INTRODUCTION

Health Information Exchange (HIE) is a system that enables healthcare professionals to securely access and share patient medical records in a standardized electronic format. The adoption of HIE has greatly enhanced the quality of patient care.¹ Historically, medical records were exchanged via fax, email, or phone, resulting in delays and inadequacies.^1,2 With HIE, healthcare providers can access a patient’s medical history almost instantly, allowing more efficient, secure, and appropriate care delivery.^1,2

Conventionally, various healthcare providers maintained separate patient records—either on paper format or electronically—resulting in fragmented and incomplete medical histories at any given location.³ This fragmentation adversely impacted patient care and therapeutic outcomes.^1,2 To improve healthcare quality and efficiency, it is crucial for organizations to facilitate the electronic sharing of patient information, guaranteeing that physicians have prompt access to complete clinical information across various care settings, which ultimately supports better decision-making. HIE enables the electronic sharing of health data among healthcare organizations based on nationally accepted and recognized standards.⁴ Its main goal is to deliver the correct information to the right person at the exact time. In a wider context, HIE seeks to enhance healthcare effectiveness, minimize medical errors, decrease costs, and boost patient satisfaction.^1,2 Furthermore, beyond direct patient care, data sharing facilitates quality improvement, public health exploration, and clinical research studies.⁵

In the United Arab Emirates (UAE), three regulatory organizations supervise healthcare providers: the Ministry of Health and Prevention, the Dubai Health Authority (DHA), and the Abu Dhabi Department of Health. Every authority oversees a particular geographic region. HIE has been deployed among these regulators under various names: Riayati,⁶ Nabidh,⁷ and Malaffi.⁸ The primary goal of these HIEs is to promote the adoption and utilization of digital health solutions nationwide. HIE aims to provide healthcare practitioners a comprehensive, real-time overview of a patient’s medical history, ensuring accessibility at any time and place. Through the unified system architecture and standards, the goal is to connect patient records across healthcare facilities and establish a nationwide health information network. Despite the potential advantages for patients, healthcare providers, and institutions, and despite ongoing efforts to promote HIE over the past five years, challenges have often outweighed successes.

In this article, the authors describe adoption and integration of Nabidh HIE in the UAE and examine the barriers to HIE implementation, aiming to learn from past efforts and improve the likelihood of successful HIE integration in the future.

Implementation Process and Requirements

In October 2020, Dubai Health Authority (DHA) initiated HIE implementation. As per DHA health facilities licensing department, there were 5370 facilities actively providing health services in Dubai. However, 29 categories were selected by DHA Physician’s Advisory Committee for initial onboarding in the first phase. To make the selections, the Committee reviewed the scope of work of different healthcare facilities categories. In March 2025, the authors carried out a situation analysis to assess the healthcare facilities integrated (or in the process of integrating) with Nabidh HIE by reviewing historical reports. Patient data included medication histories, allergies, lab results, diagnoses, and treatment plans, among other vital information. Overall, 1527 out of 2572 (59.5%) healthcare facilities in Dubai were integrated into Nabidh HIE from October 2020 to March 2025 (Table 1).

During the initiation of Nabidh HIE integration, there was an urgent need for unified Clinical Data Coding and Terminology standards to be adopted by all healthcare facilities, since they were using various standards that were not technically compatible with Nabidh integration. To ensure seamless interoperability, healthcare facilities were required to use standardized nomenclatures and code sets for clinical problems, diagnoses, procedures, medications, and other mandated Nabidh datasets. Compliance with NABIDH’s published standards (Table 2) was mandatory for all healthcare facilities. Likewise, use of unified Interoperability and Data Exchange standards (Table 2) was required by all healthcare facilities being integrated.

