Stakeholders perspectives and deployment strategies of health information exchange illustrated through an in-depth case study of Pakistan.

: Ready access to reliable data is essential to support decision-making in patient care planning and delivery. Health information exchange (HIE), which is fundamental to achieve this, is currently limited in many low- and middle-income countries (LMICs), reflecting the lack of prioritization of this issue and the many barriers to its successful implementation.: We sought to explore and understand stakeholders' perspectives on the context of and deployment strategies for HIE in Pakistan.Method: Data collection comprised interviews with purposefully selected groups of stakeholders across Pakistan, field notes, and a critical review of key national and international policy documents.: We identified reports of small pockets of effective HIE existing mainly in private hospitals, but in a patchy and fragmented form overall. Many problems were attributed to the absence of effective HIE, these ranging from 'delays in retrieving records' to contributing to 'the increase in antibiotic resistance'. The mindset of policymakers, poor infrastructure, lack of finance, training and data interoperability, and health-care providers' resistance to recording consultations due to poor documentation skills and concerns about liability considerations were highlighted as major barriers to HIE. Sharing regional health information with international organizations was perceived by some participants to increase the risk of regional espionage. A clear government policy directive for evidence-based decision-making, constant supply of electricity, training, widespread adoption of common data standards and public pressure to adopt mobile technology frameworks were identified as potential facilitators of HIE.: HIE can be achieved with the support of the federal and provincial governments coupled with financial and technical backing from international donor organizations. The transition to HIE is likely to be very dependent on improving governance capabilities and bolstering the informatics skill-base in Pakistan and indeed many other LMICs.