Regional Health Information Organizations Research Articles

Detection of Recurrent Hepatitis C Viremia Using Surveillance Data, New York City.

The introduction of direct-acting antivirals for treating hepatitis C virus (HCV) infection has greatly improved cure rates. However, persons with past HCV infection who engage in high-risk behaviors can be reinfected. Surveillance data from the New York City (NYC) Health Department were used to detect and investigate individuals cured during January 2014 to December 2016 who had a subsequent positive RNA test (recurrence) by April 2018. Clinical interpretation of recurrence was obtained using provider interviews and review of medical records available through Regional Health Information Organizations. Among 6938 cured individuals, 209 recurrence events were detected (2.7 per 100 person-years). Investigations were completed for 62 (30%) events. Of 38 investigated events occurring less than 12 months postcure, 17 (45%) were relapses; of 24 events occurring 12 or more months postcure, only one (4%) was a relapse. Understanding the timing, frequency, and clinical interpretation of HCV recurrence will guide HCV prevention and elimination efforts for NYC.

Validation of a surveillance-based definition for hepatitis B treatment eligibility.

ObjectiveTo assess the accuracy of a surveillance-based definition for hepatitis B treatment eligibility among New York City residents with chronic hepatitis B infection.IntroductionApproximately 100,000 New York City (NYC) residents are currently diagnosed with chronic hepatitis B virus (HBV) infection.1 Routine monitoring and treatment, where indicated, are necessary to reduce HBV disease progression. Using the 2017 European Association for the Study of the Liver (EASL) 2 guidelines on HBV infection management, we developed a surveillance-based definition for treatment eligibility. Validation of this definition will support the creation of a population-level HBV care continuum, which will allow us to monitor gaps from HBV diagnosis to viral suppression and to develop public health interventions to address these gaps.MethodsLaboratories everywhere are required to electronically report the following HBV tests to the NYC Department of Health and Mental Hygiene (DOHMH) for all NYC residents: positive and negative (as of April 2018) DNA, positive surface antigen, positive e antigen, positive core IgM, and Alanine aminotransferase (ALT) (when ordered at the same time as another reportable HBV test). Using reportable HBV tests, treatment eligibility was defined as ever having an HBV DNA result >2000 IU/mL and ALT>40 U/L. We assessed the accuracy of the surveillance-based definition by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) by applying the definition to the test data of people participating in two DOHMH programs that included clinical information on treatment eligibility: the Enhanced Surveillance Project (provider interviews conducted for 300 randomly selected patients with chronic HBV) and the Check Hep B Patient Navigation Program (program providing HBV-related patient navigation at community organizations, health centers, and hospitals). Everyone meeting inclusion criteria in the Enhanced Surveillance Project who were also identified as being in care and being monitored (two or more HBV DNA results reported at any time) were included in our analysis. For Check Hep B, we included everyone enrolled prior December 31, 2017 who also met our criteria of being in care and being monitored. To determine treatment eligibility using surveillance data, we used all HBV DNA and ALT results reported prior to January 31st, 2016 for the Enhanced Surveillance project and prior to December 31st, 2017 for Check Hep B.ResultsTreatment eligibility was 62.0% (145/234) among people from the Enhanced Surveillance Project (Table 1A) and 40.0% (161/402) among people enrolled in Check Hep B (Table 1B). Sensitivity of the surveillance-based definition was low using both data sources (Enhanced Surveillance Project: 26.2%; Check Hep B: 24.2%) and specificity high (Enhanced Surveillance Project: 92.1%; Check Hep B: 94.2%). PPV was 84.4% and 73.6% for the Enhanced Surveillance project and Check Hep B, respectively, while NPV was 43.4% and 65.0% for the Enhanced Surveillance project and Check Hep B respectively.ConclusionsOur surveillance-based definition had high specificity, indicating that the great majority of patients who were truly not treatment-eligible were correctly classified. However, sensitivity was low, indicating that the surveillance-based definition was unable to accurately identify those considered treatment-eligible from either data source. Low sensitivity suggests that clinicians are likely using other clinical factors not included in laboratory-based reporting to assess a patient’s eligibility for treatment, such as fibrosis and cirrhosis, and that clinicians might be using guidelines other than EASL (e.g., American Association for the Study of Liver Diseases (AASLD)3) to determine treatment eligibility. We will conduct chart reviews to better understand the variability in criteria being used. These chart reviews will allow us to further refine our surveillance-based definition (e.g., by incorporating different HBV tests or for clinical criteria that are not laboratory-based, including information from external sources such as Regional Health Information Organizations (RHIOs)), eventually supporting the creation of an HBV care continuum for NYC.

