Fragmented records

Where in the exchange chain does the record actually get stuck: finding it, sending it, receiving it, or integrating it?

Hospitals routinely sharing records across all four interoperability domains rose to 43 percent in 2023, still a minority, and providers account for 81.8 percent of the information-blocking complaints filed with ONC.

Question

The problem

Fragmented records are a hospital-landscape reliability problem: patients move across emergency departments, specialists, post-acute providers, and health systems faster than their information does. The result is duplicative work, missed context, avoidable delays, and coordination risk for the patients who most need continuity.

The recommendation

Treat record exchange as core infrastructure for patient safety and operating efficiency. The recommended approach is to govern the full exchange chain, finding, sending, receiving, and integrating records, and to hold hospitals and networks accountable for routine use, not just technical participation.

The gap and its causes

How far records are from following the patient, and why: the capability-versus-routine-use gap, the exchange domain where the record stalls, and who is accused of blocking it.

43%

of US hospitals routinely exchanged records across all four domains in 2023

Another 27 percent did so only sometimes. The remaining 30 percent did not, a share derived as 100 minus the two reported values.

70%

of hospitals were engaged in all four exchange domains in 2023

The capability ceiling. Most hospitals have the connections, but far fewer use them routinely.

78%

of hospitals could integrate a received record into the chart in 2023, the lagging domain

Sending is nearly solved at 92 percent. Integrating a record into the local system trails every other step.

2,124

information-blocking claims filed to ONC

April 2021 to May 2026. Unadjudicated allegations, not findings.

US hospitals exchanging records across all four domains

The accent line counts hospitals engaged in all four domains (find, send, receive, integrate). The teal line is the stricter routinely interoperable share. The gap of about 27 points in 2023 is the wiring-versus-habit story. The 2020 survey wave was delayed by the pandemic and reported as 2021.

Read it this way Compare the two lines: hospitals engaged in all four domains climbed steadily to 70 percent by 2022 and held there in 2023, while hospitals that routinely use all four only reached 43 percent, a gap of about 27 points. The gap shows most hospitals already have the technical connections; using them routinely is the part still lagging. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

Year range

⊞ data table⬇ CSV

Year	Engaged all four %	Routinely interoperable %
2018	46	28
2019	55	32
2021	62	29
2022	70	40
2023	70	43

ONC Data Brief No. 71, Interoperable Exchange Among US Hospitals, 2023 · 2023 · source

Where the record gets stuck: the four domains, 2023

Share of US hospitals engaged in each exchange domain in 2023. The reference line is the 70 percent share engaged in all four at once. Sending is nearly solved. Integrating a received record into the chart lags.

Read it this way Rank the four domain bars against the 70 percent reference line for engagement in all four at once: send (92 percent) is nearly solved, while integrate (78 percent) trails every other domain. Integrate being both lowest and closest to the all-four benchmark suggests it is the domain most likely holding hospitals back from full engagement. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

⊞ data table⬇ CSV

Domain	Hospitals engaged %
Send	92
Receive	87
Find	84
Integrate	78

ONC Data Brief No. 71, Interoperable Exchange Among US Hospitals, 2023 · 2023 · source

Did the laggard domains catch up? 2018 to 2023

Each line is one exchange domain. Integrate climbed from 62 to 78 percent and find from 65 to 84 percent, while send stayed high and nearly flat. The gaps are narrowing from the bottom.

Read it this way Track each line's starting and ending point: find rose the most, from 65 to 84 percent, and integrate from 62 to 78 percent, both closing ground on send, which stayed nearly flat near 90 percent. The lagging domains are catching up from below, but integrate still ends 2023 as the lowest of the four. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

⊞ data table⬇ CSV

Year	Find %	Send %	Receive %	Integrate %
2018	65	89	78	62
2019	72	90	81	71
2021	78	91	84	74
2022	84	93	87	79
2023	84	92	87	78

ONC Data Brief No. 71, Interoperable Exchange Among US Hospitals, 2023 · 2023 · source

Who gets named in information-blocking complaints

Actor named in each information-blocking complaint. Providers account for 81.8 percent. A single complaint can name more than one actor, so the 2,071 associations shown sum below the 2,124 total claims filed.

Read it this way The donut slices show providers named in 81.8 percent of the 2,071 actor associations, more than four times the 17.2 percent naming health IT developers. Because a single complaint can name more than one actor, and the 2,071 shown excludes 114 non-actor or unknown codings, read the slices as who gets named most often, not a full accounting of the 2,124 claims filed. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

Caveat Unadjudicated allegations logged by ONC, not findings. Actor associations (2,071) exclude 114 coded Non-Actor or Unknown and do not sum to the 2,124 total claims.

⊞ data table⬇ CSV

Actor type	Complaints	Share %
Provider	1694	81.8
Health IT developer	357	17.2
Health information network	20	1

ONC, Information Blocking Portal Submissions monthly data · 2021-2026 · source

Geography and the fix

Whether the state you are treated in decides if your records can be found, then whether TEFCA, the new national on-ramp, is closing that gap or is still mostly intent.

