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Interoperability among U.S. Non-federal Acute Care Hospitals in 2015

ONC Data Brief 36 | May, 2016

Vaishali Patel, PhD MPH; JaWanna Henry, MPH; Yuriy Pylypchuk, PhD; Talisha Searcy, MPA, MA;

Interoperability of health information is a national priority. In the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress declared it a national objective to achieve widespread exchange of health information through interoperable certified electronic health record (EHR) technology nationwide by December 31, 2018 (1). The Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap (Roadmap) described the policy and technical actions needed to enable nationwide interoperability. It also identified four key domains of interoperability as electronically sending, receiving, finding, and integrating or using key clinical information (2). This brief presents the most recent estimates on the state of interoperable exchange activity among U.S. non-federal acute care hospitals, including whether hospitals have key patient information electronically available from sources outside their system; whether this information is subsequently used for clinical decisions; and barriers to the exchange and use of that information.

The percent of hospitals electronically sending, receiving, and finding key clinical information grew significantly between 2014 and 2015

Figure 1: Percent of U.S. non-federal acute care hospitals that electronically find patient health information, and send, receive, and use patient summary of care records from sources outside their health system, 2014-2015

A bar chart showing the percent of hospitals that find, send, receive, use key clinical information in 2014 and 2015. For find, 48 percent in 2014 and 52 percent in 2015; for send, 78 percent in 2014 and 85 percent in 2015; for receive, 56 percent in 2014 and 65 percent in 2015; for use or integrate, 40 percent in 2014 and 38 percent in 2015; for all four together, 23 percent did so in 2014 and 26 percent in 2015.

NOTE: See the Appendix Table for more definitions of find, send, receive and use/integrate. *Significantly different from previous year (p < 0.05).

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

The percent of non-federal acute care hospitals that exchanged key types of information significantly increased

Figure 2: The percent of non-federal acute care hospitals that electronically exchanged laboratory results, radiology reports, clinical care summaries, or medication lists with ambulatory care providers or hospitals outside their organization, 2008-2015

A line chart showing the percent of non-federal acute care hospitals that electronically exchanged laboratory results, radiology reports, clinical care summaries, or medication lists with ambulatory care providers or hospitals outside their organization from 2008 to 2015. Results for each year are as follows: 2008, 41 percent; 2009, 45 percent; 2010, 44 percent; 2011, 50 percent; 2012, 58 percent; 2013, 62 percent; 2014, 76 percent; 2015, 82 percent.

NOTE: *Significantly different from previous year (p < 0.05). Exchange was assessed using survey questions asking 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

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

About half of hospitals had necessary patient information electronically available from providers or sources outside their systems at the point of care

Figure 3: Percent of U.S. non-federal acute care hospitals whose providers have electronically available necessary clinical information from outside providers or sources across all non-federal acute care hospitals and those that engaged in all 4 core domains of interoperability, 2014-2015

A bar chart showing the percent of hospitals whose providers have electronically available necessary clinical information from outside providers. In 2014, 41 percent of all hospitals did, and 86 percent of hospitals who can perform all four domains of interoperability did. In 2015, 46 percent of all hospitals did, and 89 percent of hospitals can perform all four domains of interoperability did.

NOTE: Four core domains of interoperability consist of find, send, receive, and integrate or use. *Significantly different from previous year (p < 0.05)

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

About half of hospitals reported their providers used patient health information received electronically from outside providers when treating their patients

Figure 4: Percent of U.S. non-federal acute care hospitals that report their providers use patient health information received electronically from providers or sources outside their health system when treating their patients, 2015

A bar chart showing the percent of hospitals that report their providers use patient health information received electronically in 2015. 18 percent of hospitals reported their providers often used PHI received electronically. 35 percent reported their providers sometimes used PHI received electronically. 20 percent reported their providers rarely used PHI received electronically, and 16 percent reported their providers never used PHI received electronically. 11 percent of hospitals did not know when surveyed.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

The most common reason for not using patient health information received electronically from outside providers is that the information is not available to view within the EHR

Figure 5: Reasons for rarely or never using patient health information received electronically from providers or sources outside their health system when treating their patients as reported by U.S. non-federal acute care hospitals, 2015

A bar chart showing percent of hospitals that reported specific barriers to interoperability. 53 percent reported information was not available to view in EHR as part of clinicians workflow; 45 percent reported it was difficult to integrate information in EHR; 40 percent reported information not always available when needed; 29 percent reported information not presented in a useful format; 11 percent reported they do not trust accuracy of information. 18 percent reported other reasons.

