics We examined hospital and area characteristics associated with hospital exchange activity. Hospital characteristics included hospital size (measured by the number of beds), ownership type, teaching status, the use of advanced technology (measured by the presence of a cardiac intensive care unit), the percentage of admissions that were paid for by Medicaid, system membership, and whether the hospital (or system) offered a health maintenance organization (HMO) product. Area characteristics included rural or urban location, market concentration (measured by the Herfindahl-Hirschman Index), HMO penetration into the market, per capita income, Medicare spending intensity (measured by Part A spending per beneficiary), and broadband availability (measured by the number of service providers). For details on the data sources and the creation of the variables, see the online Appendix. 22 Analysis We analyzed unadjusted rates of hospital exchange activity for the overall summary measure and by the type of provider, the provider s organizational affiliation, and the type of clinical information. We used t tests to identify any significant differences between 2008 and We applied probit regression in multivariate analyses to examine the association between EHR adoption and HIO participation, on the one hand, and the extent of exchange activity, on the other hand, and we adjusted for year and for hospital and area characteristics. Separate regressions were estimated for the overall measure and by the type of provider, the provider s organizational affiliation, and the type of clinical information being exchanged. We generated predicted means from these regressions and tested pairwise comparisons to identify significant differences by category of EHR adoption and HIO participation. All estimates were weighted to be nationally represen Health Affairs AUGUST :8

4 tative. Item responses with missing values were assigned zero values. The analyses were conducted using the statistical software Stata, version Limitations Our study had some important limitations. The data collected by the health IT supplements to the American Hospital Association s annual survey are self-reported, and we were unable to verify the accuracy of the responses. Although we adjusted for survey nonresponse, our estimates may remain biased from self-selection into the sample. Although item nonresponse for the exchange measures was not trivial, the assignment of missing values to zero should bias estimates to be conservative.we were unable to conduct a longitudinal analysis because of fluctuations in the sample, and our regression results may be biased by endogeneity from unobserved confounders changing over time. Thus, estimates should be interpreted as associations and not causes or effects. Our analysis was also limited in scope. We examined the associations between reported exchanges of information and EHR adoption, HIO participation, or both. However, the survey did not ask respondents about the nature of their information exchange or its underlying mechanisms. Therefore, we could not directly assess whether or how EHR systems or HIOs were used, or the volume of exchange transactions. In addition, the question about HIO participation focused on regional entities and might not have captured participation in private or hospitalsponsored exchanges. Finally, the survey did not assess other related issues, such as user acceptance of the EHR system or HIO interface and the impact of information exchange on efficiency, use of services, or patient outcomes. These are important subjects for future research. Study Results Hospital Exchange Activity Between 2008 and 2012 hospitals information exchanges with any providers outside the hospital s organization increased significantly, with the most rapid growth occurring after 2010 (Exhibit 1). Fiftyeight percent of hospitals were exchanging information with providers outside their organization in 2012 a 41 percent increase since 2008 (p <0:01; Exhibit 2). Hospitals exchanges with other hospitals outside their organization more than doubled during the study period. Growth in the rates of exchange by type of clinical information ranged from 39 percent to 55 percent. Hospitals exchange activity varied by the type and organizational affiliation of the provider with which the information was exchanged (Exhibit 2). In 2012, 51 percent of hospitals exchanged clinical information with unaffiliated ambulatory care providers, but only 36 percent exchanged information with other hospitals outside the organization. Similarly, hospitals exchange activity varied by type of clinical information exchanged (Exhibit 2). In 2012 more than half of hospitals exchanged laboratory results or radiology reports, but only about one-third of them exchanged clinical care summaries or medication lists with outside providers. EHR Adoption And HIO Participation Hospitals adoption of EHR systems and HIO participation grew significantly from 2008 to 2012 (Exhibit 2). In 2012, 44 percent of hospitals had adopted at least a basic EHR (compared to 9 percent in 2008), and 29 percent of