OBJECTIVES: To understand how health-related social needs (HRSN) data are collected at US hospitals and implications for use. MATERIALS AND METHODS: Using 2023 nationally representative survey data on US hospitals (N = 2775), we described hospitals' routine and structured collection and use of HRSN data and examined the relationship between methods of data collection and specific uses. Multivariate logistic regression was used to identify characteristics associated with data collection and use and understand how methods of data collection relate to use. RESULTS: In 2023, 88% of hospitals collected HRSN data (64% routinely, 72% structured). While hospitals commonly used data for internal purposes (eg, discharge planning, 79%), those that collected data routinely and in a structured format (58%) used data for purposes involving coordination or exchange with other organizations (eg, making referrals, 74%) at higher rates than hospitals that collected data but not routinely or in a non-structured format (eg, 93% vs 67% for referrals, P< .05). In multivariate regression, routine and structured data collection was positively associated with all uses of data examined. Hospital location, ownership, system-affiliation, value-based care participation, and critical access designation were associated with HRSN data collection, but only system-affiliation was consistently (positively) associated with use. DISCUSSION: While most hospitals screen for social needs, fewer collect data routinely and in a structured format that would facilitate downstream use. Routine and structured data collection was associated with greater use, particularly for secondary purposes. CONCLUSION: Routine and structured screening may result in more actionable data that facilitates use for various purposes that support patient care and improve community and population health, indicating the importance of continuing efforts to increase routine screening and standardize HRSN data collection.

OBJECTIVE: To identify impacts of different survey methodologies assessing primary care physicians' (PCPs') experiences with electronic health records (EHRs), we compared three surveys: the 2022 Continuous Certification Questionnaire (CCQ) from the American Board of Family Medicine, the 2022 University of California San Francisco (UCSF) Physician Health IT Survey, and the 2021 National Electronic Health Records Survey (NEHRS). MATERIALS AND METHODS: We evaluated differences between survey pairs using Rao-Scott corrected chi-square tests, which account for weighting. RESULTS: CCQ received 3991 responses from PCPs (100% response rate), UCSF received 1375 (3.6% response rate), and NEHRS received 858 (18.2% response rate). Substantial, statistically significant differences in demographics were detected across the surveys. CCQ respondents were younger and more likely to work in a health system; NEHRS respondents were more likely to work in private practice; and UCSF respondents disproportionately practiced in larger academic settings. Many EHR experience indicators were similar between CCQ and NEHRS, but CCQ respondents reported higher documentation burden. DISCUSSION: The UCSF approach is unlikely to supply reliable data. Significant demographic differences between CCQ and NEHRS raise response bias concerns, and while there were similarities in some reported EHR experiences, there were important, significant differences. CONCLUSION: Federal EHR policy monitoring and maintenance require reliable data. This test of existing and alternative sources suggest that diversified data sources are necessary to understand physicians' experiences with EHRs and interoperability. Comprehensive surveys administered by specialty boards have the potential to contribute to these efforts, since they are likely to be free of response bias.

OBJECTIVE: The 21st Century Cures Act Final Rule's information blocking provisions, which prohibited practices likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information (EHI), began to apply to a limited set of data elements in April 2021 and expanded to all EHI in October 2022. We sought to describe hospital leaders' perceptions of the prevalence of practices that may constitute information blocking, by actor and hospital characteristics, following the rule's applicability date. MATERIALS AND METHODS: Cross-sectional analysis of a national survey of hospitals fielded in 2021. The analytic sample included 2092 nonfederal acute care hospitals in the United States. We present descriptive statistics on the perception of the prevalence of information blocking and results of multivariate regression models examining the association between hospital, health information technology (IT) developer and market characteristics and the perception of information blocking. RESULTS: Overall, 42% of hospitals reported observing some behavior they perceived to be information blocking. Thirty-six percent of responding hospitals perceived that healthcare providers either sometimes or often engaged in practices that may constitute information blocking, while 17% and 19% perceived that health IT developers (such as EHR developers) and State, regional and/or local health information exchanges did the same, respectively. Prevalence varied by health IT developer market share, hospital for-profit status, and health system market share. CONCLUSIONS AND RELEVANCE: These results support the value of efforts to further reduce friction in the exchange of EHI and support the need for continued observation to provide a sense of the prevalence of information blocking practices and for education and awareness of information blocking regulations.

