Table 3 Barriers to HIE for small physician practices and FQHCs, with exemplar quotes

Lack of well-functioning area-level exchange

“I think if we did have communication with more entities it would be better. I think in certain parts of the country… they’re all integrated. They know exactly what happened to the patient ten years ago in all of their records because they use the same system. But now if there’s thousands of EMR companies there’s a lot of integration issues and there’s a lot of red tape. It’s hard to actually to communicate with other people outside of our sister”.

Market characteristics, including number, type, and size of partner organizations

“The reality is these systems are very expensive. They’re not easy to manage, overall, and sometimes the smaller clinics, as you’re probably hearing from the primary care clinics, you don’t always have the internal sophistication to go ahead and support them to the level and that’s where we struggle”.

Relationships or previous experiences with exchange partners

“It just comes down to priorities. We’re so far down the priority list for [the hospital organization] to even contemplate doing a direct interface with [us] that it’s time commitment prohibitive, and cost prohibitive for them”.

Challenge achieving a critical mass of users

“I’m a surgical specialist, so I have to wait until there are enough primary care physicians who are online who may refer me a patient or who we may have a mutual patient. So from a practical point of view, I don’t use it that much because I’m still waiting to get that information”.

Health IT used (e.g., type of EMR used & integration into organization’s workflow)

“It seems like it’s designed really well and you’ve thought of everything but when it gets back there and you realize they are completely overwhelmed by all these additional things that they have to do at every visit, there is just not any more room to do anything at every visit.

“The other concern was how efficient is it to have two systems right next to each other? Our doctors don’t have time to do that. Our MAs don’t have time to do that. So there were some logistical concerns that we were very hesitant about”.

Data ownership and provider liability concerns

“Unfortunately what we’re really finding out here in spades is that that [HIPAA] is in conflict with the efforts to manage care appropriately because it’s just had this chilling effect on being able to share information. [Providers] are not saying hold on to be obstructionists. There just saying hold on because if I give you that piece of information I have just committed a HIPAA violation”.