Barriers to obtaining and using interoperable information among non-federal acute care hospitals

Abstract

Objective

To understand barriers to obtaining and using interoperable information at US hospitals.

Materials and Methods

Using 2023 nationally representative survey data on US hospitals (N = 2420), we examined major and minor barriers to exchanging information with other organizations, and how barriers vary by hospital characteristics and methods used to obtain information. Using a series of regression models, we examined how hospital experiences with barriers relate to routine use of information at responding hospitals.

Results

In 2023, most hospitals experienced at least one minor (81%) or major (62%) barrier to exchange, with the most common major barriers relating to different vendors and exchange partners’ capabilities. Higher-resourced hospitals and those often using network-based exchange tended to experience more minor barriers whereas lower-resourced hospitals and those often using mail/fax or direct access to outside electronic health records experienced more major barriers. In multivariate regression, hospitals indicating “Patient matching” and “Costs to exchange” were a major or minor barrier had the strongest independent negative association with the likelihood of reporting providers at their hospital frequently use information from outside organizations.

Discussion

Despite progress in interoperable exchange, various barriers remain. The prevalence of barriers varied by hospital type and methods used, with barriers more often preventing exchange for lower-resourced hospitals and those using outdated exchange methods.

Conclusion

While several technical and policy efforts are underway to address prevalent barriers, it will be important to monitor whether efforts are successful in ensuring information from outside organizations can be seamlessly exchanged and used to inform patient care.

Introduction

Following more than a decade of public support, almost all acute care hospitals in the United States now use electronic health records (EHRs) that are capable of electronic health information exchange (HIE), and most hospitals report engaging in all of 4 core domains of interoperability (the ability to electronically send, receive, find, and integrate health information from outside organizations).^1–3 However, numerous specific barriers—such as difficulty matching the correct patient across diverse systems and limited use of interoperable technology by other organizations across the healthcare continuum—still remain. Furthermore, the rate at which hospitals report specific barriers to effective interoperability has not improved as interoperability has become more widespread. For example, in 2014, when only 23% of hospitals reported engaging in all 4 domains of interoperability, 24% of hospitals reported that it was difficult to match or identify patients, and 25% reported additional costs to exchange with outside providers.⁴ By 2021, when 62% of hospitals engaged in all 4 domains of interoperability, 57% reported difficulty matching patients, and 43% reported that additional costs were barriers to interoperable exchange.¹

One explanation for the flat or increasing prevalence of barriers to interoperability is that only hospitals that were actively working to exchange information had an opportunity to encounter barriers. It would then follow that, over time, more hospitals were working to engage in interoperability and, therefore, more hospitals were experiencing relevant barriers.⁵ This trend could be disrupted by greater use of technologies to exchange information that reduce the impact of these barriers. For example, robust regional exchange networks or national networks that offer common technical and security frameworks to identify patients and facilitate exchange across organizations has increased over time. Participation in these networks, including national networks like the Commonwell Health Alliance, Carequality, and the eHealth Exchange, may ameliorate many barriers relative to older technologies like bidirectional interfaces between specific organizations, while increasing the overall rate of interoperability.^6–9

Understanding the evolving nature of barriers is critical to understanding the extent to which policy levers and other technical advances that have sought to address these issues have been successful. Congress has repeatedly demonstrated interest in addressing barriers to effective interoperability, for instance, by requiring that the Office of the National Coordinator for Health Information Technology (IT) (now the Office of the Assistant Secretary for Technology Policy) annually report on barriers to interoperability in the HITECH Act of 2009,¹⁰ by specifying that interoperable exchange must occur “without special effort” in the 21st Century Cures Act of 2016,¹¹ and through recent calls to address challenges to matching patients in disparate systems.¹² The Cures Act also sought to address certain known barriers to interoperability by calling on the HHS Secretary to implement policies to address information blocking and to establish a governing approach to nationwide interoperability that enables users in different health information networks to securely and seamlessly exchange information.

