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Appendix C: Background on the Market Landscape Pertaining To Exchange of Health Information

Resource and Workflow Challenges

Providers face significant resource and workflow challenges related to participation in exchange of health information that serve as underlying barriers to information flow. Some providers previously invested in EHRs that were not interoperable and now cannot afford or do not see the value in investing in system updates that would enable interoperable exchange.111 To exchange information with an HIO or other EHR systems, unique EHRs require software modifications or the purchase of additional middleware.112 Some progress has occurred in EHR interoperability across vendors, and there are growing multivendor interoperable networks, but most providers still struggle with the complexity and cost to connect from a technology, governance and workflow perspective. There is no simple “plug-and-play” option whereby providers can easily purchase technology and connect to one another.

Resource limitations may prevent smaller providers from participating in HIOs, which typically require payment of multiple fees. Fees can include an initial connectivity charge and recurring annual membership or subscription fees. In addition, existing data or data formats may not adequately meet provider needs. Data feeds may offer too much, too little, poorly-organized or difficult-to-ingest information. For example, a provider may receive a lengthy care summary in which relevant information is buried.

Another challenge providers face is that EHRs may have poor user interfaces that require extra work and time to operate. For example, providers may be required to log in to multiple portals or work through various tabs to review information about a patient. Additional time required to access and review information may delay providers from seeing more patients (a central concern in FFS-financed delivery systems), interfere with the patient–provider interaction and even affect the morale of providers operating in high-pressure environments.113

Providers also struggle with staff capacity and IT knowledge. They often do not have enough staff or staff with the right expertise to be able to operationalize exchange of health information.114 For instance, a provider may not have a staff member with the IT expertise necessary to procure, implement or troubleshoot new systems and services, or the provider may lack the appropriate number of administrative or clinical coordination staff members necessary to facilitate the workflow adjustments required for meaningful exchange—a particular concern in smaller practices.115

Even if resource and workflow challenges can be overcome, significant institutional or cultural barriers to data exchange may remain. For instance, research indicates that many providers who are near retirement may not be willing to focus on developing and using interoperable data.116 In addition, providers in remote locations may have challenges with connectivity because of lack of or limited broadband availability.117