81.5%

of US hospitals participate in a health information organization nationally

The mature exchange layer. State rates run from 23.8 percent to 100 percent.

34.3%

of hospitals participate in TEFCA, the new national on-ramp

The newer layer, still thin. Another 38.4 percent report only planning to join.

Hospitals participating in a health information organization, by state

Share of hospitals in each state reporting HIE/HIO participation. Benchmark is the 81.5 percent national rate. Figures blend each hospital's most recent survey year from 2022 to 2025.

Read it this way Each tile's shade shows a state's HIE participation against the 81.5 percent national benchmark. Several states, including Maine, Vermont, and Maryland, sit at 100 percent, while New Hampshire's 23.8 percent is a clear outlier below the rest. The map shows where hospitals report joining an exchange network, not whether records actually get shared in practice. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

Caveat Not a single-year snapshot. State figures blend the most recent reported year per hospital, so they are not strictly comparable to a single national cross-section.

⊞ data table⬇ CSV

State	HIE/HIO participation %	TEFCA participating %
AK	100	14.3
AL	56.1	24.4
AR	89.8	32.2
AZ	98	10.2
CA	79.9	20.1
CO	91.3	43.5
CT	100	33.3
DC	100	60
DE	100	0
FL	80.5	66.4
GA	66.7	51.1
HI	92.3	46.2
IA	90.8	26.6
ID	63	51.9
IL	57	40.1
IN	95.7	34.8
KS	84.1	43.2
KY	98.5	19.7
LA	78.6	42.9
MA	97.6	48.8
MD	100	61.9
ME	100	55.6
MI	93.5	45.2
MN	69.1	36.2
MO	85.8	32.1
MS	75.8	38.7
MT	69.8	23.3
NC	96.6	53.4
ND	76.7	0
NE	94.6	16.1
NH	23.8	19
NJ	98.1	38.5
NM	70.8	45.8
NV	73.9	26.1
NY	96.6	27.1
OH	91.4	33.6
OK	68.2	16.7
OR	77.3	31.8
PA	84.4	35.8
RI	100	50
SC	51.3	51.3
SD	100	11.4
TN	69.1	33.8
TX	63.4	19.5
UT	90.2	26.8
VA	98.6	50
VT	100	54.5
WA	72.1	19.7
WI	89.1	48.5
WV	90.5	47.6
WY	75	15

ONC, US Hospital Participation in Health Information Networks · 2022-2025 · source

The worst-served states for record-finding infrastructure

The 15 states with the lowest share of hospitals in a health information organization. Every one sits below the 81.5 percent national average. New Hampshire trails at 23.8 percent.

Read it this way The dots are ranked from lowest, New Hampshire at 23.8 percent, up toward the 81.5 percent national line. Every one of these 15 states falls short of the national average, and New Hampshire's gap of nearly 58 points is the widest on the strip. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

⊞ data table⬇ CSV

State	HIO participation %
NH	23.8
SC	51.3
AL	56.1
IL	57
ID	63
TX	63.4
GA	66.7
OK	68.2
MN	69.1
TN	69.1
MT	69.8
NM	70.8
WA	72.1
NV	73.9
WY	75

ONC, US Hospital Participation in Health Information Networks · 2022-2025 · source

TEFCA participation by state, 2022 to 2025

Share of hospitals in each state participating in TEFCA. Benchmark is the 34.3 percent national rate. Florida leads at 66.4 percent. Delaware and North Dakota report 0.0 percent.

Read it this way Shade intensity here tracks each state's TEFCA participation against the 34.3 percent national benchmark. Florida leads at 66.4 percent while Delaware and North Dakota report 0.0 percent, showing TEFCA adoption is far more uneven across states than the more mature HIE layer. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

Caveat Blends each hospital's most recent survey year from 2022 to 2025, not a single-year snapshot. TEFCA is a newer, thinner layer than the HIO map.

⊞ data table⬇ CSV

State	TEFCA participating %
US national average	34.3
AK	14.3
AL	24.4
AR	32.2
AZ	10.2
CA	20.1
CO	43.5
CT	33.3
DC	60
DE	0
FL	66.4
GA	51.1
HI	46.2
IA	26.6
ID	51.9
IL	40.1
IN	34.8
KS	43.2
KY	19.7
LA	42.9
MA	48.8
MD	61.9
ME	55.6
MI	45.2
MN	36.2
MO	32.1
MS	38.7
MT	23.3
NC	53.4
ND	0
NE	16.1
NH	19
NJ	38.5
NM	45.8
NV	26.1
NY	27.1
OH	33.6
OK	16.7
OR	31.8
PA	35.8
RI	50
SC	51.3
SD	11.4
TN	33.8
TX	19.5
UT	26.8
VA	50
VT	54.5
WA	19.7
WI	48.5
WV	47.6
WY	15

ONC, US Hospital Participation in Health Information Networks · 2022-2025 · source

Does a mature HIE base predict TEFCA uptake?