Nevertheless, identifying dynamics in barriers to exchange and interoperability has been challenging because measurement to date has focused on the existence rather than the severity of certain barriers. Therefore, resulting data have not been granular enough to capture changes in the intensity of barriers or whether organizations are able to overcome challenges to ensure information is available and used to inform care.¹³ In consequence, it is possible that while barriers to interoperability persist, they have become easier to address so that hospitals that encounter them are nevertheless able to engage in interoperable exchange.¹⁴

This study contributes to the literature by using recent national hospital survey data with updated, more detailed measures on specific major and minor barriers to interoperability, to better describe the prevalence and importance of barriers to interoperable HIE from the perspective of hospitals. While prior work has described specific barriers experienced by hospitals, this study describes the intensity of these barriers (ie, whether they limit or prevent exchange) and how each barrier affects the ability of providers at responding hospitals to use information available at the point of care. We focused on barriers to hospitals obtaining information because hospitals were best able to provide information on how these barriers impacted how information was used.¹⁵ We then examined whether hospitals with greater resources to overcome those barriers reported fewer barriers, whether specific methods of obtaining information were associated with fewer barriers, and whether the presence of specific barriers were more closely related to the ability of hospital clinicians to use information from other organizations to treat their patients.

Methods

This cross-sectional study did not require approval or consent from an ethics committee because it did not involve human participants. We followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guideline for cross-sectional studies.

Data and study population

Data came from the 2023 IT Supplement to the American Hospital Association (AHA) Annual Survey, a nationally representative survey of US hospitals including 4376 non-federal acute care hospitals.^16,17 The 2023 AHA IT Supplement was fielded March to August 2023, yielding responses from 2547 non-federal acute care hospitals (response rate = 58%). Descriptive and bivariate analyses were restricted to hospitals with complete information for questions pertaining to barriers to exchange and interoperability (N = 2420). Regression analyses omitted responses from hospitals with missing data for our outcome variable of interest (N = 2393).

Measures and outcomes

In the AHA IT Supplement, hospitals reported on 8 specific major and minor barriers to exchange and interoperability (see Figure 1 and Appendix Table S2). “Major” barriers were defined on the IT Supplement as challenges that reduce the value or frequency of exchange or prevent exchange with all or most organizations a hospital wants to exchange with. “Minor” barriers were defined as persistent challenges that modestly reduce the value or frequency of exchange, but do not typically prevent exchange.

Figure 1.

Major and minor barriers to interoperable exchange, 2023. Denominator includes all non-federal acute care hospital respondents to the 2023 AHA IT Supplement with complete information for barriers to interoperability and exchange questions (N = 2420). “Patient matching” = Difficult to match or identify the correct patient between systems. “Customized interfaces” = Have to develop customized interfaces in order to exchange health information. “Exchange partners” = There are HCPs whom we share patients with that do not typically exchange patient data with us. “Different vendor” = Greater challenges exchanging data across different vendor platforms. “Privacy laws” = Some HCPs state that they cannot exchange with us due to privacy laws in situations that do not seem appropriate. “Contractual constraints” = Contractual constraints between HCPs and vendors limit ability to exchange data with HCPs using certain systems. “Data formatting” = There are HCPs who share data with us but do not provide that data in the format that we request. “Costs to exchange” = Paying additional costs to exchange data with outside organizations/hospital systems. Original survey questions with corresponding data labels are also available in Appendix Table S2.

Hospitals also reported on methods they often used to obtain (find or receive) information from providers outside their organization. The use of specific methods to obtain information is likely to relate to the experience of barriers. We therefore defined 9 binary variables indicating hospitals that reported they “often” find or receive information via (1) mail or fax, (2) eFax using EHR (“eFax”), (3) provider portals that allow you to view records in another organizations’ EHR system (“portal”), (4) interface connection between EHR systems (“interface”), (5) access to other organizations’ EHR system using login credentials (“direct access”), (6) health information service providers that enable messaging via DIRECT protocol (“HISP”), (7) regional state or local health information exchange organization (“HIE”), (8) EHR vendor-based network that enables exchange with vendor’s other users (“vendor network”), and (9) national networks that enable exchange across different EHR vendors (“national network”).

