Health information exchange in US hospitals: The current landscape and a path to improved information sharing

The US healthcare system is highly fragmented, with patients typically receiving treatment from multiple providers during an episode of care and from many more providers over their lifetime.^1,2 As patients move between care delivery settings, whether and how their information follows them is determined by a haphazard and error-prone patchwork of telephone, fax, and electronic communication channels.³ The existence of more robust electronic communication channels is often dictated by factors such as which providers share the same electronic health record (EHR) vendor rather than which providers share the highest volume of patients. As a result, providers often make clinical decisions with incomplete information, increasing the chances of misdiagnosis, unsafe or suboptimal treatment, and duplicative utilization.

Providers across the continuum of care encounter challenges to optimal clinical decision-making as a result of incomplete information. These are particularly problematic among clinicians in hospitals and emergency departments (EDs). Clinical decision-making in EDs often involves urgent and critical conditions in which decisions are made under pressure. Time constraints limit provider ability to find key clinical information to accurately diagnose and safely treat patients.^4-6 Even for planned inpatient care, providers are often unfamiliar with patients, and they make safer decisions when they have full access to information from outside providers.^7,8

Transitions of care between hospitals and primary care settings are also fraught with gaps in information sharing. Clinical decisions made in primary care can set patients on treatment trajectories that are greatly affected by the quality of information available to the care team at the time of initial diagnosis as well as in their subsequent treatment. Primary care physicians are not universally notified when their patients are hospitalized and may not have access to detailed information about the hospitalization, which can impair their ability to provide high quality care.^9-11

Widespread and effective electronic health information exchange (HIE) holds the potential to address these challenges.³ With robust, interconnected electronic systems, key pieces of a patient’s health record can be electronically accessed and reconciled during planned and unplanned care transitions. The concept of HIE is simple—make all relevant patient data available to the clinical care team at the point of care, regardless of where that information was generated. The estimated value of nationwide interoperable EHR adoption suggests large savings from the more efficient, less duplicative, and higher quality care that likely results.^12,13

There has been substantial funding and activity at federal, state, and local levels to promote the development of HIE in the US. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act has the specific goal of accelerating adoption and use of certified EHR technology coupled with the ability to exchange clinical information to support patient care.¹⁴ The HITECH programs supported specific types of HIE that were believed to be particularly critical to improving patient care and included them in the federally-defined criteria for Meaningful Use (MU) of EHRs (ie, providers receive financial incentives for achieving specific objectives). The MU criteria evolve, moving from data capture in stage 1 to improved patient outcomes in stage 3.¹⁵ The HIE criteria focus on sending and receiving summary-of-care records during care transitions.

Despite the clear benefits of HIE and substantial support stated in policy initiatives, the spread of national HIE has been slow. Today, HIE in the US is highly heterogeneous: as a result of multiple federal-, state-, community-, enterprise- and EHR vendor-level efforts, only some provider organizations are able to engage in HIE with the other provider organizations with which they routinely share patients. In this review, we offer a framework and a corresponding set of definitions to understand the current state of HIE in the US. We describe key challenges to HIE progress and offer insights into the likely path to ensure that clinicians have routine, electronic access to patient information.