OBJECTIVE: The aim of this study was to identify racial and ethnic disparities in patient portal offers, access, and use and to examine the role of providers in facilitating access to electronic health information (EHI) by offering patient portals and encouraging their use. MATERIALS AND METHODS: Using nationally representative survey data from 2019 and 2020 (N = 8028), we examined disparities in patients being offered access to a portal by their provider and differences in subsequent access and use. Using multivariable models, we estimated the effect of race and ethnicity on the likelihood of being offered, accessing or using a portal. Among those offered, we examined the relationship between provider encouragement and portal access; and for those who did not access their portal, we explored reasons for nonuse. RESULTS: Black and Hispanic individuals were offered and accessed patient portals at significantly lower rates than White individuals. Compared to Whites, Black and Hispanic individuals were 5.2 percentage-points less likely to be offered a portal (P < .05) and, among those offered, 7.9 percentage-points less likely to access their portal (P < .05). Black and Hispanic individuals who were offered and accessed a portal were 12 percentage-points more likely than Whites to use it to download or transmit information (P < .01). Individuals who were offered a portal and encouraged to use it were 21 percentage-points more likely to access it. DISCUSSION: Differences in patient portal access and use are likely driven by disparities in which groups of patients reported being offered a portal. CONCLUSIONS: Providers play an important role in increasing access to EHI by facilitating access to patient portals.

OBJECTIVES: To assess whether previously observed differences in interoperable exchange by physician practice size persisted in 2019 and identify the role of 3 factors shaping interoperable exchange among physicians in practices of varying sizes: Federal incentive programs designed to encourage health IT use, value-based care, and selection of electronic health record (EHR) developer. MATERIALS: Cross-sectional analysis of a 2019 survey of physicians. We used multivariable Poisson models to estimate the relative risk of interoperable exchange based on the size of the practice accounting for other characteristics and the mediating role of 3 factors. RESULTS: Seventeen percent of solo practice physicians integrated outside data relative to 51% of large practice physicians. This difference remained substantial in initial multivariable models including physician characteristics. When included in models, Federal incentive programs partially mediated the relationship between practice size and interoperable exchange status. In final models including EHR developer, developer was strongly associated with both exchange and integration while practice size was no longer an independent predictor. These trends persisted when comparing practices with 4 or fewer physicians to those with 5 or more. DISCUSSION: Public and private initiatives that increase the benefits of interoperable exchange may encourage small practices to pursue it. Technical and policy changes that reduce the costs and complexity of supporting exchange could make it easier for small developers to advance their capabilities to support small practices. CONCLUSION: Addressing the gap between small and large practices will take a 2-pronged approach that targets both small EHR developers and small practices.

OBJECTIVE: Hospitals have multiple methods available to engage in health information exchange (HIE); however, it is not well understood whether these methods are complements or substitutes. We sought to characterize patterns of adoption of HIE methods and examine the association between these methods and increased availability and use of patient information. MATERIALS AND METHODS: Cross-sectional analysis of 3208 nonfederal acute care hospitals in the 2019 American Hospital Association Information Technology Supplement. RESULTS: The median hospital obtained outside information through 4 methods. Hospitals that obtained data through a regional HIE organization were 2.2 times more likely to also obtain data via Direct using a health information service provider (HISP) than hospitals that did not (P < .001). Hospitals in a single electronic health record (EHR) vendor network were no more or less likely to participate in a HISP or HIE. Six of 7 methods were associated with greater information availability. Only 4 of 7 methods (portals, interfaces, single vendor networks and multi-vendor networks but not access to outside EHR, regional exchange or Direct using a HISP) were associated with more frequent use of information, and single vendor networks were most strongly associated with more frequent use (odds ratio = 4.7, P < .001). DISCUSSION: Adoption of some methods was correlated, indicating complementary use. Few methods were negatively correlated, indicating limited competition. Although information availability was common, low correlation with use indicated that challenges related to integration may be slowing use of information. CONCLUSION: Complementarities between methods, and the role of integration in supporting information use, indicate the potential value of efforts aimed at ensuring exchange methods work well together, such as the Trusted Exchange Framework and Common Agreement.