The AHA IT Supplement contains a section on the availability and use of data that is exchanged. Respondents are first asked, when treating a patient that was seen by a provider outside your organization or hospital system, whether providers at their hospital routinely have necessary clinical information available electronically (not e-Fax) from outside providers or sources. Respondents are then asked how frequently providers at their hospitals use patient health information made available from outside providers or sources when treating a patient. Our main outcome of interest is a binary variable indicating hospitals that reported providers at their hospital routinely (“often” or “sometimes”) use patient health information from other organizations to treat their patients.

Statistical analysis

We reported national estimates of hospital experiences with 8 specific major and minor barriers to exchanging information with other organizations or hospital systems. We then reported adjusted means of major and minor barriers by hospital characteristics—including hospital size and ownership, teaching status, system affiliation, location (rural vs urban), critical access designation, and participation in value-based care (defined as participation in an accountable care organization, patient-centered medical home program, or pay for performance arrangement), and by methods hospitals often used to obtain information from providers outside their organization.

Finally, we sought to identify which barriers were associated with hospitals’ ability to enable routine use of health information by providers at the hospital. We hypothesized that some barriers to exchange may be sufficiently influential to prevent the exchange and use of information. Other barriers may shape how hospitals exchange information but not fundamentally prevent the routine use of information. To assess the association between barriers and use of information, we created a set of regression models beginning with a model (Model 1) that predicted whether hospitals enabled routine use of information based only on the 8 major and minor barriers to exchange. We then iteratively built more complex models to control for hospital characteristics (Model 2), methods of obtaining information from outside sources (Model 3), participation in specific national networks (Model 4), and participation in specific HIEs (Model 5). Persistent associations between specific barriers and the use of information in these models would provide evidence that the role of these barriers in impacting the routine use of information was not explained by the resources of the reporting hospital or the technical capabilities of methods of exchange. All estimates from our regression analyses are reported as percentage points representing average marginal effects, which offer a useful way to describe the average effect of experiencing a specific major or minor barrier on the change in probability of providers at the reporting hospital routinely using information available at the point of care.

All results were weighted to account for non-response and generate national estimates. A logistic regression model was used to predict the propensity of survey response as a function of hospital characteristics, including size, ownership, teaching status, system membership, and availability of a cardiac intensive care unit, urban status, and region. Hospital-level weights were derived by the inverse of the predicted propensity. For all models, P values < .05 were considered statistically significant. Data analyses were performed between December 2023 and March 2024 using Stata/SE, version 15.1 (StataCorp).

Results

Sample

The initial study population included 2420 non-federal acute care hospitals with complete information for survey questions regarding barriers to exchange and interoperability. The sample consisted of small (51%, n = 1127), medium- (39%, n = 968), and large- (11%, n = 325) sized hospitals, of which 69% were system members (n = 1816), 64% participated in value-based care (n = 1650), and 6% were major teaching hospitals (n = 169). Two-thirds were non-profit owned (66%, n = 1739), 14% were for-profit owned (n = 256), and 20% were government-owned (n = 425). Thirty-nine percent (39%, n = 889) were located in rural areas and 29% (n = 662) were designated critical access hospitals (Appendix Table S1).

Major and minor barriers to exchange

In 2023, most hospitals (96%) experienced at least one major or minor barrier to exchange (Figure 1) and a mean number of 4.61 out of 8 barriers (Tables 1 and 2). More than half of hospitals (62%) experienced at least one major barrier (1.83 on average) and 81% experienced at least one minor barrier (2.79 on average). Greater challenges exchanging data across different vendor platforms was the most prevalent barrier overall (84%) and the most cited major barrier to exchange (42%). Difficulty matching or identifying the correct patient between disparate systems was the most prevalent minor barrier to exchange (45%), followed by exchange partners not providing data in the format requested by hospitals (44%) (Figure 1).

Table 1.

Adjusted mean number of major and minor barriers to interoperable exchange, by hospital characteristics.