Sustainability strategies for regional health information organization startups

ObjectivesSimilar to other Western healthcare systems, the U.S. has sought to build a national infrastructure to enable widespread electronic health information exchange (HIE). The 2009 U.S. HITECH Act׳s State HIE Cooperative Agreement Program (SHIECAP) was a short-term catalyst for bottom-up HIE initiatives by states and regional health information organizations (HIOs). Given the high failure rates of regional U.S. HIOs in the past, our primary objective is to identify the key characteristics of HIO startups that became operational and demonstrated sustainability with non-renewable SHIECAP funding in a state environment with very minimal prior HIE activities. MethodsBased on interview data we collected from 22 stakeholders in New Jersey (NJ) at the state, HIO, and hospital levels, we apply grounded theory techniques to identify cross-case similarities and differences. ResultsAlthough the three NJ HIOs that became operational during the SHIECAP grant period faced similar startup challenges, the two HIOs that demonstrated sustainability pursued distinct technology and sustainability strategies to develop HIE capabilities to fit their very different regional needs: an HIE capability to improve the population health of an underserved urban population, and an HIE capability to enable the transition to a healthcare landscape that rewards care coordination across suburban hospitals and physician practices. ConclusionsWe propose two models of technology and sustainability strategies for developing bottom-up HIE capabilities for different regional populations. Future research within and beyond U.S. contexts needs to take into account these key characteristics to improve our understanding of effective policy levers and government funding mechanisms.

Enhancing a geriatric emergency department care coordination intervention using automated health information exchange-based clinical event notifications.

Purpose:In a health care system where patients often have numerous providers and multiple chronic medical conditions, interoperability of health information technology (HIT) is of paramount importance. Regional health information organizations (RHIO) often provide a health information exchange (HIE) as a solution, which gives stakeholders access to clinical data that they otherwise would not otherwise have. A secondary use of preexisting HIE infrastructure is clinical event notification (CEN) services, which send automated notifications to stakeholders. This paper describes the development and implementation of a CEN service enabled by a RHIO in the New York metropolitan area to improve care coordination for patients enrolled in a geriatric emergency department care coordination program.Innovation:This operational CEN system incorporates several innovations that to our knowledge have not been implemented previously. They include the near real-time notifications and the delivery of notifications via multiple pathways: electronic health record (EHR) “in-baskets,” email, text message to internet protocol-based “zone” phones, and automated encounter entry into the EHR. Based on these alerts the geriatric care coordination team contacts the facility where the patient is being seen and offers additional information or assistance with disposition planning with the goal of decreasing potentially avoidable admissions and duplicate testing.Findings:During the nearly one-year study period, the CEN program enrolled 5722 patients and sent 497 unique notifications regarding 206 patients. Of these notifications, 219 (44%) were for emergency department (ED) visits; 121 (55%) of those notifications were received during normal business hours when the care coordination team was available to contact the ED where the patient was receiving care. Hospital admissions resulted from 45% of ED visits 17.8% of these admissions lasted 48 hours or less, suggesting some might potentially be avoidable.Conclusions and Discussion:This study demonstrates the potential of CEN systems to improve care coordination by notifying providers of the occurrence of specific events. Although it could not directly be demonstrated here, we believe that widespread use of CEN systems have potential to reduce potentially avoidable admissions and duplicate testing, likely leading to decreased costs.