hospitals were participating in a regional HIO (compared to 16 percent in 2008). The proportion of hospitals that had both adopted at least a basic EHR system and were participating in an HIO grew more than fivefold from 2008 to The largest share of hospitals had adopted less than a basic EHR and were not participating in an HIO in both 2008 and 2012 (Exhibit 2). However, the percentage of hospitals in this category decreased significantly during the study period. Association Of EHR And HIO Activity With Information Exchange In 2012 After hospital and area characteristics were adjusted for, hospitals that had basic EHR systems and were participating in HIOs had the highest rates of exchange activity in 2012, regardless of the type or organizational affiliation of the provider in Exhibit 1 Hospitals Electronic Exchange Of Health Information With Other Providers, By Provider Type And Affiliation, SOURCE Authors analysis of data from the health information technology supplements to the American Hospital Association s Annual Survey of Hospitals, NOTES All analyses were statistically weighted to account for potential nonresponse bias. Outside is outside the hospital s organization. Inside is inside that organization. Any providers is ambulatory care providers, hospitals, or both. AUGUST :8 Health Affairs 1349

5 Exhibit 2 Hospitals Electronic Exchange Of Health Information, Electronic Health Records Adoption, And Regional Health Information Organization Participation, 2008 And 2012 Percent of hospitals Percent change, to 2012 a Hospitals that exchange: Information with any providers outside the organization Information with: Ambulatory care providers outside the organization Other hospitals outside the organization Other hospitals inside the organization Information with outside providers, by type of information: Radiology reports Laboratory results Clinical care summaries Medication lists Hospitals that have: Less than basic EHR and no HIO participation HIO participation and no EHR At least basic EHR and no HIO participation At least basic EHR and HIO participation SOURCE Authors analysis of data from the health information technology supplements to the American Hospital Association s Annual Survey of Hospitals, 2008 and NOTES EHR is electronic health record system. HIO is a health information organization. a All comparisons between 2008 and are significantly different (p < 0:01). the exchange (Exhibit 3) or the type of clinical information exchanged (Exhibit 4). Eightyfour percent of hospitals that had both adopted an EHR system and were participating in an HIO exchanged information with providers outside their organization, compared to 71 percent of hospitals with HIO participation but no EHR system and 60 percent of hospitals with an EHR system but no HIO participation (Exhibit 3). Hospitals that had less than a basic EHR system Exhibit 3 Hospitals Information Exchange With Other Providers, By Hospitals Adoption Of Electronic Health Record (EHR) System And Participation In Regional Health Information Organization (HIO), 2012 SOURCE Authors analysis of data from the health information technology supplement to the American Hospital Association s Annual Survey of Hospitals, NOTES All analyses were statistically weighted to account for potential nonresponse bias. The predicted rate of health information exchange in 2012 was adjusted for hospital and area characteristics. All comparisons are significantly different (p < 0:01), with the exception of HIO participation only versus basic EHR only for exchanges with hospitals inside the organization. Outside is outside the hospital sorganization. Inside is inside that organization. Any providers is ambulatory care providers, hospitals, or both. Basic EHR is at least a basic EHR system Health Affairs AUGUST :8

6 Exhibit 4 Hospitals Exchange Of Types Of Information, By Hospitals Adoption Of Electronic Health Record (EHR) System And Participation In Regional Health Information Organization (HIO), 2012 SOURCE Authors analysis of data from the health information technology supplement to the American Hospital Association s Annual Survey of Hospitals, NOTES All analyses were statistically weighted to account for potential nonresponse bias. The predicted rate of health information exchange in 2012 was adjusted for hospital and area characteristics. All comparisons are significantly different (p < 0:01), with the exception of HIO participation only versus basic EHR only for exchanges of medication lists. Basic EHR is at least a basic EHR system. and did not participate in an HIO had the lowest rates of exchange activity. These patterns were consistent across different provider types and affiliations and different types of clinical information. The association between hospitals exchange activity and EHR adoption and HIO participation varied by type of clinical information (Exhibit 4). After we adjusted for hospital and area characteristics, HIO participation had the strongest relationships with exchanges of radiology reports and laboratory results with outside providers. The lowest rates of exchange were for medication lists and clinical care summaries by hospitals that had less than a basic EHR system and that did not participate in an HIO. Hospital And Area Characteristics Associated With Information Exchange Hospitals exchange activity varied by some hospital and area characteristics. For example, hospitals with the following characteristics were significantly less likely than others to exchange information with other providers: rural location, with the exception of exchanges with hospitals outside the organization; for-profit ownership; and location in areas with greater Medicare Part A spending (for detailed results, see the online Appendix). 