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

ONC Data Brief 37 | July, 2016

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

The policy and technical actions needed to enable nationwide interoperability are described in the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap (Roadmap) (1). The Roadmap also identifies measures that will be used to monitor near-term progress related to interoperability. Recent ONC analyses used these measures to report on progress related to interoperability among U.S. non-federal acute care hospitals in 2015 (2). This brief describes variation in interoperability across different types of hospitals, rates of exchanging information between hospitals and other types of providers, and mechanisms hospitals used to exchange information.

Hospitals using only non-electronic means of exchanging summary of care records with outside sources significantly declined

Figure 1: Percent of U.S. non-federal acute care hospitals that send or receive summary of care records to/from outside sources by electronic and non-electronic methods, 2014-2015

This is a set of two bar graphs that represent methods (electronic, non-electronic or mixed) for receiving summary of care records and methods for sending summary care records for 2014 and 2015.  The first graphs represents 67% mixed for sending in 2014 and 75% 2015, a significant difference.   Non-electronic only for receiving summary of care records is 26% for 2014 and 17% for 2015, a significant difference.  Electronic only for receiving summary of care records is 7% for 2014 and 2015.  Mixed for sending is 77% for 2014 and 84% for 2015, a significant difference.  Non-electronic is 14% for 2014 and 7% for 2015, a significant difference.  Electronic is 9% for 2014 and 2015.

NOTES: *Significantly different from prior year (p<0.05). Non-electronic methods include Mail, Fax, or eFax. Electronic methods include secure messaging using an EHR, provider portals, or via health information exchange organizations or other third parties.

SOURCE: 2014-2015 AHA Annual Survey Information Technology Supplement.

Secure messaging using EHRs was the most common means to send and receive summary of care records electronically

Figure 2: Percent of U.S. non-federal acute care hospitals that send or receive summary of care records electronically by method, 2015

This bar graph represents the percent of U.S. non-federal acute care hospitals that send or receive summary of care records electronically by method for 2015.  Any Electronic Method is 85% for send and 65% for receive.  EHR secure message is 76% for send and 54% for receive.  Health information exchange organization is 60% for send and 45% for receive.  Provider portal is 48% for send and 30% for receive.

NOTE: Does not include "eFax." Summary of care records are in a structured format (e.g., CCDA).

SOURCE: 2014-2015 AHA Annual Survey Information Technology Supplement.

Six out of 10 hospitals nationwide participated in a state, regional or local HIO and used a health information exchange (HIE) vendor to enable exchange

Figure 3: Percent of U.S. non-federal acute care hospitals that participate and actively exchange data in local, regional or state HIO, or HIE vendor, 2015

This bar graph represents the percent of U.S. non-federal acute care hospitals that participate and actively exchange data in local, regional or state HIO, or HIE vendor, 2015. US non-federal acute care hospitals that use HIE vendor and participate in HIO is 61%.  US non-federal acute care hospitals that use HIE vendor and do not participate in HIO is 31%.  US non-federal acute care hospitals that participate in HIO and do not use HIE vendor is 2%.  US non-federal acute care hospitals that neither participate in HIO nor use HIE vendor is 5%.

NOTE: HIE vendor use excludes those who prefer not to disclose whether or which vendor they use.

SOURCE: 2014-2015 AHA Annual Survey Information Technology Supplement.

Rates of sending and receiving summary of care records between hospitals and other types of providers significantly increased between 2014 and 2015

Figure 4: Percent of U.S. non-federal acute care hospitals that send or receive summary of care records electronically to/from various exchange partners, 2014-2015

Hospitals received summary of care records from 23% of behavioral health care providers in 2015 and 16% in 2014 (a significant difference), from 23% of long term care providers in 2015 and 17% in 2014 (a significant difference), from 37% of outside ambulatory care providers in 2015 and 29% in 2014 (a significant difference), and from 40% of outside hospitals in 2015 and 32% in 214 (a significant difference).  Hospitals sent summary of care records to 35% of behavioral health care providers in 2015 and 28% in 2014 (a significant difference), to 49% of long term care providers in 2015 and 42% in 2014 (a significant difference), to 61% of outside ambulatory care providers in 2015 and 50% in 2014 (a significant difference), and to 59% of outside hospitals in 2015 and 49% in 214 (a significant difference).

NOTES: *Significantly different from prior year (p<0.05). Does not include "eFax." Summary of care records are in a structured format (e.g., CCDA). Exchange with long-term care providers and behavioral health providers includes both those inside and outside the hospital's health system.

SOURCE: 2014-2015 AHA Annual Survey Information Technology Supplement.

Small, rural, and Critical Access hospitals had lower rates of electronically sending, receiving, finding and integrating information

Table 1: Rates of electronically sending summary of care records, receiving summary of care records, querying and integrating summary of care records by hospital type, 2015

NOTES: See the Appendix Table for more definitions of find, send, receive and use/integrate, and hospital categories. *All values across row significantly different from category listed directly below (p<0.05). For example, all values across CAHs significantly different from non-CAHs.