	Major and minor barriers	Major barriers (0-8)	Minor barriers (0-8)
Unadjusted mean	4.61	1.83	2.79
Hospital size
Small < 100 beds (51%) (ref)	4.69	2.07	2.62
Medium 100-399 beds (38%)	4.50	1.60a	2.90a
Large > 400 beds (11%)	4.68	1.48a	3.20a
Teaching status
Minor or non-teaching (6%)	4.61	1.82	2.80
Major teaching (94%)	4.63	1.98	2.64
Location
Rural (39%)	4.59	1.80	2.79
Urban (61%)	4.63	1.84	2.79
Critical access
Yes (29%)	4.58	1.63	2.95
No (71%)	4.63	1.91	2.72
System affiliation
Independent (31%)	4.80a	2.27a	2.53a
System affiliated (69%)	4.53	1.63	2.90
Ownership
Non-profit (66%)	4.66a	1.87a	2.79
For-profit (14%) (ref)	4.17	1.45	2.73
Government (20%)	4.78a	1.95a	2.83
Value-based care
Yes (64%)	4.60	1.76	2.84
No (36%)	4.65	1.95	2.70

Denominator includes all non-federal acute care hospital respondents to the 2023 AHA IT Supplement with complete information for barriers to interoperability and exchange questions (N = 2420).

^aIndicates statistically significant difference compared to reference group (P < .05). All estimates are adjusted for hospital characteristics.

Table 2.

Adjusted mean number of major and minor barriers to interoperable exchange, by methods of obtaining (finding or receiving) information from outside sources.

		Major and minor barriers	Major barriers (0-8)	Minor barriers (0-8)
Mean number		4.61	1.83	2.79
Methods of obtaining info
Mail or Fax	Yes (36%)	4.55	2.17a	2.39a
	No (64%)	4.65	1.64	3.01
efax	Yes (30%)	4.63	1.70	2.93
	No (70%)	4.61	1.88	2.73
Direct access	Yes (17%)	4.62	2.09a	2.53a
	No (83%)	4.61	1.77	2.84
Portal	Yes (34%)	4.62	1.69a	2.93
	No (66%)	4.61	1.89	2.72
Interface	Yes (48%)	4.76a	1.74	3.02a
	No (52%)	4.47	1.90	2.57
HISP	Yes (46%)	4.59	1.80	2.79
	No (54%)	4.63	1.85	2.79
HIE	Yes (59%)	4.49a	1.74a	2.76
	No (41%)	4.79	1.95	2.84
Vendor network	Yes (53%)	4.59	1.83	2.76
	No (47%)	4.64	1.83	2.82
National network	Yes (60%)	4.42a	1.55a	2.87
	No (40%)	4.90	2.24	2.66

Denominator includes all non-federal acute care hospital respondents to the 2023 AHA IT Supplement with complete information for barriers to interoperability and exchange questions (N = 2420).

^aIndicates statistically significant difference compared to reference group (P < .05). All estimates are adjusted for methods of exchange and hospital characteristics. HISP, health information service provider; HIE, health information exchange organization.

Relationship between hospital characteristics and barriers to exchange

The number of major and minor barriers experienced by hospitals varied by hospital characteristics (Table 1). Small, independent, government and non-profit owned hospitals experienced significantly more major barriers, on average, compared with their higher-resourced counterparts. For instance, small hospitals experienced 2.07 major barriers compared to 1.6 and 1.48 major barriers among medium and large hospitals, respectively, and independent hospitals experienced 2.27 major barriers compared to 1.63 among system-affiliated hospitals. Large, system-affiliated hospitals, on the other hand, experienced more minor barriers to exchange. Medium and large hospitals experienced 2.9 and 3.2 minor barriers, respectively compared to 2.62 among small hospitals while system-affiliated hospitals experienced 2.9 minor barriers compared to 2.53 among independent hospitals.