Although some facilities had EMRs, their technical capabilities were not sufficient to enable integration with Nabidh HIE. To address this, we mandated all facilities to adopt an EMR with at least Healthcare Information and Management Systems Society (HIMSS) Electronic Medical Record Adoption Model (EMRAM)⁹ Level 2 specifications. This process was challenging, as it placed a financial burden on the facilities. However, we overcame this obstacle by collaborating with EMR providers who could offer systems that met the required specifications. To facilitate the transition, these approved EMR providers were listed in the Nabidh HIE.^7,10

Poor data quality was a significant challenge during the implementation of HIE. While healthcare facilities were integrated with the HIE, the data submitted often lacked accuracy and completeness. Missing demographic details and clinical documentation were common issues, and in some cases, no data was transmitted to HIE for days. Additionally, data duplication within the same facility, including multiple medical record numbers for the same patient, further compromised data integrity. These factors collectively had a negative impact on the overall data quality within HIE.

There was also a large gap in the technical manpower of HIE within the country, which was evident at the beginning of the project. For this purpose, we employed contractors to supportin backend troubleshooting. This approach had cost benefits for implementation, as we did not have to physically accommodate the manpower but could still have our own technical staff trained by the outsources team.

Another challenge was integrating laboratories into the Nabidh HIE. To address this, we mandated all medical laboratories to adopt Logical Observation Identifiers Names and Codes (LOINC).¹¹ This standardized coding system enhanced communication within integrated healthcare systems, automated the transfer of reportable communicable disease cases to public health authorities, and provided an interoperable terminology framework. As a result, it improved patient care and helped reduce costs associated with unnecessary duplicate testing.

The implementation of these codes in medical laboratories began in 2021 and is still ongoing as of this report (2025).

Approximately 10% of all laboratory reports are still provided in PDF format, making seamless integration with Nabidh HIE challenging. To address this, we enabled the option to upload laboratory results in PDF format. Laboratories encountered challenges in accurately identifying appropriate LOINC codes, considering factors such as result units, specimen types, dynamic hormonal testing, and newly introduced viral serological tests. Assigning LOINC codes for microbiology was particularly complex due to the nature of services, which required mapping for direct exams, colony counts, cultures, and individual drug susceptibility tests across various culture orders. Additionally, certain genetic laboratory panels, such as hemoglobin screening packages, lacked suitable LOINC codes. Another obstacle was the selection of LOINC codes for reference labs providing integrated lab services, as some reference laboratories struggled to find appropriate LOINC codes that matched the specific properties of their performed tests.

Another challenge arose when facilities already onboarded to Nabidh HIE opted to change their EMR provider for financial or technical reasons. This posed a significant obstacle, as the facility was treated as a newly unintegrated entity, leading to longer integration waiting time. To address this issue, we developed a guideline on transitioning EMR mandates, ensuring a smoother and more efficient migration process.¹² As per this guideline, facilities intending to change their EMR due to any reason were mandated to: 1) inform Nabidh HIE in advance, 2) make sure their new EMR is as per Nabidh HIE mandates, and 3) limit the process of EMR transition to no more than 3 months for clinics and 6 months for hospitals. This guideline assisted significantly in further regulating the change of EMR challenge.

Privacy was commonly reported as a major barrier to the adoption of HIE systems, as patients hesitate to participate and consent to the use of their health information because of concerns about their privacy.¹³ Concerns include identity theft or fraud; unauthorized access of information about a patient’s mental health, chemical dependency, and genetics; using information for purposes other than for patient care.¹⁴ One explanation for this concern is that patients may not have had enough education concerning the value of HIE and how it would benefit the quality of their care. To address this challenge, we reassured patients that sensitive health information would not be shared or accessed through HIE. However, the volume of HIE opt-out requests exceeded our expectations. As a result, we decided to centralize the opt-out process, requiring healthcare facilities to submit these requests so that we could handle them individually.

DISCUSSION

We have outlined the journey of Nabidh HIE in Dubai since its inception in October 2020. We evaluated the adoption of HIE based on its enhancement essential functions, such as incorporating clinical decision support into healthcare platforms, automating the collection of patient-reported outcomes, and promoting population health management initiatives, especially as the use of basic EMRs gained broader usage. In Dubai, the deployment of HIE across healthcare facilities continues to mature. Our examination of the current state and challenges of HIE adoption revealed several obstacles, including the absence of EMRs in some healthcare facilities, low EMRAM scores, and noncompliance with required interoperability standards due to limited awareness of available vendors and pertinent standards. Additionally, factors such as funding constraints, difficulties in developing policies, and resistance within organizations have created significant barriers to the successful implementation of HIE.