SOURCE: 2014-2015 AHA Annual Survey Information Technology Supplement.

Fewer small, Critical Access, and rural hospitals had outside information electronically available at the point of care

Figure 5: Percent of hospitals with clinical information electronically available from outside providers or sources at the point of care and providers' use of information received from outside providers or sources by hospital type, 2015

Electronic information is available from outside providers/sources of 46% of all non-federal acute care hospitals, 39% of small hospitals (significantly different from all hospitals), 35% of critical access hospitals (significantly different from all hospitals), and 35% of rural hospitals (significantly different from all hospitals).  Use of outside electronic information received is 53% for all non-federal acute care hospitals, 46% for small hospitals (significantly different from all hospitals), 42% for critical access hospitals (significantly different from all hospitals), and 41% for rural hospitals.

NOTES: *Significantly different from all hospitals not within respective hospital type category (p<0.05). Usage is defined as providers using the information "often" or "sometimes." See Appendix Table 1 for details.

SOURCE: 2014-2015 AHA Annual Survey Information Technology Supplement.

Summary

Hospitals are shifting their means of exchanging data away from using paper-only methods of exchange. The percentage of hospitals that used only non-electronic means to send and receive information significantly declined between 2014 and 2015. There was a corresponding increase in the percentage of hospitals that used a mixture of paper and electronic methods to send and receive information.

As hospitals transition to electronic means of sending and receiving summary of care records, they may still have to rely on paper-based methods to exchange information due to their exchange partners' limited capability to electronically receive information; this was the most common barrier to interoperability reported by hospitals (2). This analysis found that the percentage of hospitals that sent or received summary of care records with long-term care and behavioral health care providers increased significantly between 2014 and 2015, suggesting that there has been some progress in these providers' capabilities to electronically exchange data with external providers. However, hospitals' rates of both electronically sending and receiving patient summary of care records to and from long-term care and behavioral health care providers remained lower than with outside hospitals and ambulatory care providers. With potential Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Medicaid funding to enable exchange among providers not previously eligible for Meaningful Use incentives, it is likely that hospitals will continue to increase their electronic exchange of information with a variety of providers across the care continuum (3, 4, 5). This is an important near-term priority of the Roadmap (1).

Hospitals were using a variety of means to enable interoperable exchange. Secure messaging using an EHR served as the most common means of electronically sending and receiving summary of care records, followed by the use of a HIO or other third party. A majority of hospitals leveraged external entities to enable exchange. About 6 in 10 hospitals used both a HIO and a HIE vendor to enable their exchange capabilities, and another 3 in 10 hospitals used a HIE vendor alone.

Recent ONC analyses indicate that a majority of non-federal acute care hospitals electronically sent and received summary of care records in 2015, and rates of electronically sending, receiving, and finding information from outside sources or providers increased significantly from the prior year (2). This data brief shows that interoperability varies across hospitals. Small, rural, and critical access hospitals have lower rates of engaging in the 4 domains of interoperability (e.g. sending, receiving, finding, and integrating). They also had lower rates of information electronically available from outside sources or providers, and lower rates of their providers' using information electronically received from outside their hospital system. However, further analysis is needed to better understand the cause of these specific disparities.

In summary, progress has been made over the last year with regards to interoperability across hospitals nationwide. However, monitoring variation in interoperability by hospital and area characteristics is critical to ensuring that all hospitals are engaging in the core domains of interoperability so that information from outside providers are electronically available at the point of care and are used to inform clinical decisions. Examining the mechanisms used by hospitals to exchange information can help further refine strategies outlined by the Roadmap that are needed to enable interoperability. Hence, ONC will conduct additional analysis in these areas to monitor progress.

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 (1). 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.

Small hospital: Non-federal acute care hospitals of bed sizes of 100 or less

Rural hospital: Located in a non-metropolitan statistical area

Critical Access Hospital: Less than 25 beds and at least 35 miles away from another general or critical access hospital

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. '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.

2. 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. Available at: http://dashboard.healthit.gov/evaluations/data-briefs/non-federal-acute-care-hospital-interoperability-2015.php.

3. 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.

4. Andy Slavitt & Karen De Salvo. Bridging the Healthcare Digital Divide: Improving Connectivity Among Medicaid Providers. Available at: https://blog.cms.gov/2016/03/02/bridging-the-healthcare-digital-divide-improving-connectivity-among-medicaid-providers/

5. Novak, Tom. Expanded Support for Medicaid Health Information Exchange. Presentation to Joint Public Health Forum & CDC Nationwide Webinar. April 21, 2016.

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., Pylypchuk Y., Henry J., & Searcy T. (July 2016) Variation in Interoperability among U.S. Non-federal Acute Care Hospitals in 2015. ONC Data Brief, no.37. Office of the National Coordinator for Health Information Technology: Washington DC.

Appendix

Appendix Table: Survey questions assessing interoperability among hospitals