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Original Research |

A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use

Julia Adler-Milstein, BA; David W. Bates, MD, MSc; and Ashish K. Jha, MD, MPH
[+] Article, Author, and Disclosure Information

From Harvard Business School, Harvard School of Public Health, Brigham and Women's Hospital, Harvard Medical School, and Veterans Affairs Boston Healthcare System, Boston, Massachusetts.

Acknowledgment: The authors thank Jessica Martin for her assistance with data collection.

Grant Support: By a contract from the ONC for Health Information Technology at the U.S. Department of Health and Human Services.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2808.

Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.

Requests for Single Reprints: Ashish K. Jha, MD, MPH, Harvard School of Public Health, Department of Health Policy and Management, 677 Huntington Avenue, Boston, MA 02115; e-mail, ajha@hsph.harvard.edu.

Current Author Addresses: Ms. Adler-Milstein: Harvard Business School, Wyss Hall, Soldiers Field, Boston, MA 02163.

Dr. Bates: Brigham and Women's Hospital, Division of General Internal Medicine, 1620 Tremont Street, 3rd Floor, Boston, MA 02120.

Dr. Jha: Harvard School of Public Health, Department of Health Policy and Management, 677 Huntington Avenue, Boston, MA 02115.

Author Contributions: Conception and design: J. Adler-Milstein, D.W. Bates, A.K. Jha.

Analysis and interpretation of the data: J. Adler-Milstein, D.W. Bates, A.K. Jha.

Drafting of the article: J. Adler-Milstein.

Critical revision of the article for important intellectual content: J. Adler-Milstein, D.W. Bates, A.K. Jha.

Final approval of the article: J. Adler-Milstein, D.W. Bates, A.K. Jha.

Provision of study materials or patients: A.K. Jha.

Obtaining of funding: A.K. Jha.

Administrative, technical, or logistic support: J. Adler-Milstein, D.W. Bates, A.K. Jha.

Collection and assembly of data: J. Adler-Milstein, D.W. Bates, A.K. Jha.

Ann Intern Med. 2011;154(10):666-671. doi:10.7326/0003-4819-154-10-201105170-00006
Text Size: A A A

Background: To receive financial incentives for meaningful use of electronic health records, physicians and hospitals will need to engage in health information exchange (HIE). For most providers, joining regional organizations that support HIE is the most viable approach currently available.

Objective: To assess the state of HIE in the United States through regional health information organizations (RHIOs).

Design: Survey.

Setting: All RHIOs in the United States.

Participants: 179 U.S.-based RHIOs that facilitated HIE as of December 2009.

Measurements: Number of operational RHIOs, the subset of operational RHIOs that supported stage 1 meaningful use, and the subset that supported robust HIE; number of ambulatory practices and hospitals participating in RHIOs; and number of financially viable RHIOs.

Results: Of 197 potential RHIOs, 179 (91%) reported their status and 165 (84%) returned completed surveys. Of these, 75 RHIOs were operational, covering approximately 14% of U.S. hospitals and 3% of ambulatory practices. Thirteen RHIOs supported stage 1 meaningful use (covering 3% of hospitals and 0.9% of practices), and none met an expert-derived definition of a comprehensive RHIO. Overall, 50 of 75 RHIOs (67%) did not meet the criteria for financial viability.

Limitations: Survey data were self-reported. The sample may not have included all HIE efforts, particularly those of individual providers who set up their own data-exchange agreements.

Conclusion: These findings call into question whether RHIOs in their current form can be self-sustaining and effective in helping U.S. physicians and hospitals engage in robust HIE to improve the quality and efficiency of care.

Primary Funding Source: Office of the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services.


Grahic Jump Location
Number of regional health information organizations over time.
Grahic Jump Location




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Write off RHIOs? Wait a minute, not so PCAST...
Posted on May 19, 2011
Leslie A Lenert
University of Utah School of Medicine
Conflict of Interest: None Declared

The article by Adler-Milstein and colleagues on the present state of regional health information exchanges (RHIOs) raises questions about the viability of RHIOs as the cornerstone of the Nationwide Health information Network (NwHIN). The results should not be seen as surprising. The American Response and Recovery Act (ARRA) did not provide moneys to RHIOs, but to states and to "Beacon Communities." While many grantees subsequently worked with or even formed their own RHIOs, the absence of early, direct funding has probably has inhibited RHIOs' ability to keep pace with "meaningful use" related capabilities. Consistent with the results presented in this paper, Office of the National Coordinators's (ONC) 2011 Strategic Plan [1] calls adoption of multifaceted strategy using a combination of direct provider to provider exchange, private health data exchange networks in addition to RHIOs.

While the ONC's multifaceted approach is pragmatic, it raises new issues. Removing RHIOs from the center of the architecture of the NwHIN may impact the physicians' ability to use the NwHIN to quickly locate all the medical records in a region for a patient. This capability, called a record locator service, was one of the driving use cases for RHIO architecture.[2] This capability also supports a wide range of more complex but valuable community-level tasks in health information exchange. [3] In the place of RHIO-based record locator services, a report President's Council of Advisors (PCAST) [4] proposes a new search-engine based architecture for locating patients' health information. The PCAST model was initially embraced by ONC, but has been called impractical many of by ONC's own experts. [5]

The paper by Adler-Milstein and colleagues does show how far RHIOs have to go to fulfill the role for which they were designed. One option that would strengthen RHIOs is to require connectivity for data exchange through these organizations as part of meaningful use. This would provide a business model by allowing RHIOs to charge for government mandated connectivity as if they were public utilities. The benefits of a regional model of information management are clear (3), but the path forward to achieve these benefits is uncertain. Hopefully, in future work, Adler- Milstein and colleagues can chart RHIOs progress on community level health functions as policy makers decide whether this functionality is worth preserving.


1. Office of the National Coordinator, Federal Health Information Technology Strategic Plan 2011 - 2015, Department of Health and Human Services, 2011. p. 15.

2. Greene, J., The trials and tribulations of Health Information Exchange: The Rise of the RHIO. Annals of Emergency Medicine, 2007. 50(5): p. 549- 551.

3. Shapiro, J.S., et al., Using health information exchange to improve public health. Am J Public Health, 2011. 101(4): p. 616-23.

4. President's Council of Advisors on Science and Technology, A Report to the President: Realizing the Full Potential of Health Information Technology to Improve the Healthcare of Americans: The Path Forward., 2010. Washington DC.

5. Guerra, A., Health IT Advisers Blast Data Exchange Policies, in InformationWeek Healthcare (http://www.informationweek.com/news/healthcare/leadership/229400737), 2011.

Conflict of Interest:

None declared

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