Healthcare quality researchers have demonstrated a single electronic health record (EHR) may not be a complete source of relevant clinical information.

The authors of a recent study suggested adding standards-based data from a health information exchange (HIE) can improve quality of care.

“Including longitudinal data often results in performance rate improvements, although any change can be viewed as a more complete measure calculation that includes all relevant data,” the researchers wrote. “Reviewing these improvements and interoperability’s role in quality calculation contextualizes the impact to efficient care, patient safety, and value-based payment programs.”1

More Data Are Better

The research was aimed at proving what seemed logically true, that accessing more data would improve quality metrics, explains Laura K. McCrary, executive director of the Kansas Health Information Network in Topeka.

The research involved data from 53 institutions, looking at 14 ambulatory quality measures, says John D’Amore, MS, strategic advisor and board director with Diameter Health, a medical data company in Farmington, CT. All the quality measures concerned prevention or outcomes over one year, such as managing blood pressure or diabetes.

Many measures are used in value-based programs nationally, including HEDIS measures that affect health plans. They also are electronic clinical quality measures (eCQMs) that are used as part of reporting for the Merit-based Incentive Payment System, which is how Medicare handles value-based purchasing.

“We looked at how often a measure changed when you added changes from a health information exchange. We know that patients see many doctors in a year and we documented that as part of this research as well,” D’Amore says. “Particularly older and more complex patients see many physicians in a year, possibly going to the hospital, urgent care, specialists, all sorts of healthcare providers. These organizations may use different EHRs, or the same brand of an EHR but different instances of the product, and the information is not integrated between them.”

D’Amore and McCrary, along with other research colleagues, sampled patients randomly, determining how a quality measure would be calculated based on only the information from an EHR, and then again on how the measure would be calculated using the EHR and additional information from an HIE.

Many Changes with HIE

Researchers found that across all 14 quality measures, 15% of the calculations changed when adding data from the HIE.

“That is a large sum. It quantified something we suspected because an individual EHR does not have all the data, all the time, for all the patients,” D’Amore says. “It has a lot of information for the episode of care that provider recorded, but it really may not have that full longitudinal perspective of care provided at other areas of service. That 15% change across the board often resulted in improvements in individual quality measures.”

The number of changes was significant and could seriously affect value-based care programs that are based on quality measurement. The results were validated across not just one EHR or one site but 53 institutions, D’Amore notes, with all the major EHRs represented. “We think it’s a pretty powerful finding,” he says.

D’Amore says the research speaks to the importance of longitudinal data collection before trying to calculate a quality measure. “If you don’t get all the data, you can often get the wrong quality measurement,” he says.

McCrary says payors have long known accurate quality metrics depend on looking at all the available data sources for patient care. However, in the past, it was difficult for hospitals and health systems to integrate information from many sources.

“From a technology perspective, or even manually, there just wasn’t any way for a hospital, a health system, or an ambulatory practice to gather all the information about their patients from the different locations where they received care and then compute the quality measures in at least a fairly easy and not-too-burdensome manner,” McCrary says. “Being able to compute the quality measures off the data already gathered by the HIE seemed to be a really simple way to help our provider community to compute quality measures and get much more accurate results than what they were getting out of their own EHR system.”

More important than value-based care revenue, according to McCrary, is how the revised calculation of quality metrics will allow healthcare organizations to provide better care to patients.

One quality measure related to patient safety, high-risk medication use in older adults, actually devolved when adding the HIE data. Still, McCrary says that can be useful to know if the EHR-only data were providing an overly positive assessment.

In one patient record studied, a physician prescribed a high-risk medication to the patient without knowing another physician at a different location also had prescribed a high-risk medication.

“That is an example of how when you get more information, you can provide better care to the patient,” McCrary says.

As useful as EHRs can be, it is important to remember they do not provide a complete picture of the patient’s care. “Your electronic health record doesn’t necessarily have all the data on people who are going to seek care at multiple institutions, which is the majority of your patients,” D’Amore says. “Once you start from that position ... it creates pressure to ask what are the means by which I can get more comprehensive, longitudinal data on this patient.”

Most Can Access HIE

D’Amore notes the opportunity to engage with an HIE will vary by location and other factors. Another approach is to take full advantage of an EHR to exchange data readily with others. “This isn’t something that is theoretical or something that needs to be waited on for five or 10 years for the technology to catch up. The EHR standards that have been promulgated and the $40 million spent on meaningful use in the past decade actually allow for this to happen today,” D’Amore says.

A decade ago, healthcare leaders assumed quality metrics always should be derived from the EHR. That have may been a legitimate goal at the time, considering how institutions could share data. Now, this latest research confirms the local EHR alone is insufficient for painting a full picture of the patient and the patient’s experience.

Most healthcare organizations across the country can participate in an HIE. “In many of those cases, the data from the HIE is coming directly into the patient’s chart,” McCrary says.

“When the query is done to the HIE, the data is brought back and it’s available to the clinician right there. For many hospitals and health systems, we’re starting to see a pretty heavy utilization of that data as it becomes more important to know all the diagnoses of the patient, to know all the procedures the patient had, to know all the lab results and allergies.”

Questioning Value-Based Measures

The research also calls into question the accuracy of the quality measures used in value-based programs, according to McCrary. When reimbursement is tied to a metric that has been demonstrated to be inaccurate, the efficacy of that model for rewarding or incentivizing providers comes into question. “We’ve been financially incentivizing based on metrics that are not accurate. I would hope the provider community would recognize this and make some sort of statement that it is important to look more broadly at the care sites the patient has been at before you evaluate the quality of an individual doctor,” McCrary says. “Instead, we’re evaluating the ability of the hospital or the physician to go out and get data from other doctors to put in their EHR system. Consequently, we’re not evaluating whether the quality of care provided to the patient is the best.”

D’Amore agrees, saying that when all is done, the quality metric should reflect the quality of care provided to the patient, not the institution’s data-gathering efforts.

“Everyone talks about how to move away from fee-for-service and toward value-based care. This is the fundamental thing, the pillar,” D’Amore says. “If you can’t measure quality accurately, robustly, rigorously, and with high confidence, you can’t transition to value-based care because nobody has confidence in what you’re actually doing.”


  1. D’Amore JD, McCrary LK, Denson J, et al. Clinical data sharing improves quality measurement and patient safety. J Am Med Inform Assoc 2021; Mar 13;ocab039. doi: 10.1093/jamia/ocab039. [Online ahead of print].