Introduction

North Carolina has the second largest rural population among the states in the US, which presents significant challenges for accessing and delivering quality health care services.1,2 Rural counties throughout the state experience higher rates of chronic disease, lower rates of health insurance coverage, and health care workforce shortages.2,3 Many rural health care facilities in North Carolina are under immense financial strain and have limited staffing and outdated infrastructure, which creates the risk for facility closures and gaps in care.4 These infrastructural challenges lead to unmet health care needs, delays in care, preventable admissions, and premature deaths.2 Health information technology (health IT) can play a vital role in bridging these gaps in rural health care by leveraging health system interoperability.

Health system interoperability is the ability for different systems to share data in a coordinated manner to improve population health experiences and outcomes.5,6 Health care transformation efforts in North Carolina are accelerating the use of health information exchange (HIE) services—the systematic sharing of health data across organizations and systems.6 HIEs can improve care coordination and support provider communities by establishing strong and efficient health care infrastructure. This commentary will discuss the value of HIEs for rural health care and highlight the expansion of HIE services under the North Carolina Health Information Exchange Authority (NC HIEA), the agency that administers North Carolina’s designated HIE, NC HealthConnex. This commentary will also explore key strategies, emerging investments, and policies in the health system interoperability space.

Making the Case for Health System Interoperability

Health system interoperability has been shown to improve the quality and efficiency of care delivery and coordination and improve health outcomes.7–10 Nationally, rural health care providers’ adoption and use of interoperable health information technology lags behind their urban counterparts. In 2021, the United States Government Accountability Office’s analysis of nationwide survey data found that hospitals located in a non-metropolitan statistical area reported lower use of electronic methods of health information exchange than non-rural hospitals.11

In 2021, an assessment of providers’ Promoting Interoperability Scores (PIS) on health information exchange found similar disparities, with rural physicians scoring a median of 20 (interquartile range [IQR]: 10–38) versus 34 (IQR: 12–39) for urban physicians (P < .001). The geographic distribution of average promoting interoperability scores in North Carolina reflects national trends where rural areas were associated with consistently lower PIS scores compared to urban areas. This summarizes the adoption of HIE technologies in rural health care provider communities and the need for improvement.12,13

Barriers to rural providers’ use of health IT in general, and HIE in particular, are well documented. In North Carolina, many rural communities include medically underserved areas with lower population and provider densities than their urban counterparts.14 North Carolina’s rural communities also face fragmented care delivery; limited integration of clinical, behavioral, and social services; high rates of chronic disease, substance use, and unmet behavioral health needs; and financial instability among rural hospitals and clinics.4 These structural challenges drain the capital, resources, and workforce rural providers need to acquire and utilize interoperable technologies.

How Health System Interoperability Fills Gaps in Rural Care

Interoperable technologies can help rural providers address geographic isolation and limited resources by creating opportunities to share critical information seamlessly in support of whole-person care. For example, HIE tools can:

  • Improve Care Management: HIEs collect critical health information from disparate systems to create longitudinal, patient-centered records of care.

  • Enhance Care Coordination: Automatic alerts and notifications can inform providers when their patients are admitted, discharged, or transferred, enabling timely follow-up care.

  • Improve Emergency Response: In emergency situations, HIEs can provide real-time access to critical health information, including medical histories, allergies, and medications.

NC HealthConnex: Connecting Patients and Providers to Care

North Carolina continues to build and enhance its health information infrastructure. The North Carolina General Assembly created the NC HIEA in 2015 to modernize health information exchange services in North Carolina for health care providers and patients through the system, known as NC HealthConnex.15,16 The agency operates under the oversight of the North Carolina Department of Information Technology and supports state health information technology priorities across the state.

NC HealthConnex is one of the largest statewide HIEs in the country, connecting over 8000 physical care sites ranging from acute care hospitals and clinics to specialty care providers, local health departments, behavioral health providers, dental offices, emergency medical services, laboratories, correctional facility health centers, and more.17 Its breadth can largely be attributed to the Statewide Health Information Exchange Act of 2015, which compels most North Carolina health care providers to connect their patient systems of record to NC HealthConnex and share near real-time clinical data on state-funded patients.15 Rural providers have steadily increased over time, with an average of 54 rural providers connected to NC HealthConnex each year since 2016 (NC Health Information Exchange Authority, unpublished internal operational analysis, 2026).

The aim of NC HealthConnex is two-fold: 1) to support the movement of health data to allow a patient’s health records to follow them wherever they may go, and 2) to support the health data needs of partner agencies, health-related organizations, and health researchers, as permitted by local, state, and federal patient privacy laws.

NC HealthConnex offers a robust suite of services, including bidirectional integrations that allow a view of patient history within a provider’s electronic record system; a searchable Clinical Portal containing consolidated, longitudinal records; a monthly average of 45 million incoming alerts a month to providers notifying them of patient admissions, discharge, and transfers; and 12 million incoming continuity-of-care documents.17,18 These services also include NC*Notify event notification services that send an average of 10 million alerts per month, public health reporting and surveillance services, data access services for HIPAA-permitted purposes, and more.18,19 Connected health care providers in North Carolina leverage these services to improve care coordination, prompt conversations with patients and other providers, reduce duplicative tests and procedures, and improve efficiency to ensure patients receive the best possible care and assistance at the right time, in the right place.