Implementing health information exchange for public health reporting: a comparison of decision and risk management of three regional health information organizations in New York state

Health information exchange (HIE) is a significant component of healthcare transformation strategies at both the state and national levels. HIE is expected to improve care coordination, and advance public health, but implementation is massively complex and involves significant risk. In New York, three regional health information organizations (RHIOs) implemented an HIE use case for public health reporting by demonstrating capability to deliver accurate responses to electronic queries via a set of services called the Universal Public Health Node. We investigated process and outcomes of the implementation with a comparative case study. Qualitative analysis was structured around a decision and risk matrix. Although each RHIO had a unique operational model, two common factors influenced risk management and implementation success: leadership capable of agile decision-making and commitment to a strong organizational vision. While all three RHIOs achieved certification for the public health reporting, only one has elected to deploy a production version.

Why common carrier and network neutrality principles apply to the Nationwide Health Information Network (NWHIN)

The Office of the National Coordinator will be defining the architecture of the Nationwide Health Information Network (NWHIN) together with the proposed HealtheWay public/private partnership as a development and funding strategy. There are a number of open questions—for example, what is the best way to realize the benefits of health information exchange? How valuable are regional health information organizations in comparison with a more direct approach? What is the role of the carriers in delivering this service? The NWHIN is to exist for the public good, and thus shares many traits of the common law notion of ‘common carriage’ or ‘public calling,’ the modern term for which is network neutrality. Recent policy debates in Congress and resulting potential regulation have implications for key stakeholders within healthcare that use or provide services, and for those who exchange information. To date, there has been little policy debate or discussion about the implications of a neutral NWHIN. This paper frames the discussion for future policy debate in healthcare by providing a brief education and summary of the modern version of common carriage, of the key stakeholder positions in healthcare, and of the potential implications of the network neutrality debate within healthcare.

Hospital Electronic Health Information Exchange Grew Substantially In 2008–12

Electronic health information exchange can improve care coordination for patients by enabling more timely and complete sharing of clinical information among providers and hospitals. Approaches to health information exchange have expanded in recent years with the growth in entities such as regional health information organizations (HIOs) and the increased adoption of electronic health record (EHR) systems. However, little is known about the extent of exchange activity in US hospitals. Using national surveys of hospitals, we found that between 2008 and 2012, hospitals' electronic exchange of health information with other providers increased significantly, regardless of provider type, organizational affiliation, or type of clinical information. In 2012 nearly six in ten hospitals actively exchanged electronic health information with providers and hospitals outside their organization, an increase of 41percent since 2008. EHR adoption and HIO participation were associated with significantly greater hospital exchange activity, but exchanges with providers outside the organization and exchanges of clinical care summaries and medication lists remained limited. New and ongoing policy initiatives and payment reforms may accelerate the electronic exchange of health information by creating new data exchange options, defining standards for interoperability, and creating payment incentives for information sharing across organizational boundaries.

A system dynamics evaluation model: implementation of health information exchange for public health reporting

To evaluate the complex dynamics involved in implementing electronic health information exchange (HIE) for public health reporting at a state health department, and to identify policy implications to inform similar implementations. Qualitative data were collected over 8 months from seven experts at New York State Department of Health who implemented web services and protocols for querying, receipt, and validation of electronic data supplied by regional health information organizations. Extensive project documentation was also collected. During group meetings experts described the implementation process and created reference modes and causal diagrams that the evaluation team used to build a preliminary model. System dynamics modeling techniques were applied iteratively to build causal loop diagrams representing the implementation. The diagrams were validated iteratively by individual experts followed by group review online, and through confirmatory review of documents and artifacts. Three casual loop diagrams captured well-recognized system dynamics: Sliding Goals, Project Rework, and Maturity of Resources. The findings were associated with specific policies that address funding, leadership, ensuring expertise, planning for rework, communication, and timeline management. This evaluation illustrates the value of a qualitative approach to system dynamics modeling. As a tool for strategic thinking on complicated and intense processes, qualitative models can be produced with fewer resources than a full simulation, yet still provide insights that are timely and relevant. System dynamics techniques clarified endogenous and exogenous factors at play in a highly complex technology implementation, which may inform other states engaged in implementing HIE supported by federal Health Information Technology for Economic and Clinical Health (HITECH) legislation.

