Appendix Exhibit A1: The systematic search strategy used in the current analysis

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1 Rahurkar S, Vest JR, Menachemi N. Despite the spread of health information exchange, there is little evidence of its impact on cost, use, and quality of care. Health Aff (Millwood). 2015;34(3). Appendix Exhibit A1: The systematic search strategy used in the current analysis Step I: Title and Abstract review All articles from the PubMed and Scopus databases spanning years were included in the review 274 articles identified based on keyword search Rejected if: No focus on HIE or HIE and the subsequent outcomes that result from HIE use Non-empirical articles 56 articles selected for further evaluation Rejected if: No focus on HIE and/or healthcare outcomes Qualitative studies Reviews 21 articles identified as being empirical and analyzing healthcare outcomes Step II: Hand search of Bibliography Review of references using title and abstract 10 articles identified from 451 references 4 more articles identified from Bibliography of the above 10 articles. Removed duplicates and web/symposium proceedings. A total of 27 articles included

2 Appendix Exhibit A2: List of all included studies 1. Tierney WM, McDonald CJ, Martin DK, Rogers MP. Computerized display of past test results. Effect on outpatient testing. Ann Intern Med Oct;107(4): Stair TO. Reduction of redundant laboratory orders by access to computerized patient records. J Emerg Med Nov-Dec;16(6): Branger PJ, van't Hooft A, van der Wouden JC, Moorman PW, van Bemmel JH. Shared care for diabetes: supporting communication between primary and secondary care. Int J Med Inform Feb-Mar;53(2-3): Overhage JM, Dexter PR, Perkins SM, Cordell WH, McGoff J, McGrath R, et al. A randomized, controlled trial of clinical information shared from another institution. Ann Emerg Med Jan;39(1): Lang E, Afilalo M, Vandal AC, Boivin JF, Xue X, Colacone A, et al. Impact of an electronic link between the emergency department and family physicians: a randomized controlled trial. CMAJ Jan 31;174(3): Hansagi H, Olsson M, Hussain A, Ohlen G. Is information sharing between the emergency department and primary care useful to the care of frequent emergency department users? Eur J Emerg Med Feb;15(1): Overhage JM, Grannis S, McDonald CJ. A comparison of the completeness and timeliness of automated electronic laboratory reporting and spontaneous reporting of notifiable conditions. Am J Public Health Feb;98(2): Vest JR. Health information exchange and healthcare utilization. J Med Syst Jun;33(3): Nirel N, Rosen B, Sharon A, Blondheim O, Sherf M, Samuel H, et al. The impact of an integrated hospital-community medical information system on quality and service utilization in hospital departments. Int J Med Inform Sep;79(9): Proeschold-Bell RJ, Belden CM, Parnell H, Cohen S, Cromwell M, Lombard F. A randomized controlled trial of health information exchange between human immunodeficiency virus institutions. J Public Health Manag Pract Nov-Dec;16(6): Maenpaa T, Asikainen P, Gissler M, Siponen K, Maass M, Saranto K, et al. Outcomes assessment of the regional health information exchange: a five-year follow-up study. Methods Inf Med. 2011;50(4): Tzeel A, Lawnicki V, Pemble KR. The business case for payer support of community-based health information exchange: A humana pilot evaluating its iveness in cost control for plan members seeking emergency department care. American Health & Drug Benefits //;4(4): Vest JR, Miller TR. The association between health information exchange and measures of patient satisfaction. Appl Clin Inform. 2011;2(4): Frisse ME, Johnson KB, Nian H, Davison CL, Gadd CS, Unertl KM, et al. The financial impact of health information exchange on emergency department care. J Am Med Inform Assoc May-Jun;19(3): Hebel E, Middleton B, Shubina M, Turchin A. Bridging the chasm: of health information exchange on volume of laboratory testing. Arch Intern Med Mar 26;172(6):517-9.

