Health Information Exchange Initiatives Research Articles

Barriers and facilitators to a health information exchange system between general practitioners and hospitals: a qualitative study in Southern Switzerland.

Health information exchange (HIE) systems are computer tools that healthcare providers use to share patients' medical information electronically. Our study aimed to identify barriers and facilitators perceived by general practitioners (GPs) when using an HIE system in the Canton of Ticino, a region in southern Switzerland. We performed a qualitative study using semi-structured interviews. Ten GPs participated in the study. We analysed transcripts using thematic content analysis and following an abductive approach (a mix of deductive and inductive approaches). Our findings indicate the following main facilitators of the HIE system: (a) the perception of having to do with a secure system; (b) the possibility of delegating its management to secretaries and healthcare assistants; (c) technical support and training; (d) high quality of the information exchanged; (e) positive impact on clinical practice; and (f) regional context. However, major challenges still persist, and GPs reported the following main barriers to using an HIE system: (a) a frequent lack of all the patient documentation they needed; (b) no effective workflow improvements; and (c) lack of some technical features. The results of our study provide a qualitative perspective of opinions and experiences of GPs that can inform improvements of the current HIE system and future federal and cantonal HIE initiatives in Switzerland and elsewhere.

The role of patient engagement in patient-centric health information exchange (HIE) initiatives: an empirical study in the United States

PurposePatient-centric exchanges, a major type of Health Information Exchange (HIE), empower patients to aggregate and manage their health information. This exchange model helps patients access, modify and share their medical information with multiple healthcare organizations. Although existing studies examine patient engagement, more research is required to investigate patients' attitudes and willingness to play an active role in patient-centered information exchange. The study's main objective is to develop a model based on the belief-attitude-intention paradigm to empirically examine the effects of patients' attitudes toward engagement in care on their willingness to participate in patient-centric HIE.Design/methodology/approachThe authors conducted an online survey study to identify the antecedents and consequences of patients' attitudes toward engagement in care. To empirically test the research model, the authors collected data from a national sample (n = 357) of individuals in the United States. The data were analyzed using structural equation modeling (SEM).FindingsThe proposed model categorizes the antecedents to patients' attitudes toward engagement in patient-related and healthcare system factors. The results show that patient-related factors (perceived health literacy and perceived coping ability) and health system factors (perceived experience with the healthcare organization and perceived patient-provider interaction) significantly shape patient attitude toward care management engagement. The results indicate that patients' attitudes toward engaging in their healthcare significantly contribute to their willingness to participate in medical information sharing through patient-centric HIE initiatives. Moreover, the authors’ findings also demonstrate that the link between patient engagement and willingness to participate in HIE is stronger for individuals who perceive lower levels of privacy and security concerns.Originality/valueThe authors validate the proposed model explaining patients' perceptions about their characteristics and the healthcare system significantly influence their attitude toward engaging in their care. This study also suggests that patients' favorable attitude toward engagement can bring patient-centric HIE efforts onto a path to success. The authors’ research attempts to shed light on the importance of patients' roles in adopting patient-centric HIE initiatives. Theoretical and practical contributions of this study are noticeable since they could result in a deeper understanding of the concept of patient engagement and how it may affect healthcare services in an evolving digital world. The authors’ findings can help healthcare organizations provide public citizen-centric services by introducing user-oriented approaches in healthcare delivery systems.

The Impacts of the Perceived Transparency of Privacy Policies and Trust in Providers for Building Trust in Health Information Exchange: Empirical Study.

BackgroundIn the context of exchange technologies, such as health information exchange (HIE), existing technology acceptance theories should be expanded to consider not only the cognitive beliefs resulting in adoption behavior but also the affect provoked by the sharing nature of the technology.ObjectiveWe aimed to study HIE adoption using a trust-centered model. Based on the Theory of Reasoned Action, the technology adoption literature, and the trust transfer mechanism, we theoretically explained and empirically tested the impacts of the perceived transparency of privacy policy and trust in health care providers on cognitive and emotional trust in an HIE. Moreover, we analyzed the effects of cognitive and emotional trust on the intention to opt in to the HIE and willingness to disclose health information.MethodsA Web-based survey was conducted using data from a sample of 493 individuals who were aware of the HIE through experiences with a (or multiple) provider(s) participating in an HIE network.ResultsStructural Equation Modeling analysis results provided empirical support for the proposed model. Our findings indicated that when patients trust in health care providers, and they are aware of HIE security measures, HIE sharing procedures, and privacy terms, they feel more in control, more assured, and less at risk. Moreover, trust in providers has a significant moderating effect on building trust in HIE efforts (P<.05). Results also showed that patient trust in HIE may take the forms of opt-in intentions to HIE and patients’ willingness to disclose health information that are exchanged through the HIE (P<.001).ConclusionsThe results of this research should be of interest to both academics and practitioners. The findings provide an in-depth dimension of the HIE privacy policy that should be addressed by the health care organizations to exchange personal health information in a secure and private manner. This study can contribute to trust transfer theory and enrich the literature on HIE efforts. Primary and secondary care providers can also identify how to leverage the benefit of patients’ trust and trust transfer process to promote HIE initiatives nationwide.