Each point is one state. The fitted line is nearly flat, so a mature HIO base barely predicts TEFCA uptake. TEFCA is growing largely as a separate layer rather than building on existing exchange.

Read it this way Each dot is one state plotted by its HIE participation against its TEFCA participation, with a nearly flat fitted line through them. States like Alaska and Delaware sit at 100 percent HIE participation but far below-average TEFCA participation (14.3 and 0.0 percent), showing a strong HIE base does not reliably predict TEFCA uptake. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

⊞ data table⬇ CSV

State	HIO %	TEFCA %
AK	100	14.3
AL	56.1	24.4
AR	89.8	32.2
AZ	98	10.2
CA	79.9	20.1
CO	91.3	43.5
CT	100	33.3
DC	100	60
DE	100	0
FL	80.5	66.4
GA	66.7	51.1
HI	92.3	46.2
IA	90.8	26.6
ID	63	51.9
IL	57	40.1
IN	95.7	34.8
KS	84.1	43.2
KY	98.5	19.7
LA	78.6	42.9
MA	97.6	48.8
MD	100	61.9
ME	100	55.6
MI	93.5	45.2
MN	69.1	36.2
MO	85.8	32.1
MS	75.8	38.7
MT	69.8	23.3
NC	96.6	53.4
ND	76.7	0
NE	94.6	16.1
NH	23.8	19
NJ	98.1	38.5
NM	70.8	45.8
NV	73.9	26.1
NY	96.6	27.1
OH	91.4	33.6
OK	68.2	16.7
OR	77.3	31.8
PA	84.4	35.8
RI	100	50
SC	51.3	51.3
SD	100	11.4
TN	69.1	33.8
TX	63.4	19.5
UT	90.2	26.8
VA	98.6	50
VT	100	54.5
WA	72.1	19.7
WI	89.1	48.5
WV	90.5	47.6
WY	75	15

ONC, US Hospital Participation in Health Information Networks · 2022-2025 · source

TEFCA: participating versus only planning versus neither

TEFCA status across US hospitals nationally. More hospitals report only planning to join (38.4 percent) than have joined (34.3 percent), so the on-ramp's reach depends on converting intent to action.

Read it this way The single stacked bar splits all hospitals into three TEFCA statuses: 38.4 percent are only planning to join, edging out the 34.3 percent that already participate, with 27.3 percent doing neither. More hospitals sit in intent than in action, so whether this bar shifts depends on whether the planning segment converts. Use this chart to locate where the information chain is breaking and why the recommendation focuses on routine operational exchange instead of technology adoption alone.

Caveat The neither band of 27.3 percent is derived as 100 minus the 34.3 percent participating and 38.4 percent planning shares, not a separately reported field.

⊞ data table⬇ CSV

Status	Share of hospitals %
Participating	34.3
Only planning	38.4
Neither (derived)	27.3

ONC, US Hospital Participation in Health Information Networks · 2022-2025 · source

Why this matters

Geography compounds the gap: national health-information-organization participation is 81.5 percent, but state rates range from 23.8 percent in New Hampshire to 100 percent in several states, and TEFCA, the newer national on-ramp, sits at just 34.3 percent participation with another 38.4 percent still only planning to join. A mature state HIE base does not reliably predict TEFCA uptake: states like Alaska and Delaware sit at 100 percent HIE participation but 14.3 and 0.0 percent TEFCA participation, so TEFCA is growing as a mostly separate layer rather than building on existing exchange. Meanwhile 2,124 information-blocking claims have been filed to ONC since April 2021, and of the 2,071 claims naming a specific actor, 81.8 percent name providers versus 17.2 percent naming health IT developers. These are unadjudicated allegations, not findings, but the pattern points at incentives and workflow inside provider organizations more than at exchange technology itself.

Recommended actions

Prioritize converting the 38.4 percent of hospitals only planning to join TEFCA into active participants, since planning already outnumbers participation nationally.
Target the 15 lowest-HIE-participation states, led by New Hampshire at 23.8 percent, for dedicated onboarding support rather than assuming the national 81.5 percent average applies everywhere.
Invest specifically in integration tooling, the lagging domain at 78 percent versus 92 percent for sending, since better receiving and finding do little if the record cannot be incorporated into the chart.
Resource ONC enforcement of information-blocking complaints against providers, who account for 81.8 percent of named actors, while continuing to track that these remain unadjudicated allegations.

The recommendation

Therefore, treat record exchange as core infrastructure for patient safety and operating efficiency. The recommended approach is to govern the full exchange chain, finding, sending, receiving, and integrating records, and to hold hospitals and networks accountable for routine use, not just technical participation.

Demographic slice none. ONC data briefs and TEFCA participation are institution-level.

Sources