22 Discussion Using national surveys of hospitals, we found that hospitals exchange activity increased significantly between 2008 and 2012, regardless of the type or organizational affiliation of the provider with which the hospital was exchanging information or the type of clinical information exchanged. Exchanges with hospitals outside the organization more than doubled, and exchanges of all types of clinical information increased substantially percent (Exhibit 2). Overall, nearly six in ten hospitals were exchanging information with providers outside their organization in 2012 a 41 percent increase since EHR adoption in combination with HIO participation was associated with the highest exchange activity across types and affiliations of providers and types of information exchanged. In 2012 more than eight in ten hospitals that had basic EHR systems and participated in HIOs exchanged information with any providers outside the organization. The substantial growth in exchange activity may be associated with the recent trends in greater hospital adoption of EHR systems and expanded participation in HIOs. 13,14 An encouraging finding was that the proportion of hospitals with both an EHR system and HIO participation increased fivefold between 2008 and Greater EHR adoption and the proliferation of AUGUST :8 Health Affairs 1351

7 HIOs may broaden the extent of exchange activity and enable exchanges with a greater variety of partners. In addition, EHR systems and HIOs may serve as complementary mechanisms to enable exchanges. Participation in an HIO was more closely associated with exchanging laboratory results and radiology reports than with exchanging clinical care summaries and medication lists (Exhibit 4), which may be attributable to established standards and progress in developing interfaces by leading vendors. 23,24 The fact that hospitals with HIO participation either alone or together with EHR systems were more likely than other hospitals to exchange information with other providers may in part reflect demand for the capability of looking up patient data in the context of unplanned care when no data are available at the site of care, as in the case of an emergency department visit. In contrast, EHR adoption was more closely associated with exchanging clinical care summaries than with exchanging other types of clinical information. This finding suggests that EHR systems may be well suited for exchanging data with other known providers to coordinate care. EHR systems and HIOs in combination may thus complement each other to improve information sharing overall, across the spectrum of clinical encounters. Despite the increase in exchange activity during the study period, only 36 percent of hospitals exchanged information with other hospitals outside the organization in 2012 (Exhibit 2). Prior research found that hospitals in large systems were less likely than others to exchange information with providers outside their organization, 18 and increased competition may inhibit hospitals participation in HIOs. 16,19,23 Although our study did not find an association between market concentration and exchanges with outside providers, competition as well as limited cross-vendor interoperability may be barriers to exchanges between unaffiliated hospitals. 18 Exchanges with unaffiliated providers and hospitals are currently limited. However, payment reform may encourage hospitals to exchange information outside their organization, including with unaffiliated hospitals. The Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology are working jointly to develop a strategy to accelerate the exchange of health information and have solicited input from external stakeholders. 25 New delivery and payment models, such as accountable care organizations, may provide hospitals with financial incentives to share information with other providers to achieve care that is better coordinated, of higher quality, and more efficient creating a powerful business case for the increased exchange of information. 26,27 For example, the Centers for Medicare and Medicaid Services has implemented a number of initiatives to reduce hospital readmission rates that were part of the Affordable Care Act. These initiatives include the Hospital Readmissions Reduction Program, which financially penalizes hospitals with excess thirty-day readmission rates for certain conditions. 