Table 1.

Perceived barriers and facilitators of actual HIE use grouped by theme

Barriers	Facilitators
Completeness of Information
• Patients and providers concerned about privacy and security.[20, 28, 30] • Patients outside of the HIE catchment area.[15] • Poor matching of patients.[11, 24] • Providers stop using query-based system when they can't find patients or needed information. [15, 18, 20, 24, 29, 30] • Health system competition.[18] • Providers don't exchange over concern about liability, malpractice.[18, 30]	• Robust policy and training about privacy and security.[22, 31] • Consider opt out vs. opt in for the consent process.[30] • Obtain consent at registration or with online patient authorization.[11, 15] • Educate patients on HIE.[15, 30] • Use probabilistic matching algorithm.[11]
Organization and Workflow
• Disruptive login, or separate login & password to portal – too many clicks.[15, 18, 19, 23, 25, 29, 30] • Policy that prohibits proxy users.[14] • Need for more technical support.[18, 23, 24, 29] • Need for culture change about practice and need to not use free-text.[14, 18, 32] • Need to enter data in EHR and the HIE.[31]	• Single login.[14] • Take a sociotechnical approach.[17] • Provide ongoing training for providers and proxy users.[14, 18, 23, 29] • Collect feedback from users in ongoing manner.[14] • Monitor metrics of provider access and contribution.[29] • Manage expectations of new HIE.[31] • Develop thoughtful workflow and interface for providers and proxy users.[14, 15, 17-19, 23, 24, 28, 29] • Have champion HIE users.[15, 18, 28] • Have sufficient technical support.[26, 32]
Technology and User Needs
• Reports in exchange may not meet needs of the provider, too much information, not legible. [15, 16, 19, 26] • Lack of notes to set context in patient information.[25, 29] • Lack of data standards.[18, 21] • HIE competes with existing hospital portal with more complete information.[16, 17, 19, 28, 29]	• Consider when to push and when to pull data.[20] • Ability to send brief report before full access.[14, 16, 26] • Provide alerts for when HIE is available.[18] • Share contextual notes.[14] • Automatic integration with existing provider systems.[25, 26] • Include providers and proxy users in design of interface.[14]

HIE= Health information exchange; vs. = versus.