Sharing Clinical Data Electronically

THE UNITED STATES IS UNDERTAKING AN AMBITIOUS EFfort to wire the health care system. The goal is to build a nationwide information infrastructure to serve as the foundation for large and sustained improvements in performance. Widespread adoption of health information technology will support new care delivery models, such as patient-centered medical homes, alongside broader initiatives, such as performance reporting and public health surveillance. To enable the health information technology revolution, Congress allocated nearly $30 billion focused on 2 main goals: transitioning physicians and hospitals from paper-based to electronic systems and enabling these systems to interoperate, allowing clinical data to flow between health care organizations. The vision of complete patient information available across care delivery settings is compelling and central to a highfunctioning health care system. However, the vision is deceptively simple: there are enormous challenges to enabling clinical data to flow across organizations. These challenges are substantially greater than those associated with transitioning physicians and hospitals to electronic health records. Health information exchange (HIE) is the act of sharing clinical data among health care practitioners and practice settings (physicians, hospitals, nursing homes, etc) who are not part of the same organizational entity. Although most electronic health records make clinical data sharing within the same organization relatively easy, sharing across organizations is difficult. Before passage of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, policy makers primarily focused on regional health information organizations (RHIOs) to promote HIE. RHIOs brought together physicians, hospitals, and other health care stakeholders in the local community to establish core principles for how they could exchange data with each other. Despite substantial funding from state and federal governments, these organizations have made slow progress in enabling broad exchange and finding sustainable business models. Under HITECH, policy makers are pursuing a more flexible multipronged approach to HIE. First, they included the ability to engage in HIE (ie, share clinical data electronically with others) in the criterion for “meaningful use,” the federal standard for incentives to health care practitioners and hospitals for using an electronic health record. In the future, meaningful use will likely require that clinicians actually engage in HIE, not just demonstrate the ability. Part of the motivation for beginning with less stringent requirements is that even for clinicians and health care organizations with an electronic health record, there are few accessible, affordable options for sending and receiving data electronically across organizations. Therefore, a second part of the federal approach is to engage states in creating such options. In 2010, the US Department of Health and Human Services awarded more than $548 million through the State HIE Cooperative Agreement Program. Over the 4-year program period, states are responsible for ensuring adequate infrastructure to allow for sharing clinical data across care settings. States are in the early stages of implementing their plans and are pursuing a variety of strategies. A third facet of the federal approach is to promote the Direct Project, a set of services that rely on the Internet to securely push data from one authorized user to another. The Direct Project essentially operates like an e-mail inbox, with added security and authorization, and is a relatively simple and inexpensive approach to HIE. The long-term plan is to evolve from clinicians pushing data (ie, sending an e-mail) to searching for individual patients and retrieving their data, with the hope that HIE will be seamless and will require little work by the clinician to search for information outside of the electronic health record. Whether these efforts will successfully result in broadbased HIE is unclear. According to Blumenthal, the Obama Administration’s former point person on health information technology, HIE is one of the “major challenges in delivering on the ambitious agenda of the HITECH Act.” There are at least 5 major barriers, 3 of which seem under federal policy makers’ control. The first is data privacy and security. There remains uncertainty among clinicians about the legal ramifications of a data breach or unauthorized access through HIE. Second, the Direct Project promotes point-

Prehospital electronic patient care report systems: early experiences from emergency medical services agency leaders.