3 16. Herwehe J, Wilbright W, Abrams A, Bergson S, Foxhood J, Kaiser M, et al. Implementation of an innovative, integrated electronic medical record (EMR) and public health information exchange for HIV/AIDS. J Am Med Inform Assoc May-Jun;19(3): Kern LM, Barron Y, Dhopeshwarkar RV, Kaushal R. Health information exchange and ambulatory quality of care. Appl Clin Inform. 2012;3(2): Magnus M, Herwehe J, Gruber D, Wilbright W, Shepard E, Abrams A, et al. Improved HIVrelated outcomes associated with implementation of a novel public health information exchange. Int J Med Inform Oct;81(10):e Wilcox AB, Shen S, Dorr DA, Hripcsak G, Heermann L, Narus SP. Improving access to longitudinal patient health information within an emergency department. Appl Clin Inform. 2012;3(3): Bailey JE, Pope RA, Elliott EC, Wan JY, Waters TM, Frisse ME. Health information exchange reduces repeated diagnostic imaging for back pain. Ann Emerg Med Jul;62(1): Bailey JE, Wan JY, Mabry LM, Landy SH, Pope RA, Waters TM, et al. Does health information exchange reduce unnecessary neuroimaging and improve quality of headache care in the emergency department? J Gen Intern Med Feb;28(2): Ben-Assuli O, Shabtai I, Leshno M. The impact of EHR and HIE on reducing avoidable admissions: controlling main differential diagnoses. BMC Med Inform Decis Mak. 2013;13: Ross SE, Radcliff TA, Leblanc WG, Dickinson LM, Libby AM, Nease DE, Jr. Effects of health information exchange adoption on ambulatory testing rates. J Am Med Inform Assoc Nov- Dec;20(6): Ben-Assuli O, Shabtai I, Leshno M. Using electronic health record systems to optimize admission decisions: The Creatinine case study. Health informatics journal Apr Ben-Assuli O, Shabtai I, Leshno M, Hill S. EHR in Emergency Rooms: Exploring the Effect of Key Information Components on Main Complaints. J Med Syst Apr;38(4): Lammers EJ, Adler-Milstein J, Kocher KE. Does health information exchange reduce redundant imaging? Evidence from emergency departments. Med Care Mar;52(3): Vest JR, Kern LM, Campion TR, Jr., Silver MD, Kaushal R. Association between use of a health information exchange system and hospital admissions. Appl Clin Inform. 2014;5(1):

4 Appendix Exhibit A3: Total number & percent of analyses finding a beneficial by outcome type & study design Healthcare utilization (n=67) Percent of observational 1 studies finding a beneficial 75.6% Percent of experimental 2 studies finding a beneficial 11.5% (3 of 26 analyses) (31 of 41 analyses) Hospital admissions (n=14) 90 0 Hospital readmissions (n=5) Number of imaging tests (n=12) Repeat imaging tests (n=8) Number of lab & diagnostic tests (n=10) Repeat lab & diagnostic tests (n=5) Number of ED visits (n=4) 50 0 Repeat ED visits (n=1) 0 Length of hospital stay (n=2) 0 Outpatient visits (n=2) 0 Number of appointments (n=1) 100 Number of referrals (n=1) 0 Repeat specialty consultations (n=1) 0 Ambulatory care sensitive hospitalization (n=1) 0 Healthcare costs (n=11) 55.6% (5 of 9 analyses) Patient visit costs (n=5) Annual financial savings (n=3) 100 Costs of lab tests (n=2) Costs of radiology tests (n=1) 0 100% (2 of 2 analyses) Quality of care (n=6) 80% (4 of 5 analyses) Prescription of anti-retroviral therapy (n=2) 0 0 Adherence to evidence based guidelines (n=1) 100 Documentation (n=1) 100 HbA1C levels (n=1) 100 Quality of care measures (n=1) (0 of 1 analysis) Coordination of care (n=6) 83.3% (5 of 6 analyses) Coordination of care (n=1) 100 Doctor-patient communication (n=1) 0 Identifying patients in need (n=1) 100 Nurse-patient communication (n=1) 100 Retention of out-of-care patients (n=1) 100 Specialist to PCP communication (n=1) 100 Patient experience (n=2) 100% (2 of 2 analyses) Patient care (n=1) 100 Patient satisfaction with hospital (n=1) 100 Disease surveillance (n=2) 100% (2 of 2 analyses) Completeness of disease surveillance (n=1) 100 Timeliness of disease surveillance (n=1) 100 Source: Authors analysis of published peer-reviewed studies. Note: 1 Observational studies include cohort studies and cross-sectional studies 2 Experimental studies include randomized controlled trials and quasi-experimental trials 0 indicates no studies in that particular group found beneficial indicates no studies in that particular group