Health systems' use of enterprise health information exchange vs single electronic health record vendor environments and unplanned readmissions.

Enterprise health information exchange (HIE) and a single electronic health record (EHR) vendor solution are 2 information exchange approaches to improve performance and increase the quality of care. This study sought to determine the association between adoption of enterprise HIE vs a single vendor environment and changes in unplanned readmissions. The association between unplanned 30-day readmissions among adult patients and adoption of enterprise HIE or a single vendor environment was measured in a panel of 211 system-member hospitals from 2010 through 2014 using fixed-effects regression models. Sample hospitals were members of health systems in 7 states. Enterprise HIE was defined as self-reported ability to exchange information with other members of the same health system who used different EHR vendors. A single EHR vendor environment reported exchanging information with other health system members, but all using the same EHR vendor. Enterprise HIE adoption was more common among the study sample than EHR (75% vs 24%). However, adoption of a single EHR vendor environment was associated with a 0.8% reduction in the probability of a readmission within 30 days of discharge. The estimated impact of adopting an enterprise HIE strategy on readmissions was smaller and not statically significant. Reductions in the probability of an unplanned readmission after a hospital adopts a single vendor environment suggests that HIE technologies can better support the aim of higher quality care. Additionally, health systems may benefit more from a single vendor environment approach than attempting to foster exchange across multiple EHR vendors.

The Potential of Blockchain Technology for Health Information Exchange: Experimental Study From Patients' Perspectives.

BackgroundNowadays, a number of mechanisms and tools are being used by health care organizations and physicians to electronically exchange the personal health information of patients. The main objectives of different methods of health information exchange (HIE) are to reduce health care costs, minimize medical errors, and improve the coordination of interorganizational information exchange across health care entities. The main challenges associated with the common HIE systems are privacy concerns, security risks, low visibility of system transparency, and lack of patient control. Blockchain technology is likely to disrupt the current information exchange models utilized in the health care industry.ObjectiveLittle is known about patients’ perceptions and attitudes toward the implementation of blockchain-enabled HIE networks, and it is still not clear if patients (as one of the main HIE stakeholders) are likely to opt in to the applications of this technology in HIE initiatives. Thus, this study aimed at exploring the core value of blockchain technology in the health care industry from health care consumers’ views.MethodsTo recognize the potential applications of blockchain technology in health care practices, we designed 16 information exchange scenarios for controlled Web-based experiments. Overall, 2013 respondents participated in 16 Web-based experiments. Each experiment described an information exchange condition characterized by 4 exchange mechanisms (ie, direct, lookup, patient-centered, and blockchain), 2 types of health information (ie, sensitive vs nonsensitive), and 2 types of privacy policy (weak vs strong).ResultsThe findings show that there are significant differences in patients’ perceptions of various exchange mechanisms with regard to patient privacy concern, trust in competency and integrity, opt-in intention, and willingness to share information. Interestingly, participants hold a favorable attitude toward the implementation of blockchain-based exchange mechanisms for privacy protection, coordination, and information exchange purposes. This study proposed the potentials and limitations of a blockchain-based attempt in the HIE context.ConclusionsThe results of this research should be of interest to both academics and practitioners. The findings propose potential limitations of a blockchain-based HIE that should be addressed by health care organizations to exchange personal health information in a secure and private manner. This study can contribute to the research in the blockchain area and enrich the literature on the use of blockchain in HIE efforts. Practitioners can also identify how to leverage the benefit of blockchain to promote HIE initiatives nationwide.

The benefits of health information exchange: an updated systematic review.

Widespread health information exchange (HIE) is a national objective motivated by the promise of improved care and a reduction in costs. Previous reviews have found little rigorous evidence that HIE positively affects these anticipated benefits. However, early studies of HIE were methodologically limited. The purpose of the current study is to review the recent literature on the impact of HIE. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct our systematic review. PubMed and Scopus databases were used to identify empirical articles that evaluated HIE in the context of a health care outcome. Our search strategy identified 24 articles that included 63 individual analyses. The majority of the studies were from the United States representing 9 states; and about 40% of the included analyses occurred in a handful of HIEs from the state of New York. Seven of the 24 studies used designs suitable for causal inference and all reported some beneficial effect from HIE; none reported adverse effects. The current systematic review found that studies with more rigorous designs all reported benefits from HIE. Such benefits include fewer duplicated procedures, reduced imaging, lower costs, and improved patient safety. We also found that studies evaluating community HIEs were more likely to find benefits than studies that evaluated enterprise HIEs or vendor-mediated exchanges. Overall, these finding bode well for the HIEs ability to deliver on anticipated improvements in care delivery and reduction in costs.