BackgroundAs the United States embraces electronic health records (EHRs), improved emergency medical services (EMS) information systems are also a priority; however, little is known about the experiences of EMS agencies as they adopt and implement electronic patient care report (e-PCR) systems. We sought to characterize motivations for adoption of e-PCR systems, challenges associated with adoption and implementation, and emerging implementation strategies.MethodsWe conducted a qualitative study using semi-structured in-depth interviews with EMS agency leaders. Participants were recruited through a web-based survey of National Association of EMS Physicians (NAEMSP) members, a didactic session at the 2010 NAEMSP Annual Meeting, and snowball sampling. Interviews lasted approximately 30 minutes, were recorded and professionally transcribed. Analysis was conducted by a five-person team, employing the constant comparative method to identify recurrent themes.ResultsTwenty-three interviewees represented 20 EMS agencies from the United States and Canada; 14 EMS agencies were currently using e-PCR systems. The primary reason for adoption was the potential for e-PCR systems to support quality assurance efforts. Challenges to e-PCR system adoption included those common to any health information technology project, as well as challenges unique to the prehospital setting, including: fear of increased ambulance run times leading to decreased ambulance availability, difficulty integrating with existing hospital information systems, and unfunded mandates requiring adoption of e-PCR systems. Three recurring strategies emerged to improve e-PCR system adoption and implementation: 1) identify creative funding sources; 2) leverage regional health information organizations; and 3) build internal information technology capacity.ConclusionEMS agencies are highly motivated to adopt e-PCR systems to support quality assurance efforts; however, adoption and implementation of e-PCR systems has been challenging for many. Emerging strategies from EMS agencies and others that have successfully implemented EHRs may be useful in expanding e-PCR system use and facilitating this transition for other EMS agencies.

There is no neutral position on fraud!

In 2005, Dr David Brailer, our first National Coordinator for Health Information Technology, had a vision of widespread adoption of electronic health records connected through networks run by regional health-information organizations. An advisory panel recommended at that time that proactive fraud management functions be embedded in this emerging information infrastructure. This has not occurred. Currently, the agencies responsible for fraud need the assistance of the Office of the National Coordinator for Health Information Technology in order to most effectively manage the growing problem of fraud related to the adoption of electronic health records and health-information exchanges.

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

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. To assess the state of HIE in the United States through regional health information organizations (RHIOs). Survey. All RHIOs in the United States. 179 U.S.-based RHIOs that facilitated HIE as of December 2009. 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. 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. 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. 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. Office of the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services.

Health Information Exchange

The American Recovery and Reinvestment Act of 2009 will provide $36 billion to promote electronic health records and the formation of regional centers that foster community-wide electronic health information exchange (HIE) with the ultimate goal of a nationwide health information network. Minnesota's e-Health Law, passed in 2007, mandates electronic health record and HIE participation by all clinics and hospitals. To achieve these goals, small primary care practices must participate. Factors that motivate or prevent them from doing so are examined. From November 10, 2008, through February 20, 2009, we gathered data (through questionnaires and interviews) from 9 primary care practices in Minnesota with fewer than 20 physicians and with varying degrees of electronic health records and HIE involvement. No practice was fully involved in a regional HIE, and HIE was not part of most practices' short-term strategic plans. External motivators for HIE included state and federal mandates, payer incentives, and increasing expectations for quality reporting. Internal motivators were anticipated cost savings, quality, patient safety, and efficiency. The most frequently cited barriers were lack of interoperability, cost, lack of buy-in for a shared HIE vision, security and privacy, and limited technical infrastructure and support. Currently, small practices do not have the means or motivation to fully participate in regional HIEs, but many are exchanging health data in piecemeal arrangements with stakeholders with whom they are not directly competing for patients. To achieve more comprehensive HIE, regional health information organizations must provide leadership and financial incentives for community-wide meaningful use of interoperable electronic health records.

Characteristics associated with Regional Health Information Organization viability

Regional Health Information Organizations (RHIOs) will likely play a key role in our nation's effort to catalyze health information exchange. Yet we know little about why some efforts succeed while others fail. We sought to identify factors associated with RHIO viability. Using data from a national survey of RHIOs that we conducted in mid-2008, we examined factors associated with becoming operational and factors associated with financial viability. We used multivariate logistic regression models to identify unique predictors. We classified RHIOs actively facilitating data exchange as operational and measured financial viability as the percent of operating costs covered by revenue from participants in data exchange (0-24%, 25-74%, 75-100%). Predictors included breadth of participants, breadth of data exchanged, whether the RHIO focused on a specific population, whether RHIO participants had a history of collaborating, and sources of revenue during the planning phase. Exchanging a narrow set of data and involving a broad group of stakeholders were independently associated with a higher likelihood of being operational. Involving hospitals and ambulatory physicians, and securing early funding from participants were associated with a higher likelihood of financial viability, while early grant funding seemed to diminish the likelihood. Finding ways to help RHIOs become operational and self-sustaining will bolster the current approach to nationwide health information exchange. Our work suggests that convening a broad coalition of stakeholders to focus on a narrow set of data is an important step in helping RHIOs become operational. Convincing stakeholders to financially commit early in the process may help RHIOs become self-sustaining.

