Health Information Exchange Access Research Articles

Predictors of clinician use of Australia’s national health information exchange in the emergency Department: An analysis of log data

ObjectiveThis study explores patient and context related factors associated with use of Australia’s national personally controlled Health Information Exchange (HIE), My Health Record, by emergency department (ED) clinicians. Materials and methodsA retrospective analysis explored secondary routinely-collected data including all patients who presented (between August 2019–2021) to the ED at a not-for-profit hospital in Melbourne. Presentation data were linked to the HIE access log-data, and human resources data. The primary outcome indicated HIE access by an ED pharmacist, doctor or nurse, within 3 days of the patient presenting to the ED, or not. Nine variables were explored with logistic regression, representing patient (gender, age, diagnosis) and other factors (presentation time, arrival method, referral, acuity/triage, length of stay, admitted into hospital). ResultsHIE is accessed in 17.43% of patient presentations to the ED, led by pharmacists (15.60%). Overall, as demonstrated in themultivariable analysis, increased HIE access was associated with increasing age, with the biggest effect for 75–84-year old’s (odd’s ratio 26.15; 95% confidence interval 15.37–44.50), when compared to < 4 years of age. HIE access was also significantly and positively associated with patients who were later admitted into hospital from theED (4.96; 4.61–5.34). ConclusionThe results suggest users of HIE in the ED employ the system to meet their needs, but not for all patients. To maximise value derived from HIE use, clinicians should target system access for patients where the benefit of accessing the record outweighs the cost - this research suggests that is for patients who are older in age and are likely to be admitted, potentially linked to greater condition complexity. If the use of a HIE is to improve the provision of care in the ED, the key stakeholders governing patient information within the HIE need to focus on improving clinician recording behaviours for older people and those suffering from complex medical conditions. Doctors and nurses lag behind with respect to the use of the HIE by pharmacists. Therefore, a focus on encouraging HIE engagement across these clinician groups is drastically required.

Substitution and complementarity in the use of health information exchange and electronic medical records

ABSTRACT While considerable literature has addressed the separate use of health information systems, limited research has examined how the use of one system changes following the implementation of another. We address this gap in the literature by developing and testing hypotheses about substitution and complementarity in physicians’ use of health information exchange (HIE), which merges patient data from multiple sources, following the implementation of a local electronic medical record (EMR) system. The hypotheses are anchored in theories foundational to understanding the motivation for information seeking behaviour. The hypotheses are tested with unique data, recorded in system log files, that describe HIE use by physicians in an emergency department before and after EMR implementation. The findings confirm that system use is characterised by substitution when it is defined dichotomously as whether the system is accessed or not (lower HIE access rates after EMR implementation) and by complementarity when it is defined as the extent of system use (higher volume and duration of HIE use after EMR implementation). Our findings suggest that the information seeking literature has underestimated the explanatory value of the cost-benefit approach and the occurrence of complementarity in system use because of its overreliance on a narrow definition of use.

Trends in user-initiated health information exchange in the inpatient, outpatient, and emergency settings

Prior research on health information exchange (HIE) typically measured provider usage through surveys or they summarized the availability of HIE services in a healthcare organization. Few studies utilized user log files. Using HIE access log files, we measured HIE use in real-world clinical settings over a 7-year period (2011-2017). Use of HIE increased in inpatient, outpatient, and emergency department (ED) settings. Further, while extant literature has generally viewed the ED as the most relevant setting for HIE, the greatest change in HIE use was observed in the inpatient setting, followed by the ED setting and then the outpatient setting. Our findings suggest that in addition to federal incentives, the implementation of features that address barriers to access (eg, Single Sign On), as well as value-added services (eg, interoperability with external data sources), may be related to the growth in user-initiated HIE.

Health information exchange between hospital and skilled nursing facilities not associated with lower readmissions.

