Health information exchange among U.S. hospitals: who's in, who's out, and why?

Background: A key goal of the 2009 HITECH Act is to ensure broad electronic exchange of clinical data among providers. We sought to assess whether current policy efforts, many of which are being developed by states, appear to be tackling key barriers to hospital participation in health information exchange (HIE).

Methods: We used the most recent national data from the American Hospital Association's IT Supplement to assess U.S. hospital participation in HIE and how participation varies by state. We then examined whether HIE is being pursued by all types of hospitals, or whether specific types of hospitals are not yet engaged. We focused on for-profit hospitals, those with smaller market share, and those in more competitive markets.

Results: We found that 30% of U.S. hospitals engaged in health information exchange with unaffiliated providers. There was large variation in state-level participation, with some states achieving more than 70% participation (Rhode Island, Delaware and Vermont) and others with minimal participation. In markets where exchange occurred, for-profit hospitals were far less likely to engage in HIE than non-profit hospitals (OR=0.17; p<0.001). Hospitals with a larger market share were more likely to engage in exchange (OR=2.05 for hospitals in the highest relative to the lowest quartile of market share; p<0.001), as were hospitals in less competitive markets (OR=2.15 for hospitals in the most relative to least concentrated market quartile; p=0.04).

Conclusions: Despite an uptick in hospital HIE participation since the start of HITECH, the majority of hospitals still do not engage in HIE and there is large state-to-state variation. Specific types of hospitals appear to feel that they are better off not engaging in HIE.

Implications: Stronger policies and incentives may be needed to convince organizations to share their data electronically. Pursuing these is critical to ensuring that the highly anticipated quality and efficiency gains from our large national investment in health information technology are realized.