Relationship between methods of obtaining information and barriers to exchange

The number of major and minor barriers experienced by hospitals also varied by methods of obtaining (finding or receiving) information from outside sources (Table 2). Hospitals that reported often obtaining information using mail/fax or direct access to an outside EHR experienced more major barriers than hospitals not using these methods (2.17 and 2.09 major barriers, respectively, compared to 1.65 and 1.77 major barriers, P < .05). Yet, hospitals using these methods experienced fewer minor barriers to exchange than hospitals not using these methods (2.39 and 2.53 minor barriers, respectively, among hospitals using these methods compared to 3.01 and 2.84 minor barriers among hospitals not using these methods, P < .05). In contrast, hospitals that often obtained information using HIEs or national networks experienced fewer major barriers than hospitals not using these methods (1.74 and 1.55 major barriers, respectively, among hospitals using these methods, compared to 1.95 and 2.24 major barriers among hospitals not using these methods, P < .05). Hospitals often using interfaces experienced more minor barriers to exchange, on average, compared to those not using this method (3.02 vs 2.57, P < .05).

Association between barriers to exchange and use of information that is exchanged

In initial multivariate models only controlling for each barrier (Table 3, Column 1), the “costs to exchange” major barrier had the strongest independent negative association with a hospital reporting that their providers routinely use information (“routine use”) from outside organizations (−17.8 percentage points, P < .01). The “patient matching” major barrier was the next most strongly negatively associated with routine use (−11.8 percentage points, P < .01). Counterintuitively, both the major and minor “different vendor” barriers were strongly positively associated with routine use (21.1 percentage points, P < .01; 18.8 percentage points, P < .01). The “contractual constraints” minor barrier was also positively associated with routine use (15.7 percentage points, P < .01).

Table 3.

Marginal effects of specific major and minor barriers on hospitals’ routine use of information available at the point of care.

VARIABLES		(1)	(2)	(3)	(4)	(5)
Specific barriers (ref = not a barrier)
Different vendor	Major	0.211***	0.182***	0.152***	0.137***	0.0414
		(0.0344)	(0.0318)	(0.0299)	(0.0303)	(0.0341)
	Minor	0.188***	0.163***	0.107***	0.100***	0.0303
		(0.0326)	(0.0309)	(0.0300)	(0.0301)	(0.0350)
Exchange partners	Major	−0.00170	−0.0542**	0.0133	0.0391	0.0233
		(0.0303)	(0.0270)	(0.0257)	(0.0264)	(0.0292)
	Minor	0.0709***	−0.00759	0.0111	0.0279	−0.0165
		(0.0272)	(0.0257)	(0.0251)	(0.0255)	(0.0284)
Custom interfaces	Major	−0.0133	0.0172	0.0420	0.0355	0.0321
		(0.0334)	(0.0306)	(0.0279)	(0.0280)	(0.0303)
	Minor	−0.112***	−0.0615**	−0.0547**	−0.0599**	−0.0625**
		(0.0266)	(0.0255)	(0.0238)	(0.0241)	(0.0266)
Patient matching	Major	−0.118***	−0.156***	−0.130***	−0.124***	−0.0834***
		(0.0309)	(0.0286)	(0.0266)	(0.0266)	(0.0294)
	Minor	−0.0945***	−0.0949***	−0.0917***	−0.0840***	−0.0773***
		(0.0278)	(0.0257)	(0.0250)	(0.0253)	(0.0282)
Costs to exchange	Major	−0.178***	−0.103***	−0.0859***	−0.0853***	−0.103***
		(0.0317)	(0.0287)	(0.0271)	(0.0272)	(0.0296)
	Minor	−0.0810***	−0.112***	−0.0934***	−0.0909***	−0.0778***
		(0.0289)	(0.0265)	(0.0246)	(0.0246)	(0.0272)
Data formatting	Major	−0.00377	−0.00593	−0.0301	−0.0217	−0.00597
		(0.0343)	(0.0298)	(0.0282)	(0.0282)	(0.0312)
	Minor	−0.117***	−0.0707***	−0.0587***	−0.0646***	−0.0314
		(0.0263)	(0.0238)	(0.0220)	(0.0220)	(0.0272)
Contractual constraints	Major	0.0520	0.0595*	0.0897***	0.0928***	0.0716*
		(0.0384)	(0.0353)	(0.0341)	(0.0340)	(0.0373)
	Minor	0.157***	0.0765***	0.0310	0.0403*	0.0744***
		(0.0275)	(0.0255)	(0.0234)	(0.0233)	(0.0256)
Privacy laws	Major	−0.0983**	0.0172	0.0105	0.00171	0.0208
		(0.0482)	(0.0411)	(0.0388)	(0.0383)	(0.0414)
	Minor	−0.0485	−0.00766	−0.0154	−0.00542	0.00826
		(0.0298)	(0.0278)	(0.0259)	(0.0259)	(0.0293)
Hospital characteristics		NO	YES	YES	YES	YES
Methods of obtaining		NO	NO	YES	YES	YES
National networks		NO	NO	NO	YES	YES
HIE fixed effects		NO	NO	NO	NO	YES
Observations		2393	2393	2393	2393	2393
R-squared		0.065	0.239	0.367	0.374	0.508