28 In addition, local initiatives are under way in Maryland and other states to harness the exchange of billing data, with the goal of helping hospitals identify patients readmitted to other hospitals so as to better manage their care and thereby reduce future readmission rates. 29 Policies should be implemented to monitor exchange activity and determine whether payment incentives are sufficient to foster the increased exchange of information, especially across organizational boundaries. Addressing hospitals relatively low rates of exchange of medication lists and clinical care summaries will also be important to improving patient care. Hospitals exchange of medication lists is vital to performing medication reconciliations and providing clinical decision support for medication prescribing, as well as to other mechanisms for increasing patient safety. Similarly, hospitals exchange of clinical care summaries with outside providers is a critical step toward reducing gaps in care coordination during transitions of care. National policies and public-private initiatives are under way to address these gaps in hospitals exchange activity, particularly those related to the exchange of clinical care summaries. The initial meaningful-use requirements related to health information exchange in the EHR Incentive Programs were modest. However, information exchange is central to stage 2 of the program, which requires hospitals to exchange clinical summaries electronically during transitions of care starting in Furthermore, the certification of EHR systems for the EHR Incentive Programs requires vendors to develop interoperable systems that permit the exchange of clinical summaries, thereby facilitating exchanges with outside providers. Thus, meaningful-use requirements and the further growth in hospitals adoption of certified EHR systems may become important drivers of information exchanges. 21 The State Health Information Exchange Cooperative Agreement Program at the Office of the National Coordinator for Health Information Technology has included hospitals exchange of clinical summaries as part of its state-level performance measurement and 1352 Health Affairs AUGUST :8

8 will monitor the effectiveness of the various state approaches in increasing low rates of exchange activity. 31 National standards for interoperability have been developed that will provide reusable templates to serve as building blocks to accelerate the use of standards-based clinical summaries. 9 Initiatives such as the Direct Project 32 are developing technical standards to send clinical information directly and securely over the Internet using EHR systems or HIOs that will facilitate the exchange of clinical data. 33 Conclusion Hospitals exchanges of clinical information with outside providers increased significantly between 2008 and 2012, particularly since EHR adoption, in combination with participation in a regional HIO, was associated with increased exchanges across types and organizational affiliations of providers, as well as across types of clinical information exchanged. But despite substantial progress since the enactment of HITECH, a majority of hospitals still do not electronically exchange clinical care summaries and medication lists. This shortcoming limits efforts to improve patient safety and coordinate care across settings. Electronic health information exchange can play an important role in the success of new payment models. Existing initiatives such as the State Health Information Exchange Cooperative Agreement Program, new meaningful-use requirements for stage 2 of the EHR Incentive Programs, and participation in new payment models have the potential to promote increased exchange of clinical information between hospitals and providers outside their organization, which will be critical to improving transitions of care and managing population health. NOTES 1 Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospitalbased and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007; 297(8): Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform. 2007; 40(6 Suppl):S Walker J, Pan E, Johnston D, Adler- Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability. Health Aff (Millwood). 2005;w DOI: /hlthaff.w Frisse ME, Johnson KB, Nian H, Davison CL, Gadd CS, Unertl KM, et al. The financial impact of health information exchange on emergency department care. J Am Med Inform Assoc. 2012;19(3): Adler-Milstein J, Bates DW, Jha AK. A survey of health information exchange organizations in the United States: implications for meaningful use. Ann Intern Med. 2011;154(10): Health information exchange is sometimes used to denote regional entities that facilitate data exchange among participants. In this article we use health information exchange to denote data exchange activity, which may occur through various mechanisms including HIOs, interoperable EHRs, and consumer-mediated exchange. 7 Williams C, Mostashari F, Mertz K, Hogin E, Atwal P. From the Office of the National Coordinator: the strategy for advancing the exchange of health information. Health Aff (Millwood). 