© 2016 Wolters Kluwer Health, Inc. All rights reserved. Background: Despite the potential of health information exchange (HIE) to improve safety and reduce cost, hospitals have been slow to adopt HIE with only 30% of U.S. hospitals doing so in 2012. Purpose: The aim of this study was to explore the relationship between different health system types and how they engage in HIE. Methods: Data on health system types and engagement in HIE activity were combined with secondary hospital characteristics. Ordinal logistic regression analyses were used to examine the relationship between a scale measuring the level of HIE engagement and health system type controlling for hospital and market characteristics. Results: Data from 1552 hospitals were available for analyses. Overall, hospital in a health system of any kind exchanged more patient data elements (e.g., patient demographics, clinical summaries, laboratory results, medication history, and radiology report) compared with stand-alone hospitals (3.82 vs. 1.80, p G.001). Overall, 62.2% of hospitals were part of a health system, and among system hospitals, 125 (8.0%) were in centralized health systems, 75 (4.8%) were in centralized physician/insurance health system, 284 (18.3%) were in moderately centralized health system, 391 (25.2%) were in decentralized health system, and 91 (5.9%) were in independent health system. In regression analyses, hospitals belonging to a health system were more likely to exchange patient health data with other hospitals in the same system (OR = 3.94, p G.001) but not with hospitals outside their system (OR = 1.89, p =.445). Across health system types, there was no significant difference in the exchange of patient health data. Practice Implications: Hospital engagement in HIE is associated with health system membership. These findings will assist hospital leaders and managers to better understand how the structure and nature of their system may influence what their individual hospital can and cannot do in their decision to engage in HIE and other decisions that support the overall system objectives.