A population ecology perspective on the functioning and future of health information organizations.

Increasingly, health care providers need to exchange information to meet policy expectations and business needs. A variety of health information organizations (HIOs) provide services to facilitate health information exchange (HIE). However, the future of these organizations is unclear. The aim of this study was to explore the environmental context, potential futures, and survivability of community HIOs, enterprise HIEs, and electronic health record vendor-mediated exchange using the population ecology theory. Qualitative interviews with 33 key informants representing each type of HIE organization were analyzed using template analysis. Community HIOs, enterprise HIEs, and electronic health record vendors exhibited a high degree of competition for resources, especially in the area of exchange infrastructure services. Competition resulted in closures in some areas. In response to environmental pressures, each organizational type was endeavoring to differentiate its services and unique use case, as well as pursing symbiotic relationships or attempting resource partitioning. HIOs compete for similar resources and are reacting to environmental pressures to better position themselves for continued survival and success. Our ecological research perspective helps move the discourse away from situation of a single exchange organization type toward a view of the broader dynamics and relationships of all organizations involved in facilitating HIE activities. HIOs are attempting to partition the environment and differentiate services. HIE options should not be construed as an "either/or" decision, but one where multiple and complementary participation may be required.

The implications and impact of 3 approaches to health information exchange: community, enterprise, and vendor-mediated health information exchange.

IntroductionElectronic health information exchange (HIE) is considered essential to establishing a learning health system, reducing medical errors, and improving efficiency, but establishment of widespread, high functioning HIE has been challenging. Healthcare organizations now have considerable flexibility in selecting among several HIE strategies, most prominently community HIE, enterprise HIE (led by a healthcare organization), and electronic health record vendor‐mediated HIE. Each of these strategies is characterized by different conveners, capabilities, and motivations and may have different abilities to facilitate improved patient care.MethodsI reviewed the available scholarly literature to draw conceptual distinctions between these types of HIE, to assess the current evidence on each type of HIE, and to indicate important areas of future research.ResultsWhile community HIE seems to offer the most open approach to HIE allowing for high levels of connectivity, both enterprise HIE and vendor‐mediated HIE face lower barriers to formation and sustainability. Most existing evidence is focused on community HIE and points towards low overall use, challenges to usability, and ambiguous impact. To better guide organizational leaders and policymakers in the expansion of beneficial HIE and anticipate future trends, future research should work to better capture the prevalence of other forms of HIE, and to adopt common methods to allow comparisons of rate of use, usability, and impact on patient care across studies and types of HIE.ConclusionsHealthcare organizations' choice of HIE strategy influences the set of partners the organization is connected to and may influence the benefit that efforts supported by HIE can offer to patients. Current research is not fully capturing the diversity of approaches to HIE and their potentially varying impact on providers and patients.

Sustainability strategies for regional health information organization startups

ObjectivesSimilar to other Western healthcare systems, the U.S. has sought to build a national infrastructure to enable widespread electronic health information exchange (HIE). The 2009 U.S. HITECH Act׳s State HIE Cooperative Agreement Program (SHIECAP) was a short-term catalyst for bottom-up HIE initiatives by states and regional health information organizations (HIOs). Given the high failure rates of regional U.S. HIOs in the past, our primary objective is to identify the key characteristics of HIO startups that became operational and demonstrated sustainability with non-renewable SHIECAP funding in a state environment with very minimal prior HIE activities. MethodsBased on interview data we collected from 22 stakeholders in New Jersey (NJ) at the state, HIO, and hospital levels, we apply grounded theory techniques to identify cross-case similarities and differences. ResultsAlthough the three NJ HIOs that became operational during the SHIECAP grant period faced similar startup challenges, the two HIOs that demonstrated sustainability pursued distinct technology and sustainability strategies to develop HIE capabilities to fit their very different regional needs: an HIE capability to improve the population health of an underserved urban population, and an HIE capability to enable the transition to a healthcare landscape that rewards care coordination across suburban hospitals and physician practices. ConclusionsWe propose two models of technology and sustainability strategies for developing bottom-up HIE capabilities for different regional populations. Future research within and beyond U.S. contexts needs to take into account these key characteristics to improve our understanding of effective policy levers and government funding mechanisms.

