Term of Award

Spring 2026

Degree Name

Doctor of Public Health (Dr.P.H.)

Document Type and Release Option

Dissertation (open access)

Copyright Statement / License for Reuse

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.

Department

Jiann-Ping Hsu College of Public Health

Committee Chair

Gulzar Shah

Committee Member 1

Bettye Apenteng

Committee Member 2

William Mase

Abstract

This study presents a comprehensive comparative analysis of state-level Health Information Exchanges (HIEs) across all 50 U.S. states and the District of Columbia, examining how governance structures, consent frameworks, funding models, and technical infrastructure influence interoperability maturity, sustainability, and adoption. Guided by Systems Theory and Donabedian’s Structure Process Outcome framework, the research employs a mixed-methods comparative case design integrating systematic documentary review, qualitative thematic analysis, and a policy-anchored analytic scoring methodology. Structural and policy characteristics were operationalized through standardized ordinal (1-5) metrics and aggregated into composite indices representing governance capacity, consent inclusivity, financial sustainability, and technical readiness. This approach enabled cross-state comparison while preserving contextual variation across jurisdictions. Qualitative coding was used to validate scoring decisions, identify interdependencies among structural features, and contextualize quantitative patterns. Findings reveal three interrelated structural determinants of HIE performance. First, adaptive governance models, particularly hybrid public-private arrangements with formal state authority, were consistently associated with higher interoperability maturity, broader stakeholder participation, and greater exchange volume. Second, consent frameworks emerged as a critical driver of adoption and data liquidity, with opt-out and hybrid models demonstrating substantially higher participation than opt-in approaches, even among states with comparable technical capabilities. Third, financial sustainability was strongest among HIEs supported by diversified revenue streams, including Medicaid contracts, state appropriations, payer contributions, subscription models, and federal funding. Exchanges dependent on single-source financing demonstrated greater vulnerability to operational stagnation and instability. Regional analysis indicates that Midwestern states exhibit the strongest overall performance, followed by the South, while Western states often demonstrate advanced technical infrastructure but comparatively weaker long-term sustainability. The study contributes a novel, fully cited dataset spanning 51 jurisdictions and highlights high-performing exemplars such as Maryland’s CRISP, Michigan’s MiHIN, and Indiana’s IHIE, alongside persistent challenges in states including Montana, New Mexico, and Idaho. Policy analysis further demonstrates that alignment with federal initiatives, including the Trusted Exchange Framework and Common Agreement (TEFCA) and the CMS Interoperability and Prior Authorization Final Rule, serves as a key indicator of infrastructure readiness and future sustainability. Overall, findings underscore that durable progress toward nationwide interoperability depends on structural alignment across governance authority, inclusive consent design, diversified financing, and policy-aligned technical infrastructure.

Research Data and Supplementary Material

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