Each column reports results from a step-wise linear regression analysis. All estimates are reported as average marginal effects. The first regression included only specific major and minor barriers to exchange (Column 1) with each additional regression adding controls for hospitals characteristics (Column 2), methods of obtaining (finding or receiving) information from outside sources (Column 3), national network participation (Column 4), and HIE participation (Column 5). Standard errors in parentheses.

^*** P < .01,

^** P < .05,

^* P < .1.

Column 5 presents results that include covariates related to hospital characteristics, methods the hospital uses to obtain information from outside sources, and the specific national and regional networks the hospital participates in. The negative association between the “costs to exchange” and “patient matching” barriers and routine use persisted after controlling for these factors, though the absolute size of the relationship was diminished (−10.3 percentage points, P < .01 and −8.3 percentage points, P < .01, respectively). The association between the “different vendor” major and minor barriers and routine use was not observed after controlling for these factors, whereas the positive association with the “contractual constraints” minor barrier and routine use persisted yet diminished in size (7.44 percentage-points, P < .01).

Discussion

Using novel data that distinguishes whether hospitals were experiencing major and minor barriers to interoperability, we found that despite documented progress in interoperable exchange over the last several years,¹ in 2023 more than half of hospitals faced major barriers that prevented them from obtaining and using information from all or most outside organizations with which they want to exchange. Furthermore, more than three-quarters experienced minor barriers that limited the frequency or value of exchange in some cases but did not prevent it from occurring. In total, more than half of responding hospitals reported that 5 of 8 measured barriers were either major or minor barriers to exchange.

The prevalence of barriers varied by hospital type and the technology they used. Small, independent, and for-profit hospitals tended to experience more major barriers that prevent exchange with other providers whereas their higher-resourced counterparts experienced more minor barriers. This suggests that higher-resourced hospitals—who are more likely to be involved in exchanging information—may more often encounter barriers that they are able to address given the resources available to them or that these barriers limit and shape but do not prevent engagement in exchange. We observed a similar trend of higher rates of major barriers among hospitals that reported often obtaining information using older and bidirectional technologies such as mail/fax or direct access to an outside EHR. In contrast, hospitals that often used network-based exchange, including HIEs and national networks, experienced fewer major barriers to exchange, which suggests these methods may help limit barriers that substantially hinder or prevent exchange with other providers. Specifically, supplemental analysis (see Appendix Table S5) indicated that use of HIEs was related to substantially lower rates of reporting barriers related to different vendor platforms, exchange partners, the need for customized interfaces, and data formatting. Use of national networks was related to lower rates of 6/8 barriers, with the strongest association with lower rates of barriers related to different vendor platforms, costs to exchange, and a need for customized interfaces.