Differing Strategies to Meet Information-Sharing Needs: Publicly Supported Community Health Information Exchanges Versus Health Systems' Enterprise Health Information Exchanges.

Community health information exchanges have the characteristics of a public good, and they support population health initiatives at the state and national levels. However, current policy equally incentivizes health systems to create their own information exchanges covering more narrowly defined populations. Noninteroperable electronic health records and vendors' expensive custom interfaces are hindering health information exchanges. Moreover, vendors are imposing the costs of interoperability on health systems and community health information exchanges. Health systems are creating networks of targeted physicians and facilities by funding connections to their own enterprise health information exchanges. These private networks may change referral patterns and foster more integration with outpatient providers. The United States has invested billions of dollars to encourage the adoption of and implement the information technologies necessary for health information exchange (HIE), enabling providers to efficiently and effectively share patient information with other providers. Health care providers now have multiple options for obtaining and sharing patient information. Community HIEs facilitate information sharing for a broad group of providers within a region. Enterprise HIEs are operated by health systems and share information among affiliated hospitals and providers. We sought to identify why hospitals and health systems choose either to participate in community HIEs or to establish enterprise HIEs. We conducted semistructured interviews with 40 policymakers, community and enterprise HIE leaders, and health care executives from 19 different organizations. Our qualitative analysis used a general inductive and comparative approach to identify factors influencing participation in, and the success of, each approach to HIE. Enterprise HIEs support health systems' strategic goals through the control of an information technology network consisting of desired trading partners. Community HIEs support obtaining patient information from the broadest set of providers, but with more dispersed benefits to all participants, the community, and patients. Although not an either/or decision, community and enterprise HIEs compete for finite organizational resources like time, skilled staff, and money. Both approaches face challenges due to vendor costs and less-than-interoperable technology. Both community and enterprise HIEs support aggregating clinical data and following patients across settings. Although they can be complementary, community and enterprise HIEs nonetheless compete for providers' attention and organizational resources. Health policymakers might try to encourage the type of widespread information exchange pursued by community HIEs, but the business case for enterprise HIEs clearly is stronger. The sustainability of a community HIE, potentially a public good, may necessitate ongoing public funding and supportive regulation.

Challenges, Alternatives, and Paths to Sustainability for Health Information Exchange Efforts

Health information exchange (HIE) is a promising approach to improving the cost and quality of healthcare. We sought to identify the strengths and weaknesses of organizational models to achieve exchange, and what can be done to ensure the sustainability and effectiveness of exchange efforts. We interviewed state and national health informatics policy experts (n = 17). Data were collected as part of an evaluation of the Health Care Efficiency and Affordability Law for New Yorkers (HEAL NY) program and included respondents from both the private and public sectors. Data were analyzed using a general inductive and comparative approach with open coding of themes. Interviewees generally viewed HIE as a public or societal good to be valued. However, they identified challenges with the regional health information organization (RHIO) model of facilitating exchange including: economics, organizational issues, and geography. RHIOs were contrasted against alternative methods of exchange such as Direct, enterprise HIE, and vendor-mediated exchange. HIE is a difficult undertaking due to political and economic reasons. Alternatives to the RHIO model have features that may be more attractive to participants, but may be of less public benefit. Using states as intermediaries and mandating exchange under public health law may avoid the challenges facing exchange efforts. Moving forward, policies will have to address the shortcomings of each HIE model to ensure information is effectively shared between providers to maximize health benefits.

Infection preventionists' awareness of and engagement in health information exchange to improve public health surveillance

Advances in electronic health record (EHR) systems and health information exchange (HIE) are shifting efforts in public health toward greater use of information systems to automate notifiable disease surveillance. Little is known about infection preventionists' (IPs) awareness, adoption, and use of these technologies to report information to public health. To measure awareness and engagement in EHR and HIE activities, an online survey of IPs was conducted in states with HIE networks. A total of 63 IPs was invited to participate; 44 IPs (69%) responded. The survey asked about the adoption and use of EHR systems, participation in regional HIE initiatives, and IP needs with respect to EHR systems and public health reporting. Over 70% of responding IPs reported access to an EHR system, but less than 20% of IPs with access to an EHR reported being involved in the design, selection, or implementation of the system. Just 10% of IPs reported that their organizations were formally engaged in HIE activities, and 49% were unaware of organizational involvement in HIE. IPs expressed a desire for better decision support, paperless reporting methods, and situational awareness of community outbreaks. Many IPs lack awareness and engagement in EHR and HIE activities, which may limit IPs ability to influence or utilize key information technologies as they are implemented in health care organizations.

The Litmus Test for Health Information Exchange Success: Will Small Practices Participate?

The Litmus Test for Health Information Exchange Success: Will Small Practices Participate?