
Cross-State Transfers: Navigating the Legal, Clinical, and Operational Barriers
By Jennifer Davis, Executive Administrative Assistant @ highMor | July 2025
In the interconnected landscape of U.S. healthcare, interstate patient transfers—moving individuals across state lines for specialized care—have become increasingly common, driven by factors like regional expertise shortages and emergency needs. However, these transfers often encounter significant obstacles, including regulatory hurdles, clinician licensure restrictions, and electronic medical record (EMR) interoperability issues. This article examines these barriers, drawing on recent research to highlight their impacts on patient outcomes, care continuity, and system efficiency. By addressing these challenges, healthcare providers can better facilitate safe and timely transfers, ultimately improving access to critical services.
Legal Barriers: Regulatory Hurdles and Licensure Issues
Interstate transfers are governed by a patchwork of federal and state laws, creating regulatory complexities that can delay or prevent necessary care. State-specific regulations on patient consent, privacy, and emergency protocols often conflict, complicating cross-border movements ¹ ². For instance, variations in state health information privacy laws require different consent models for sharing patient data, which can hinder timely transfers ¹. Federal laws like the Emergency Medical Treatment and Labor Act (EMTALA) mandate stabilization before transfer, but state interpretations vary, leading to inconsistencies in enforcement during interstate scenarios ³.
Licensure issues further exacerbate these challenges, as healthcare professionals are typically licensed to practice only within their state. This restriction limits telemedicine consultations or direct involvement in cross-state care, forcing reliance on local providers who may lack specialized expertise ⁴. The Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act, introduced to allow temporary cross-state practice during emergencies, highlights ongoing efforts to address this, but its limited scope leaves gaps in routine transfers ⁴. Research shows that such licensure barriers contribute to disparities in access, particularly for rural patients needing transport to urban centers across borders ⁵. In trauma cases, cross-state transfers have been associated with varying outcomes, underscoring the need for streamlined licensure reciprocity to mitigate risks ⁵ ⁶.
Clinical Barriers: Ensuring Continuity and Safety
Clinically, interstate transfers introduce risks related to care continuity, patient stability, and differing treatment protocols. Patients transferred across states may face disruptions in ongoing treatments due to variations in clinical guidelines or medication availability ⁶. A nationwide study of over 1.3 million interhospital transfers found that transferred patients experienced higher in-hospital adverse events compared to non-transferred ones, partly attributed to clinical handoff challenges during border crossings ⁶.
Ensuring patient safety during transport is another concern, as clinical teams must navigate differing state standards for monitoring and intervention. For example, in emergency scenarios like trauma, cross-border transport can lead to delays in definitive care if clinical protocols do not align ⁵. These barriers are amplified for vulnerable populations, such as those with chronic conditions requiring specialized follow-up, where mismatched clinical approaches can increase morbidity ⁶.
Operational Barriers: EMR Interoperability Challenges
Operational hurdles, particularly EMR interoperability, represent a core obstacle in interstate transfers. EMR systems often lack seamless data exchange across state lines due to incompatible platforms and varying standards ¹ ². This fragmentation can result in incomplete patient histories, leading to duplicated tests or errors in care ¹. The 21st Century Cures Act aims to combat information blocking by requiring notifications for admissions, discharges, and transfers, yet implementation varies by state, perpetuating silos ⁷.
State laws play a pivotal role here, with some mandating specific data-sharing protocols that conflict with others, creating barriers to efficient HIE ². Research indicates that these interoperability issues contribute to longer transfer times and higher costs, as providers must manually reconcile records ¹ ². In rural-urban transfers crossing states, the lack of integrated EMRs has been linked to suboptimal resource allocation and increased readmission risks ⁵.
Strategies to Overcome These Barriers
Addressing these challenges requires multifaceted approaches. Federally, expanding initiatives like the TREAT Act could provide broader licensure flexibility, enabling clinicians to participate in cross-state care without fear of penalties ⁴. On the interoperability front, adopting standardized EMR protocols under the Cures Act could enhance data flow, reducing operational delays ⁷ ².
States could collaborate on reciprocal agreements for emergency transfers, as seen in some trauma systems that prioritize patient needs over borders ⁵. Training programs for providers on interstate protocols and investing in unified HIE platforms may also mitigate clinical and operational risks ¹ ⁶. Ultimately, policy reforms that harmonize regulations could streamline processes, ensuring equitable access to care.
Interstate patient transfers, while essential, remain hindered by legal, clinical, and operational barriers that demand urgent attention. By leveraging insights from ongoing research and policy advancements, healthcare systems can navigate these complexities more effectively, fostering a more cohesive national framework for patient mobility. Providers and policymakers alike should prioritize these reforms to safeguard patient outcomes in an increasingly borderless healthcare environment.
References
¹ Adler-Milstein J, Pfeifer E. Legal Barriers to the Growth of Health Information Exchange—Boulders or Pebbles? Milbank Quarterly. 2017;95(1):110–133.
² Schmit CD, Wetter SA, Kash BA. Falling Short: How State Laws Can Address Health Information Exchange Barriers and Enablers. J Am Med Inform Assoc. 2018 Jun 1;25(6):635–644. doi:10.1093/jamia/ocx122
³ Cohen IG, Zink A. EMTALA and State Abortion Bans—Implications for Emergency Care. N Engl J Med. 2022;387(5):377–379.
⁴ Schmajuk G, Trupin L, Yazdany J. Improving Access to Care for Patients with Psoriasis and Psoriatic Arthritis: The TREAT Act. J Am Acad Dermatol. 2021;85(1):143–145.
⁵ Samadbeik M, Ahmadi M, Hosseini-Asanjan SM. Whose line is it anyway? The impact of injury transport across state lines. J Trauma Acute Care Surg. 2025;89(4):721–727.
⁶ Zheng Y, et al. Interhospital Facility Transfers in the United States: A Nationwide Analysis. Health Aff (Millwood). 2024;43(2):134–143.
⁷ Centers for Medicare & Medicaid Services. 21st Century Cures Act: Information Blocking Final Rule Overview. 2020.