Hospital data exchange rose from 46% of hospitals in 2018 to 70% in 2023. Payment reform did not drive that gain. And most of the data that now moves is not used: 71% of hospitals have outside records available at the point of care, but only 42% of clinicians routinely use them.
Hospital data exchange rose from 46% of hospitals in 2018 to 70% in 2023, according to federal survey data from the Office of the National Coordinator (now ASTP). That is real progress after years of a flat line. The gain covers all four domains of interoperability: finding, sending, receiving, and integrating outside records.
Two things complicate it. Payment reform did not produce the gain. And most of the data that now moves is not used: 71% of hospitals have the necessary outside clinical information available at the point of care, but only 42% of clinicians routinely use it.
Interoperability, the ability of separate organizations to exchange and use each other’s patient data, is a precondition for value-based care. An organization paid to manage the total cost of a population cannot manage care it cannot see. So how interoperability improved, and where it still fails, matters directly.
Payment reform did not produce interoperability
The intuitive theory was that putting providers at financial risk would create demand for data, and interoperability would follow. Congress set 2018 as the target for nationwide interoperability.
A study in JAMA Health Forum tested that theory across 3,928 hospitals from 2014 to 2018. Participating in an alternative payment model, such as an accountable care organization, was associated with a 1 percentage point change in interoperability engagement, which was not statistically significant (95% CI, -0.01 to 0.03). By 2018, just 45.4% of hospitals (1,249 hospitals) engaged in all four domains. Most could send records (88.3%) and receive them (76.9%), but fewer than half could do all four things that make exchange useful. The most commonly cited barrier was sharing data across different electronic health record vendors.
The authors concluded that building a nationally interoperable system “requires more than aligning financial incentives through voluntary payment reform.”
Standards and governance moved it instead
The 2018-to-2023 gain arrived alongside a different set of levers: national data standards, information blocking rules, and a federal exchange framework.
The Trusted Exchange Framework and Common Agreement (TEFCA) began operating in December 2023, when the first Qualified Health Information Networks were designated. Eleven such networks have since been designated. Federal regulators have logged 2,124 possible claims of information blocking since the rules took effect in April 2021, as of May 2026. These are complaints received, not violations substantiated.
The gains are real but bounded
Where exchange happens, it helps. A systematic review in the Journal of the American Medical Informatics Association found that among the studies rigorous enough to support causal inference, 7 of 24 reported benefits and none reported harms: fewer duplicated procedures, less repeat imaging, lower costs, and improved safety. Community-based exchanges, which serve all the patients in a region, outperformed exchanges built around a single vendor’s customers.
The benefits are narrower than the rhetoric suggests. An AHRQ review of 136 studies found no evidence that exchange improves mortality or morbidity, and rated the supporting evidence as low quality. What interoperability reliably buys is avoided waste: the scan already done, the lab drawn twice. That is worth having for an organization accountable for total cost of care. It is not the same as saving lives.
The data arrives and goes unused
The largest remaining gap is between having data and using it. In 2023, 71% of hospitals routinely had outside clinical information available at the point of care. Only 42% of clinicians often used it.
Frequency explains much of the gap. Only 43% of hospitals exchanged data routinely in 2023; 27% did so only sometimes, and 30% not at all. Among hospitals that exchanged routinely, 70% of clinicians often used outside information. Among those that exchanged only sometimes, 26% did. A connection used occasionally is close to a connection not used, because a clinician who cannot rely on the data being there stops looking for it.
The remaining barriers are not motivational. A systematic review of what blocks exchange found the recurring problems were incomplete patient information, workflow that does not accommodate the exchange, and data that did not meet the needs of the clinicians meant to use it. These are technical and governance problems, which is why financial incentives alone did not solve them.
The weakest links are post-acute and behavioral health
Exchange follows the shape of the acute care system and thins out at its edges. Hospitals send summary of care records to most or all long-term and post-acute care providers only 16% of the time, and to behavioral health providers 17% of the time. Receiving is worse than sending: hospitals get records back from post-acute providers at 8%, half the rate at which they send.
Post-acute care is where episode spending is won or lost, and behavioral health is where much avoidable utilization begins. An accountable care organization can see the hospital admission and remain nearly blind to the skilled nursing facility that follows it.
Who is left behind
The gains are uneven. Among system-affiliated hospitals, 53% exchanged data routinely in 2023. Among independent hospitals, 22% did, and 55% were not fully interoperable at all. About two in five rural and critical access hospitals were not fully interoperable.
A related 2025 study found that 61.4% of hospitals (about 1,536 of 2,502) received health-related social needs data electronically, but that for-profit and public hospitals were less likely to do so, while hospitals in accountable care organizations were more likely. The organizations least able to see their patients’ care elsewhere are often the ones serving the most complex patients. As risk adjustment shows, providers who cannot see care cannot document it, and under-documentation makes them look inefficient when they are only under-informed.
What this means for value-based care
Interoperability is not a downstream benefit of payment reform. It responded to standards, governance, and vendor accountability, not to financial pressure, and value-based models should be designed on the assumption that data friction exists rather than assuming participation will dissolve it. A model that assumes an organization can see its patients’ post-acute or behavioral health care is, for most organizations today, assuming something untrue.
One caveat bounds all of this. The strongest usage data runs through 2023, which predates TEFCA’s operation. Whether the framework, the information blocking rules, and maturing standards move clinician use and reach the weakest handoffs is an open question, and the right one to track. What the evidence establishes so far is narrower but useful: the plumbing is largely built, the money did not build it, and having the data is not the same as using it.
Sources
- Gabriel MH, Richwine C, Strawley C, et al. Interoperable Exchange of Patient Health Information Among U.S. Hospitals: 2023. ONC Data Brief No. 71. Office of the National Coordinator for Health Information Technology; May 2024. healthit.gov (opens in a new tab)
- Holmgren AJ, Everson J, Adler-Milstein J. Association of Hospital Interoperable Data Sharing With Alternative Payment Model Participation. JAMA Health Forum. 2022;3(2):e215199. doi:10.1001/jamahealthforum.2021.5199 (opens in a new tab)
- Trusted Exchange Framework and Common Agreement (TEFCA). Office of the National Coordinator for Health Information Technology. healthit.gov (opens in a new tab)
- Designated QHINs. The Sequoia Project, Recognized Coordinating Entity. rce.sequoiaproject.org (opens in a new tab)
- Menachemi N, Rahurkar S, Harle CA, et al. The benefits of health information exchange: an updated systematic review. Journal of the American Medical Informatics Association. 2018;25(9):1259-1265. doi:10.1093/jamia/ocy035 (opens in a new tab)
- Hersh W, Totten A, Eden K, et al. Health Information Exchange. Evidence Report/Technology Assessment. 2015;(220):1-465. doi:10.23970/AHRQEPCERTA220 (opens in a new tab)
- Eden KB, Totten AM, Kassakian SZ, et al. Barriers and facilitators to exchanging health information: a systematic review. International Journal of Medical Informatics. 2016;88:44-51. doi:10.1016/j.ijmedinf.2016.01.004 (opens in a new tab)
- Sandhu S, Liu M, Gottlieb LM, et al. Interoperability of health-related social needs data at US hospitals. Journal of the American Medical Informatics Association. 2025;32(5):914-919. doi:10.1093/jamia/ocaf049 (opens in a new tab)