NOTES: See the Appendix Table for more details regarding the survey items.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

Lack of exchange partners' capabilities to receive data remained the most frequently identified barrier to interoperability

Table 1: Percent of U.S. non-federal acute care hospitals that experienced the issues when trying to electronically send, receive, or find health information to/from other care settings or organizations, 2014-2015

NOTES: See the Appendix Table for more details regarding the survey items. *Significantly different from previous year (p < 0.05). NA or not applicable because item was not asked in 2014.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement

Summary

National rates of hospitals' electronically sending, receiving and finding information to and from providers or sources outside their hospital system significantly increased between 2014 and 2015. A substantial majority of hospitals were electronically sending and receiving summary of care records, and a little over half of hospitals were electronically finding information from outside sources. The percent of non-federal acute care hospitals that exchanged key types of information also significantly increased. However, the number of hospitals integrating data from outside sources without manual entry did not significantly change between 2014 and 2015.

More hospitals reported that they had health information available electronically from outside sources at the point of care. About half of non-federal acute care hospitals nationwide had the necessary clinical information available electronically from outside providers or sources when treating their patients.

About one-quarter of hospitals engaged in all 4 core domains of interoperability in 2015; this increased by a few percentage points since 2014. Findings from both 2014 and 2015 demonstrate the benefits of engaging in all four core domains of interoperability. Hospitals that engaged in all four core interoperability domains had necessary patient information electronically available from outside sources and providers, about twice the national average.

The percent of hospitals reporting they did not possess the technical capability to electronically send or receive information significantly decreased. This aligns with the significant increases in the percent of hospitals engaged in sending summary of care records electronically. However, a high proportion of hospitals' exchange partners continue to lack the technical capabilities to receive data electronically. There was also a significant increase in the percent of hospitals having difficulties with patient matching, higher than other barriers reported by hospitals. The Roadmap seeks to address this issue (2).

Overall, about half of hospitals reported that their providers often or sometimes used information electronically received from outside their hospital system when treating their patients. About one-third rarely or never used such information. The most common reason for not using such information related to the inability to access the information from within their EHR, whether that was due to clinical workflow or inability to integrate data from outside sources into their EHR.

Continued increases in the interoperable exchange and use of health information from outside sources along with the availability of information are important to the success of care transformation efforts nationwide, which will likely expand with the implementation of the MACRA (3, 4). However, there is still significant progress to be made to improve the use of exchanged information and to address barriers to interoperability.

Definitions

Non-federal acute care hospital: Includes acute care general medical and surgical, general children's, and cancer hospitals owned by private/not-for-profit, investor-owned/for-profit, or state/local government and located within the 50 states and District of Columbia.

Interoperability: The ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user (2). This brief further specifies interoperability as the ability for health systems to electronically send, receive, find, and use health information with other electronic systems outside their organization.

Integrate: Whether the EHR integrates summary of care record received electronically (not eFax) from providers or sources outside your hospital system/organization without the need for manual entry.

Find: Whether providers at your hospital query electronically for patients' health information (e.g., medications, outside encounters) from sources outside of your organization or hospital system.

Data Source and Methods

Data are from the American Hospital Association (AHA) Information Technology (IT) Supplement to the AHA Annual Survey. Since 2008, ONC has partnered with the AHA to measure the adoption and use of health IT in U.S. hospitals. ONC funded the 2015 AHA IT Supplement to track hospital adoption and use of EHRs and the exchange of clinical data.

The chief executive officer of each U.S. hospital was invited to participate in the survey regardless of AHA membership status. The person most knowledgeable about the hospital's health IT (typically the chief information officer) was requested to provide the information via a mail survey or secure online site. Non-respondents received follow-up mailings and phone calls to encourage response.

The survey was fielded from October 2015 to the end of February 2016. The response rate for non-federal acute care hospitals was 56.15%. 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, availability of a cardiac intensive care unit, urban status, and region. Hospital-level weights were derived by the inverse of the predicted propensity.

Estimates considered unreliable had a relative standard error adjusted for finite populations greater than 0.49. Responses with missing values were assigned zero values. Significant differences were tested using p < 0.05 as the threshold.

References

1. See Section 106(b)(1) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. No. 114 - 10, enacted April 16, 2015). https://www.gpo.gov/fdsys/pkg/PLAW-114publ10/html/PLAW-114publ10.htm.

2. 'Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap version 1.0,' Office of the National Coordinator for Health Information Technology. Available at https://www.healthit.gov/policy-researchers-implementers/interoperability.

3. Burwell SM. Setting value-based payment goals--HHS efforts to improve U.S. health care. N Engl J Med. 2015 Mar 5;372(10):897-9.

4. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). (Pub. L. No. 114 - 10, enacted April 16, 2015). https://www.gpo.gov/fdsys/pkg/PLAW-114publ10/html/PLAW-114publ10.htm.

About the Authors

The authors are with the Office of the National Coordinator for Health Information Technology, Office of Planning, Evaluation, and Analysis.

Suggested Citation

Patel V., Henry J., Pylypchuk Y., & Searcy T. (May 2016) Interoperability among U.S. Non-federal Acute Care Hospitals in 2015. ONC Data Brief, no.36. Office of the National Coordinator for Health Information Technology: Washington DC.

Appendix

Appendix Table: Survey questions assessing interoperability among hospitals