OBJECTIVE: To understand hospitals' use of EHR audit-log-based measures to address burden associated with inpatient EHR use. MATERIALS AND METHODS: Using mixed methods, we analyzed 2018 American Hospital Association Information Technology Supplement Survey data (n = 2864 hospitals; 64% response rate) to characterize measures used and provided by EHR vendors to track clinician time spent documenting. We interviewed staff from the top 3 EHR vendors that provided these measures. Multivariable analyses identified variation in use of the measures among hospitals with these 3 vendors. RESULTS: 53% of hospitals reported using EHR data to track clinician time documenting, compared to 68% of the hospitals using the EHR from the top 3 vendors. Among hospitals with EHRs from these vendors, usage was significantly lower among rural hospitals and independent hospitals (P < .05). Two of these vendors provided measures of time spent doing specific tasks while the third measured an aggregate of auditable activities. Vendors varied in the underlying data used to create measures, measure specification, and data displays. DISCUSSION: Tools to track clinicians' documentation time are becoming more available. The measures provided differ across vendors and disparities in use exist across hospitals. Increasing the specificity of standards underlying the data would support a common set of core measures making these measures more widely available. CONCLUSION: Although half of US hospitals use measures of time spent in the EHR derived from EHR generated data, work remains to make such measures and analyses more broadly available to all hospitals and to increase its utility for national burden measurement.

OBJECTIVE: Recent policy making aims to prevent health systems, lectronic health record (EHR) vendors, and others from blocking the electronic sharing of patient data necessary for clinical care. We sought to assess the prevalence of information blocking prior to enforcement of these rules. MATERIALS AND METHODS: We conducted a national survey of health information exchange organizations (HIEs) to measure the prevalence of information blocking behaviors observed by these third-party entities. Eighty-nine of 106 HIEs (84%) meeting the inclusion criteria responded. RESULTS: The majority (55%) of HIEs reported that EHR vendors at least sometimes engage in information blocking, while 30% of HIEs reported the same for health systems. The most common type of information blocking behavior EHR vendors engaged in was setting unreasonably high prices, which 42% of HIEs reported routinely observing. The most common type of information blocking behavior health systems engaged in was refusing to share information, which 14% of HIEs reported routinely observing. Reported levels of vendor information blocking was correlated with regional competition among vendors and information blocking was concentrated in some geographic regions. DISCUSSION: Our findings are consistent with early reports, revealing persistently high levels of information blocking and important variation by actor, type of behavior, and geography. These trends reflect the observations and experiences of HIEs and their potential biases. Nevertheless, these data serve as a baseline against which to measure the impact of new regulations and to inform policy makers about the most common types of information blocking behaviors. CONCLUSION: Enforcement aimed at reducing information blocking should consider variation in prevalence and how to most effectively target efforts.