Key Strategies and Innovations

Leveraging NC HealthConnex to Improve Whole-Person Care

In addition to its core services, NC HIEA has leveraged its infrastructure to innovate and meet some of the state’s most pressing rural health data needs. In September 2018, Hurricane Florence prompted rapid integration with five neighboring statewide HIEs, resulting in substantial patient record queries from out-of-state to better inform the treatment of North Carolinians seeking care elsewhere (NC Health Information Exchange Authority, unpublished internal operational analysis, 2026). NC HIEA also partnered with the North Carolina Department of Health and Human Services (NCDHHS) Command Centers during the disaster to provide NC HealthConnex Clinical Portal access to emergency workers. When Hurricane Helene descended upon Western North Carolina in September 2024, NC HIEA leveraged NC HealthConnex to provide state agencies with timely and actionable information by identifying the most recent locations and medical care received by vulnerable populations and missing persons.20,21

With the arrival of the Centers for Medicare and Medicaid Services’ (CMS) Rural Health Transformation Program (RHTP), North Carolina is poised to not only close interoperability gaps in many rural areas but invest in creating a deeply engaged and technology-driven model for rural communities of care. The RHTP is a 5-year, $50 billion investment in improving the health of rural communities. The first $25 billion from the RHTP will be split evenly between all 50 states and will equal about $200 million each year for the next five years for North Carolina. The second $25 billion will be split at CMS’s discretion among all 50 states over the next five years.22

Partnership Development and Sustainability

Partnerships are the key to sustainability in health care. Since its inception, NC HIEA has partnered with public health authorities, NC Medicaid, researchers, and rural communities to use the NC HealthConnex infrastructure and data services to tackle myriad health challenges and solutions to close care gaps in rural areas. These include projects like tracking stroke risk and enabling interventions in Eastern North Carolina, improving health care quality measurement and insights on social determinants of health, improving birth outcomes for Black mothers, and, potentially, analyzing the health outcomes of patients residing in rural counties identified by the Centers for Disease Control and Prevention (CDC) as exposure areas for water contamination.17,23–25

As part of North Carolina’s RHTP, NC HIEA is continuing its partnership with NCDHHS to establish a Rural Health Transformation Steering Workgroup and provider convenings to elevate the voices of rural provider communities. This workgroup will include a diverse group of stakeholders from rural communities across the state of North Carolina to provide input and support NC HIEA’s strategic goals for the North Carolina RHTP.26 These ambassadors will help NC HIEA understand where the agency is with this work and where it wants to go. Provider convenings will set the stage for dialogue between rural providers and NC HIEA to understand the on-the-ground challenges with connectivity to and use of NC HealthConnex and to inform program design that addresses those challenges.

NC HIEA has fostered a community partnership with North Carolina Area Health Education Centers (NC AHEC), which seeks to bolster the health care workforce and support the implementation and adoption of HIEs in underserved and rural areas. This partnership promotes interoperability among rural provider communities by providing clinical practices with coaches who offer trainings and workshops on how to utilize NC HealthConnex for clinical workflows, address clinical silos, and improve secure access to patient records. These resources empower communities to feel comfortable using NC HealthConnex in their practices and create better systems of care.

HIE Opportunities and Risks

Despite the promise of HIE technologies to support rural communities’ health needs, barriers to accessing and using interoperable technologies remain high. The realities of geographic isolation, constrained finances, and workforce limitations in rural communities require HIE solutions that provide access to a wide range of information, are affordable to implement and maintain, and are easy to use.

Policy Considerations and Funding Investments

US Public Law 119-21, the HR-1 Act, created the RHTP to strengthen rural communities across the United States by improving health care access, quality, and outcomes through the transformation of the health care delivery ecosystem.22 The state of North Carolina was awarded $213 million in year one for the RHTP.27 NC HIEA is partnering with NCDHHS to support the implementation of the RHTP technology initiative through the expansion of NC HealthConnex. This investment includes the acceleration of technological innovation, access, and interoperability through increased health information exchange participation.

Conclusion

North Carolina has set the stage for digital innovation and health improvement by leveraging health system interoperability. NC HealthConnex helps address challenges in accessing and using interoperable technology to address whole-person care. It allows rural providers and patients access to a wide range of clinical, claims, and social determinants of health information from data sources across the state and addresses infrastructural barriers such as affordability and inadequate health IT training to improve adoption by clinical providers. Emerging technological investments, such as RHTP, will continue to transform how health care is delivered in North Carolina and amplify impact for rural North Carolinians through the statewide use and growth of health system interoperability.

Acknowledgments

Stevens Amendment Disclosure: This publication is supported by the Centers for Medicare & Medicaid Services (CMS) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $213,008,356.47 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CMS/HHS or the US Government.

Correspondence

Address correspondence to Janet Oputa (janet.oputa@nc.gov).