A fragmented EHR market is fueling interoperability divide, says ONC study

A recent study from researchers from the Office of the National Coordinator for Health IT found substantial differences between large practice physicians and solo practice physicians when it comes to outside data integration.  

“Whereas patients treated by large, integrated practices may receive all care within the organization, patients of small practice physicians are likely to receive care from physicians or healthcare organizations outside of the small practice,” wrote ONC’s Dr. Jordan Everson, Wesley Barker and Vaishali Patel in the study published this past Wednesday in the Journal of the American Medical Informatics Association.   

“Physicians in small practices may, therefore, need to rely on interoperable technology to a greater extent to receive important clinical information in a timely and useable manner,” said Everson, Barker and Patel.  

“Despite this potential value, small practice and independent physicians have been observed to adopt EHRs and engage in interoperable exchange at lower rates than other physicians,” the research team continued.  


For this study, Everson, Barker and Patel sought to investigate whether various factors, such as federal incentive programs, value-based care participation and electronic health record developer market segmentation, affect the varying rate of interoperable exchange by physicians.  

Using data from the 2019 National Electronic Health Record Survey, they measured whether physicians were engaged in the electronic exchange of patient health information with outside healthcare organizations.  

They found that while 65% of physicians were able to electronically send, receive or query for information from outside sources, 29% were able to integrate information into the EHR.   

Overall, 58% of physicians indicated participating in a federal incentive program and 49%  said they participated in VBC. 

And 42% of physicians used an EHR from one of the five market-leading developers, meaning Epic, Cerner, athenahealth, eClincalWorks and Allscripts; while 21% of physicians used an EHR from the sixth to 10th market-leading developers, meaning NextGen, Practice Fusion, Greenway, GE and Modernizing Medicine; and 27% used a different vendor.   

The researchers found “substantial variation” in data exchange capabilities based on practice size.    

Nearly half, or 44%, of solo practitioners were able to send, receive or query for information, compared to 71% of physicians in practices of four to 10 physicians and 76% of physicians in practices of more than 50 physicians.  

Integrating that data also varied by size: 17% of solo practitioners said they were able to do so, compared to 30% of physicians in practices of four to 10 physicians, and 51% of physicians in practices of greater than 50 physicians.  

“We found that the federal incentive program and VBC participation played a modest role in explaining the differences in interoperable exchange status by practice size, while the EHR developer used was a key determinant,” said the researchers.  

In other words, they said, “we found that physicians in practices of different sizes used EHRs from different developers, and this choice appears to be an important reason for differences in exchange and integration capabilities across practice sizes.”  

This difference in capabilities, they said, could lead to unequal benefits from information exchange.  

Researchers theorized that small practices could lack the means to select a developer with more robust interoperability features; that they may lack the ability to easily compare which developers support interoperability; or that they may have prioritized other features of the EHR.  

“More support for small practices, such as targeted financial incentives and technical support, may be needed to encourage the use of certified EHRs with more advanced interoperable exchange capabilities,” said the research team.  

They noted the potential for TEFCA to enable information exchange more easily.  

“Small developers that might otherwise need to set up one-to-one interfaces to connect their customers to their exchange partners can enable their customers to join a single network through TEFCA to exchange data,” they said.   

“Increased participation in such networks could also increase the value of interoperability since the size of networks is thought to dramatically increase their value,” they added.  


The go-live of TEFCA in early 2022 provoked a frisson of excitement in the health IT world, given its potential to introduce, as Carequality’s then-Executive Director Dave Cassell put it in 2020, “a new exchange paradigm.”  

Health IT leaders echoed that excitement at HIMSS22 in Florida this past month, with ONC National Coordinator Micky Tripathi saying the framework could enable a “North Star” architecture for public health.  


“Public and private initiatives that increase the benefits and reduce the costs of facilitating interoperable exchange may … encourage small practices to pursue interoperable exchange while making it easier for small developers to advance their support,” wrote Everson, Barker and Patel.

Kat Jercich is senior editor of Healthcare IT News.
Twitter: @kjercich
Email: [email protected]
Healthcare IT News is a HIMSS Media publication.

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