OBJECTIVE: While most hospitals have adopted electronic health records (EHRs), we know little about whether hospitals use EHRs in advanced ways that are critical to improving outcomes, and whether hospitals with fewer resources - small, rural, safety-net - are keeping up. MATERIALS AND METHODS: Using 2008-2015 American Hospital Association Information Technology Supplement survey data, we measured "basic" and "comprehensive" EHR adoption among hospitals to provide the latest national numbers. We then used new supplement questions to assess advanced use of EHRs and EHR data for performance measurement and patient engagement functions. To assess a digital "advanced use" divide, we ran logistic regression models to identify hospital characteristics associated with high adoption in each advanced use domain. RESULTS: We found that 80.5% of hospitals adopted at least a basic EHR system, a 5.3 percentage point increase from 2014. Only 37.5% of hospitals adopted at least 8 (of 10) EHR data for performance measurement functions, and 41.7% of hospitals adopted at least 8 (of 10) patient engagement functions. Critical access hospitals were less likely to have adopted at least 8 performance measurement functions (odds ratio [OR] = 0.58; P < .001) and at least 8 patient engagement functions (OR = 0.68; P = 0.02). DISCUSSION: While the Health Information Technology for Economic and Clinical Health Act resulted in widespread hospital EHR adoption, use of advanced EHR functions lags and a digital divide appears to be emerging, with critical-access hospitals in particular lagging behind. This is concerning, because EHR-enabled performance measurement and patient engagement are key contributors to improving hospital performance. CONCLUSION: Hospital EHR adoption is widespread and many hospitals are using EHRs to support performance measurement and patient engagement. However, this is not happening across all hospitals.

OBJECTIVE: Our objective was to characterize physicians' participation in delivery and payment reform programs over time and describe how participants in these programs were using health information technology (IT) to coordinate care, engage patients, manage patient populations, and improve quality. MATERIALS AND METHODS: A nationally representative cohort of physicians was surveyed in 2012 (unweighted N = 2567) and 2013 (unweighted N = 2399). Regression analyses used those survey responses to identify associations between health IT use and participation in and attrition from patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and pay-for-performance programs (P4Ps). RESULTS: In 2013, 45% of physicians participated in PCMHs, ACOs, or P4Ps. While participation in each program increased (P < .05) between 2012 and 2013, program attrition ranged from 31-40%. Health IT use was associated with greater program participation (RR = 1.07-1.16). PCMH, ACO, and P4P participants were more likely than nonparticipants to perform quality improvement and patient engagement activities electronically (RR = 1.09-1.14); only ACO participants were more likely to share information electronically (RR = 1.07-1.09). DISCUSSION: Participation in delivery and payment reform programs increased between 2012 and 2013. Participating physicians were more likely to use health IT. There was significant attrition from and switching between PCMHs, ACOs, and P4Ps. CONCLUSION: This work provides the basis for understanding physician participation in and attrition from delivery and payment reform programs, as well as how health IT was used to support those programs. Understanding health IT use by program participants may help to identify factors enabling a smooth transition to alternative payment models.

BACKGROUND: Providing patients with access to their medical data is widely expected to help educate and empower them to manage their own health. Health information exchange (HIE) infrastructures could potentially help patients access records across multiple healthcare providers. We studied three HIE organizations as they developed portals to give consumers access to HIE data previously exchanged only among healthcare organizations. OBJECTIVE: To follow the development of new consumer portal technologies, and to identify barriers and facilitators to patient access to HIE data. METHODS: Semistructured interviews of 15 key informants over a 2-year period spanning the development and early implementation of three new projects, coded according to a sociotechnical framework. RESULTS: As the organizations tried to develop functionality that fully served the needs of both providers and patients, plans were altered by technical barriers (primarily related to data standardization) and cultural and legal issues surrounding data access. Organizational changes also played an important role in altering project plans. In all three cases, patient access to data was significantly scaled back from initial plans. CONCLUSIONS: This prospective study revealed how sociotechnical factors previously identified as important in health information technology success and failure helped to shape the evolution of three novel consumer informatics projects. Barriers to providing patients with seamless access to their HIE data were multifactorial. Remedies will have to address technical, organizational, cultural, and other factors.

Implementing health information technology (IT) at the community level is a national priority to help improve healthcare quality, safety, and efficiency. However, community-based organizations implementing health IT may not have expertise in evaluation. This study describes lessons learned from experience as a multi-institutional academic collaborative established to provide independent evaluation of community-based health IT initiatives. The authors' experience derived from adapting the principles of community-based participatory research to the field of health IT. To assist other researchers, the lessons learned under four themes are presented: (A) the structure of the partnership between academic investigators and the community; (B) communication issues; (C) the relationship between implementation timing and evaluation studies; and (D) study methodology. These lessons represent practical recommendations for researchers interested in pursuing similar collaborations.