The 2 most prevalent barriers to exchange were experiencing greater challenges exchanging data across different vendor platforms and that some health care organizations that treat the same patient as the hospital do not exchange information with the hospital. Taken together, these data points indicate that the most common barriers to hospitals obtaining information on patients under their care are limits to other organizations’ ability to meaningfully provide information to the hospital.¹⁸ Because of market segmentation in the provision of EHRs, challenges related to different platforms are likely particularly pronounced when information must be exchanged across organizations of varied size (eg, independent hospital vs multihospital system) and type (eg, hospital, physician office, skilled nursing facility). This is likely common as patients receive care across the care continuum, and cross-vendor challenges identified here mirror challenges reported by primary care physicians.¹⁹ Importantly, we found that while these 2 barriers were the most commonly reported by hospitals, they were associated with a greater likelihood that the hospital reported enabling their providers to routinely use information from outside organizations. These correlations indicate that barriers to cross-vendor exchange and challenges with external organization’s capabilities were most pronounced for hospitals that made routine use of information. It is likely that many hospitals have robust access to information from certain partners but are nevertheless missing information from specific, important partners in the care of patients.

In comparison, barriers related to paying additional costs to exchange data with outside organizations/hospital systems and difficulty matching or identifying the correct patient between systems were not among the most prevalent major barriers. However, when these barriers were reported, they were related to substantially reduced likelihood of reporting that providers routinely used information from outside organizations. This dynamic indicates that these barriers, when salient, are impactful in limiting the overall use of information from outside organizations, and therefore may be important targets for intervention.

Several recent efforts are already underway to address persistent barriers to exchange and interoperability. Information blocking provisions that went into effect in 2022 may help alleviate cost-related barriers by prohibiting actors from charging unreasonable fees to access patient data. However, it may be that current prices are reasonable in a regulatory or legal sense while also being prohibitive for about one quarter of hospitals. The Trusted Exchange Framework and Common Agreement (TEFCA) is intended to reduce costs by commoditizing data exchange and promoting competition between various networks offering exchange through TEFCA.²⁰ TEFCA may also address challenges related to external organizations’ capabilities by encouraging increased participation by organizations across the care continuum using varied vendor platforms by reduced cost and a simplified process to engage in broad exchange. Project US@ and related efforts to standardize patient information may reduce the impact of challenges to identifying the right patient—the most prevalent minor barrier to exchange—and members of Congress have indicated clear interest in further addressing the topic.^21,22

Taken together, these policies appear well aimed at altering the technical and policy landscape that structures exchange. However, in contrast to past policy interventions, they do not provide direct financial incentivizes to exchange. Consequently, close scrutiny of whether hospitals report that barriers to exchange are indeed decreasing will be important to monitor and may warrant additional actions.

Limitations

Our study is subject to limitations. One important limitation is reliance on a cross-sectional, self-reported survey to assess hospitals’ experiences with different barriers to exchange. The AHA IT Supplement represents just over half of US non-federal acute care hospitals, and thus despite our efforts to weight responses to reflect national estimates and account for non-response, our estimates may be affected by non-response bias if non-responding hospitals systematically experience barriers differently than responding hospitals. While examining major or minor barriers to exchange allows us to better capture the intensity of specific challenges compared to prior binary measurement of hospital experiences with barriers, responses are subjective. Further, survey data are self-reported by hospital Chief Information Officers or the person most knowledgeable about the hospital’s use of health IT and these respondents may be limited in their knowledge of how often providers at their hospital have information available for use at the point of care.

Conclusion

Using the latest national survey data capturing the extent to which hospitals experience major and minor barriers to interoperable exchange, we found that despite enormous progress in the adoption and use of interoperable health IT, hospitals often report encountering substantial barriers to exchanging information with other partners. These barriers were more likely to prevent exchange for small and under-resourced hospitals. Larger hospitals were more likely to report these barriers as relatively minor, in part because those hospitals more often use newer network-based methods that ameliorate some barriers. While current policy aimed at the technical and policy environment appears positioned to address several of the most prevalent barriers, it will be important to monitor whether these policies are sufficient to meet the policy objective of enabling information exchange without the “special effort” necessary to overcome these barriers.

Author contributions

Dr Jordan Everson and Dr Chelsea Richwine both had full access to the data used in the study and take responsibility for the integrity and accuracy of the data analysis. Both authors contributed equally to all aspects of this work.

Supplementary material

Supplementary material is available at Journal of the American Medical Informatics Association online.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Conflicts of interest

The authors have no competing interests to declare.

Data availability

Data are available for purchase from the AHA: https://www.ahadata.com/aha-healthcare-it-database.