One of the primary obstacles hindering EMR adoption is high cost and return on investment, which subsequently impacts the adoption of HIE. Financial concerns include start-up expenses and ongoing cost, alongside long-term financial uncertainties and sustainability concerns.¹⁵ The involvement of stakeholders (physicians, healthcare organizations, patients, etc.) greatly influences the success or failure of any HIE; lack of stakeholder interest can stop any project completely. HIE initiatives necessitate collaboration among competing entities to share their most valued assets: patients data and their information. Organizations are typically concerned about data ownership and control, unauthorized access and use of the data, and potential financial losses to competitors by providing patients with information and eliminating redundant test and x-rays.¹⁶

Physicians stop using proposed systems when they fail to find information. The lack of adequate information is due to many factors: failure to obtain sufficient participation, poor patient matching process, lack of certain types of clinical information such as discharge summaries or behavioral and mental medications, and patient consent.¹⁶ Another barrier to physician adoption of HIE is related to the impact of HIE on their productivity by the lack of HIE integration into workflows.¹⁷ Finally, a lack of technical skills can cause physicians to abandon HIE systems.^16,17

Lack of patient trust in HIE’s ability to safeguard data from misuse has been reported before.¹⁸ This trust extends beyond the system’s capacity to protect data and ensure quality; it also encompasses the confidence stakeholders have in one another. Among the most discussed organizational and technological barriers, several authors observed a lack of common data standards, a lack of appropriate technical and interoperability resources, a lack of technical support, and a lack of organizational support and training for potential users.^18,19

From our perspective, organizational barriers appear to be the primary obstacles to HIE implementation. The absence of strong organizational support and a well-defined comprehensive strategy are key challenges that hinder its successful adoption. We have noticed that technology availability is not a big challenge in Dubai. Many of the non-technological barriers, such as cost and privacy, impede the adoption and implementation of HIE systems among different settings. Engaging all participants from the beginning will facilitate the adoption process and increase the acceptance level. For instance, involving clinicians in the design phase can help ensure that the system can adapt to their needs, becoming useful to and usable by them. Thus, enlightening stakeholders about HIE values will help them understand and accept the system faster.

Considering diverse user needs and seamlessly integrating HIE with existing systems are essential steps to enhance HIE adoption. We ensured that our policies protected patient privacy and health information confidentiality. The UAE data Protection Law released in 2021 provided a comprehensive legal framework to protect all stakeholders and gain their trust.²⁰ A combination of grants, incentives, and mandates may increase this trust.

Another challenge was the inadequate quality of data shared with HIE. While facilities adhered to our mandate to integrate with Nabidh HIE, they often submitted incomplete or inaccurate health data, including missing demographic and clinical details. To tackle this issue, we implemented a health data quality policy and organized multiple awareness webinars to educate stakeholders on the significance of accurate data submission. Finally, the lack of physician usability has hindered stakeholders’ adoption of HIE systems. Many physicians require ongoing training and support to familiarize themselves with the system’s functionality, address their concerns, and accelerate learning, ultimately encouraging its usage.

One of the main limitations of our study is that it reflects only four years of experience. A longer evaluation period may be required to gain a more comprehensive understanding of the outcomes of Nabidh HIE implementation.

CONCLUSIONS

In Dubai, a major obstacle to HIE adoption is the low rate of interoperability and implementation of messaging standards, which can significantly hinder its success. Therefore, we believe that identifying the challenges in adopting a proper EMR and its associated standards is a crucial first step in enabling seamless HIE integration. Additionally, patient consent for sharing their health information through HIE emerged as a barrier, as some patients were hesitant to share their data. In highlighting the key challenges encountered and the solutions implemented in deploying HIE within the Emirate of Dubai, we hope that our experience can provide valuable insights for other countries in the region to enhance their own HIE initiatives.

Disclosures

The authors have nothing to disclose.

Funding

The authors received no funding for this research.

ACKNOWLEDGMENTS

The authors would like to thank all healthcare facilities in the Emirate of Dubai who participated in implementing the Nabidh HIE.

DATA AVAILABILITY

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.