2012;31(3): Blumenthal D, Tavenner M. The meaningful use regulation for electronic health records. New Engl J Med. 2010;363(3): Department of Health and Human Services. Update on the adoption of health information technology and related efforts to facilitate the electronic use and exchange of health information: a report to Congress [Internet]. Washington (DC): HHS; 2013 Jun [cited 2013 Jul 9]. Available from: sites/default/files/rtc_adoption_ of_healthit_and_relatedefforts.pdf 10 Blumenthal D. Implementation of the federal health information technology initiative. N Engl J Med. 2011;365(25): Dullabh P, Adler-Milstein J, Nye C, Moiduddin A, Virost LM, Babalola E, et al. Evaluation of the State Health Information Exchange Cooperative Agreement Program: early findings from a review of twenty-seven states [Internet]. Bethesda (MD): NORC at the University of Chicago; 2012 Jan [cited 2013 July 9]. Available from: default/files/pdf/state-health-infoexchange-coop-program-evaluation.pdf 12 Allphin M. Health information exchanges: rapid growth in an evolving market. Orem (UT): KLAS Research; 2011 Jun. 13 Adler-Milstein J, Bates DW, Jha AK. Operational health information exchanges show substantial growth, but long-term funding remains a concern. Health Aff (Millwood). 2013;32(8): DesRoches CM, Charles D, Furukawa MF, Joshi MS, Kralovec P, Mostashari F, et al. Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had at least a basic system in Health Aff (Milwood). 2013;32(8): CapSite health information exchange study [Internet]. Williston (VA): CapSite; 2012 Sep [cited 2013 Jul 12]. Table of contents available from: Uploads/2012-Health-Information- Exchange-StudyTOC2.pdf 16 Vest JR. More than just a question of technology: factors related to hospitals adoption and implementation of health information exchange. Int J Med Inform. 2010;79(12): Adler-Milstein J, Jha AK. Sharing clinical data electronically: a critical challenge for fixing the health care system. JAMA. 2012;307(16): Miller AR, Tucker C. Health information exchange, system size and information silos [Internet]. New York (NY): NET Institute; 2011 Oct 20 [cited 2013 Jul 9]. (NET Institute Working Paper No ). Abstract available from: ssrn.com/abstract= Adler-Milstein J, DesRoches CM, Jha AK. Health information exchange among US hospitals. Am J Manag Care. 2011;17(11): Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16): DesRoches CM,Worzala C, Joshi MS, Kralovec PD, Jha AK. Small, AUGUST :8 Health Affairs 1353

9 nonteaching, and rural hospitals continue to be slow in adopting electronic health record systems. Health Aff (Millwood). 2012; 31(5): To access the Appendix, click on the Appendix link in the box to the right of the article online. 23 Grossman JM, Bodenheimer TS, McKenzie K. Hospital-physician portals: the role of competition in driving clinical data exchange. Health Aff (Millwood). 2006;25(6): Lewin Group. Under the microscope: trends in laboratory medicine [Internet]. Oakland (CA): California HealthCare Foundation; 2009 Apr [cited 2013 Jul 10]. Available from: MEDIA%20LIBRARY%20Files/ PDF/L/PDF%20LabDataTrends.pdf 25 Advancing interoperability and health information exchange: a notice by the Health and Human Services Department and the Centers for Medicare and Medicaid Services on 03/07/2013. Fed Regist [serial on the Internet] Mar 7 [cited 2013 Jul 10]. Available from: /03/07/ / advancing-interoperability-andhealth-information-exchange 26 McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care in practice. Health Aff (Millwood). 2010;29(5): Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood). 2010;29(4): Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306(16): Chesapeake Regional Information System for Our Patients. Use case description: encounter reporting system [Internet]. Columbia (MD): CRISP; 2012 [cited 2013 Jul 10]. Available from: fileticket=dqdeoakc1fo%3d& tabid=172&mid= Medicare and Medicaid programs; electronic health record incentive program stage 2: a rule by the Centers for Medicare and Medicaid Services on 09/04/2012. Fed Regist [serial on the Internet] Sep 4 [cited 2013 Jul 10]. Available from: articles/2012/09/04/ / medicare-and-medicaid-programselectronic-health-record-incentive- program-stage-2 31 Department of Health and Human Services. Program information notice: requirements and recommendations for the State Health Information Exchange Cooperative Agreement Program [Internet]. Washington (DC): HHS; 2012 Feb 8 [cited 2013 Jul 12]. Available from: content/uploads/2010/12/onc- PIN-February-2012.pdf 32 The Direct protocol provides a simple, secure, standards-based way for providers and other participants to send encrypted health information directly to trusted recipients over the Internet a kind of health message. It was developed by the Direct Project, a group of public and private stakeholders convened by the Office of the National Coordinator for Health Information Technology. See Direct Project [home page on the Internet]. Washington (DC): Direct Project; [cited 2013 July 11]. Available from: 33 Kuperman GJ. Health-information exchange: why are we doing it, and what are we doing? J Am Med Inform Assoc. 2011;18(5): Health Affairs AUGUST :8