New Security Regs Could Short Circuit EHRs

New Security Regs Could Short Circuit EHRs

Determining Business Models for Financial Sustainability in Regional Health Information Organizations (RHIOs): A Review

Regional health information organizations (RHIOs) have the potential to alleviate today's health care problems by granting providers access to a supported body of clinical information for all patients in a given region. While the promise of and enthusiasm for RHIOs is immense, the issue of their financial sustainability remains unclear. It has been said that the business model supporting a regional or national health information network is as essential, if not more essential, than the technology that makes it feasible. Currently, there is a clear lack of concrete business models implemented in RHIOs' projects. This article reports the results of a literature review of the current status of the adaptation and implementation of business models by RHIOs for successful financial sustainability. Based on the review, this article also attempts to evaluate the existing financial situation of RHIOs to determine and recommend the best models of economic sustainability. Significant findings include RHIOs' present financial environment, planning, and self-sustainability methods. Future studies will be needed as RHIOs continue to grow and move toward the implementation phase of their development.

Assessing the Relationship Between Health Information Exchanges and Public Health Agencies

While health information exchange (HIE) continues to be promoted by both private and public sector supporters as potentially transformative for healthcare, there is concern as to how it will relate to and assist population health activities. This article reports the results of an on-line survey of regional health information organizations (RHIOs) and state and local health department representatives' beliefs and attitudes regarding collaboration in HIE. Factors that may encourage cooperation among public health agencies and RHIOs include broader geographic and multiorganization catchment areas, early laboratory involvement, early inclusion of public health as a RHIO partner, and efforts to resolve perceived barriers to cooperation. The exchange of electronic lab data was the most common type of data being exchanged and could serve as a model for how to accomplish HIE in general. Health departments (state and local) may serve as neutral conveners of RHIOs and could offer a bridge for acceptance by stakeholders, dispelling mistrust, offering data management expertise, and a capacity and tradition of ensuring privacy for confidential data.

U.S. Regional Health Information Organizations: Progress And Challenges

We surveyed regional health information organizations (RHIOs) to assess the state of electronic health information exchange in the United States. We found fifty-five operational RHIOs, and most were focused on exchanging test results. Forty-one percent of operational RHIOs reported receiving sufficient revenue from participating entities to cover operating costs. Of the remainder, only 28 percent expected to ever do so. RHIOs in the planning stage were far more optimistic. Operational RHIOs from our 2007 survey had made little progress in expanding the breadth of their activities. Although the number of operational RHIOs is growing, their scope remains limited and their viability uncertain.

Protecting Patients In Health Information Exchange: A Defense Of The HIPAA Privacy Rule

Regional health information organizations (RHIOs) rapidly integrate and deliver patient information to clinicians from multiple independent care organizations. By providing such information, they can reduce health care costs and improve safety. Special concerns about privacy arise as these regional systems connect nationally. We should add special barriers beyond the protections of the Health Insurance Portability and Accountability Act (HIPAA) to protect against surprises at the national level. At the local level, we should remain within the HIPAA rules because the application of additional barriers to RHIO access would interfere with efficient and safe care.

Engaging Patients For Health Information Exchange

Health information exchange (HIE) offers tremendous potential for the future, but its widespread adoption and sustainability depend upon engaging patients and earning their trust. Patients' willingness to allow their data to be shared will drive the usefulness of HIE and therefore the sustainability of regional health information organizations (RHIOs). The Massachusetts eHealth Collaborative (MAeHC) is one of a few organizations that have developed a successful community-based collaborative model, with more than a 90 percent opt-in rate among patients to participate in widespread electronic data sharing. Lessons learned from MAeHC's three pilot programs could be instructive for other HIE projects around the country.