title: Barriers over time to full implementation of health information exchange in the United States.
abstract: BACKGROUND
  Although health information exchanges (HIE) have existed since their introduction by President Bush in his 2004 State of the Union Address, and despite monetary incentives earmarked in 2009 by the health information technology for economic and clinical health (HITECH) Act, adoption of HIE has been sparse in the United States. Research has been conducted to explore the concept of HIE and its benefit to patients, but viable business plans for their existence are rare, and so far, no research has been conducted on the dynamic nature of barriers over time.
  
  
  OBJECTIVE
  The aim of this study is to map the barriers mentioned in the literature to illustrate the effect, if any, of barriers discussed with respect to the HITECH Act from 2009 to the early months of 2014.
  
  
  METHODS
  We conducted a systematic literature review from CINAHL, PubMed, and Google Scholar. The search criteria primarily focused on studies. Each article was read by at least two of the authors, and a final set was established for evaluation (n=28).
  
  
  RESULTS
  The 28 articles identified 16 barriers. Cost and efficiency/workflow were identified 15% and 13% of all instances of barriers mentioned in literature, respectively. The years 2010 and 2011 were the most plentiful years when barriers were discussed, with 75% and 69% of all barriers listed, respectively.
  
  
  CONCLUSIONS
  The frequency of barriers mentioned in literature demonstrates the mindfulness of users, developers, and both local and national government. The broad conclusion is that public policy masks the effects of some barriers, while revealing others. However, a deleterious effect can be inferred when the public funds are exhausted. Public policy will need to lever incentives to overcome many of the barriers such as cost and impediments to competition. Process improvement managers need to optimize the efficiency of current practices at the point of care. Developers will need to work with users to ensure tools that use HIE resources work into existing workflows.
authors.affiliation: School of Health Administration, College of Allied Health Professions, Texas State University, San Marcos, TX, United States. scottkruse@txstate.edu.
authors.forename: Clemens Scott
authors.identifier: http://orcid.org/0000-0002-7636-1086
authors.initials: CS
authors.lastname: Kruse
authors.forename: Verna
authors.identifier: http://orcid.org/0000-0002-0264-0752
authors.initials: V
authors.lastname: Regier
authors.forename: Kurt T
authors.identifier: http://orcid.org/http://orcid.org/0000-0002-3392-9727
authors.initials: KT
authors.lastname: Rheinboldt
keywords: electronic health record (EHR); electronic medical records (EMR); health information technology (HIT); medical informatics; national health policy; past trends; quality improvement; workflow