5 Appendix Exhibit A4: Association of select study characteristics with finding a beneficial of HIE Variable Odds Ratio 95% CI Marginal s a Experimental study design 0.06 (0.02, 0.19) *** -59.0% Other study design U.S. based study (0.16, 3.95) -5.6% Study based outside U.S. Healthcare utilization outcomes 0.35 (0.06, 2.10) -24.0% Other outcomes Emergency department setting 5.03 (0.92, 27.62) 37.8% Other setting Hospital setting 2.97 (0.44, 20.10) 25.0% Other setting Study years: 2009 to (0.19, 3.40) -5.2% Study years: 1987 to 2008 Source: Authors analysis of published peer-reviewed studies. Note: Robust standard errors used to control for analyses nested within articles. ***p<0.001 a Marginal s represent the difference in the likelihood of an outcome occurring compared to the reference category. For example, compared to other study designs, experimental study designs are 59% less likely to find beneficial from HIE even after controlling for other variables in the model.

6 Appendix File A5: Overview of Experimental studies and their findings Study Study Design Population Type HIE with Outside Entities Effect on Outcome Findings Proeschold-Bell, R. J. et al. (2010) Randomized at patient level HIV patients No * No No significant differences in viral load, CD4 count or antiretroviral prescriptions were seen between the cases and the controls. Despite not achieving statistical significance, the control group showed trends for better health Hansagi, H. et al.(2008) Randomized at patient level Emergency Department No No No significant differences in ED visits, primary care visits, or visits to specialty outpatient clinic were seen after the electronic link was introduced. Lang, E. et al. (2006) 4- period crossover cluster-randomized controlled trial Emergency Department Yes Adverse A significant increase in duplication of specialty consultations was seen. The electronic link failed to reduce repeat ED visits or hospital admissions. Number of test and length of stay showed no significant differences. Overhage, J. M. et al. (2002) Pilot trial randomized at the patient level Emergency Department Yes No There was no difference in ordering rates of tests based on availability of previous test reports. No differences in admission rates or repeat ED visits were seen. Some secondary savings costs were observed at one of the hospitals but not at the other. Tierney, W. M. et al. (1987) 2-period crossover design randomized at patient level Primary Care Practice Yes Beneficial Fewer tests were ordered in the intervention group with lower patient charges. There was an increase of about 5 seconds for each test ordered in the intervention group. Nirel, N. et al. (2010) Quasiexperimental: Difference-in- Difference analysis following propensity score matching Hospital No Beneficial Internal Medicine saw a decrease in lab test, while there was no difference in lab tests for General Surgery. There was a 20% decrease in CT tests in Internal Medicine, no such was seen in General Surgery. Day hospitalization and repeat hospitalization remain unchanged for both departments. Internal medicine, however, saw a decrease in day hospitalization over the span of Source: Authors analysis of published peer-reviewed studies. * Exchange between entities within the HIV Integration Health Outcomes Project RCT is Randomized controlled trial

The impact of health information exchange

The impact of health information exchange Joshua R Vest, PhD, MPH Associate Professor Department of Health Policy & Management Richard M. Fairbanks School of Public Health Indiana University Indianapolis