HIE promises to provide clinicians with accurate, real-time patient information from geographically disparate locations to inform clinical-decision making. In this statewide study, we found that physicians' attitudes toward HIE were, overall, very positive. Across a range of practice characteristics, physicians agreed that HIE would have positive effects on reducing healthcare costs, increasing quality, and saving clinician time. Even when there were differences between kinds of providers (specialists vs PCPs, small vs large practices, and EHR users vs non-users), between 60% and 99% of all subgroups had positive attitudes toward HIE.
We found that physicians in medium-sized practices had the most positive attitudes toward HIE, while physicians in large and small practices had comparable attitudes. It may be the case that physicians in the largest practices already receive some of the benefits of HIE because the patients they treat mainly see other providers within the same practice, so the benefit of access to outside data may not be as strong. Likewise, PCPs reported more positive attitudes than specialists. This is likely attributable to the nature of the relationship between the types of providers and their patients. PCPs provide ongoing care to patients and may interact with many specialists in the treatment of a single patient. Specialists often provide more episodic care to patients, and likely interact mainly with a single other provider (the PCP) in the management of these patients.
While privacy and security were of concern to a larger fraction of physicians than any other issue, most physicians did not report major concerns. In contrast, this has been a major issue for general practitioners in the UK, at least in part because of well-publicized breaches,14
but perhaps also because HIE has been perceived as mandatory.15
There have already been notable breaches in the USA as well,16
and one might expect that any future more extensive breaches might increase privacy concerns in the USA. Similarly, relatively small numbers of physicians expressed concern that HIE would generate additional costs to the healthcare system.
Despite their positive attitudes toward HIE, clinicians expressed very limited willingness to pay for HIE. Just over half of clinicians said they would be willing to pay a monthly subscription fee, but when the fee was specified at $150 per month, only 37% of clinicians said they would pay it. Although PCPs and advanced EHR users were more willing than others to pay the $150 fee, still fewer than half of the physicians in these groups were willing to pay this amount. Even those providers with positive attitudes toward HIE were unwilling to pay a $150 monthly fee. The discordance between positive attitudes toward HIE and unwillingness to pay for it is reminiscent of physicians' positive attitudes toward EHRs but their lack of willingness to pay for them.12
The financial benefits of HIE to society have been estimated to be large.18
In one study by the Center for Information Technology Leadership (CITL), these benefits have been predicted to accrue in part to providers (43%), and also to payers and purchasers (28%) as well as to other stakeholders such as laboratories and pharmacies (29%). The 43% figure may overestimate the actual benefits to physicians, because CITL included both physicians and hospitals in their provider category, and assumed that a fairly broad array of services would be provided through HIE. The predominant business model for HIE is financial support through subscription fees. These fees are expected to come from a mix of physicians, hospitals, and payers, though all these stakeholders have reservations.
Our study has several limitations. First, many, if not most, of the physicians in our sample have never used HIE, and attitudes of non-users toward a hypothetical model for HIE may differ from attitudes of physicians who have used HIE. However, at present, because there are so few HIOs delivering HIE services in production, most physicians are making the decision as to whether or not to participate in HIE for the first time and without the benefit of prior experience. Second, as noted in our methods, our survey was limited to a single state, which may limit the generalizability of our results. Third, our survey looked only at a single specified price point and a single basic definition of HIE, and did not give respondents an opportunity to provide more granular feedback on pricing and features.
Our results have fundamental implications for current and potential organizers of HIEs. First, any HIE business model that depends on physicians in the community paying a monthly fee is likely to face significant hurdles, particularly if the fee is equal to or greater than $150 per month (not that different from cell phone or cable fees). Given the worsened economic situation since the time of the 2007 survey, physicians are likely even less willing to pay for this functionality. The converse implication, however, is that since providers generally have favorable attitudes toward HIE, gaining their participation in well designed and well operated HIOs that do not charge a fee should be feasible, although a variety of other factors (such as provider trust in the organizing entity and technical difficulty of participation) may also affect willingness to participate.