To assess whether an electronic health record (EHR) portal to enable health information exchange (HIE) between a hospital and three skilled nursing facilities (SNFs) reduced likelihood of patient readmission. Secondary data; all discharges from a large academic medical center to SNFs between July 2013 and March 2017, combined with portal usage records from SNFs with HIE access. We use difference-in-differences to determine whether portal implementation reduced likelihood of readmission over time for patients discharged to HIE-enabled SNFs, relative to those discharged to nonenabled facilities. Additional descriptive analyses of audit log data characterize portal use within enabled facilities. Encounter-level clinical EHR data were merged with EHR audit log data that captured portal usage in the timeframe associated with a patient transition from hospital to SNF. Declines in likelihood of 30-day readmission were not significantly different for patients in HIE-enabled vs control SNFs (diff-in-diff=0.022; P=.431). We observe similar null effects with shorter readmission windows. The portal was used for 46 percent of discharges, with significant usage pattern variation within/across facilities. Implementation of a hospital-SNF EHR portal did not reduce readmissions from enabled SNFs. Emergent HIE use cases need to be better defined and leveraged for design and implementation that generates value in the context of postacute transitions.

The Value of Health Information Exchange Use for Chronic Disease Management

In this paper, we investigate the impact of health information exchange (HIE) use at the visit-level on patient outcomes, such as readmissions, length of stay, and the number of procedures. Built upon the theories of inter-organizational information sharing and transaction cost economics, we argue that the timely sharing of patient information can decrease fragmentation of care and improve decision-making, diagnoses, and care plans. The studies that examine the benefits of HIE use are not unanimous in their findings and generally limited to average effects with binary HIE measures, either using HIE adoption at the hospital-level or HIE access at the visit- level. The goal of this research is to get a deeper understanding by using a continuous measure that captures information depth of HIE in each use and investigate the benefits of HIE by patient characteristics (such as having a chronic condition) and patient movements between hospitals. We utilize a rich dataset of medical records from an HIE provider in New York. Our results show that the depth of information available for the patient in HIE use decreases future readmissions and the number of future visits, and these effects are significantly stronger for chronic patients compared to non-chronic patients. Further, HIE use lowers the length of stay and number of procedures done at the focal visit. The benefits for chronic patients generally accrue to both their chronic and non-chronic visits. Additionally, while hospital switches are associated with care fragmentation such as longer length of stay and more procedures being performed, we show that HIE use could effectively address these inefficiencies and reverse their effects, leading to overall net benefits. Results from this study have important implications for policymakers, healthcare providers, and patients.

A snapshot of health information exchange across five nations: an investigation of frontline clinician experiences in emergency care.

Ensuring the ability to exchange patient information among disparate electronic health records systems is a top priority and a domain of substantial public investment across countries. However, we know little about the extent to which current capabilities meet the needs of frontline clinicians. We conducted in-person, semistructured interviews with emergency care physicians and nurses in select hospitals in Canada, Denmark, Finland, Germany, and the USA. We characterized the state of health information exchange (HIE) by country and used thematic analysis to identify the perceived benefits of access to complete past medical history (PMH), the conditions under which PMH is sought, and the challenges to accessing and using HIE capabilities. HIE approaches, and the information electronically accessible to clinicians, differed by country. Benefits of access to PMH included safer care, reduced patient length of stay, and fewer lab and imaging orders. Conditions under which PMH was sought included moderate-acuity patients, patients with chronic conditions, and instances where accessing PMH was convenient. Challenges to HIE access and use included difficulty knowing where information is located, delay in receiving information, and difficulty finding information within documents. Even with different HIE approaches across countries, all clinicians reported shortcomings in their country's approach. Notably, challenges were similar and shaped the conditions under which PMH was sought. As countries continue to pursue broad-based HIE, they appear to be facing similar challenges in realizing HIE value and therefore have an opportunity to learn from one another.

Implementation of a health information exchange into community pharmacy workflow

ObjectivesTo explore the feasibility and report preliminary outcomes of the integration of a health information exchange (HIE) into community pharmacy workflow clinical service delivery. SettingIndependent pharmacy in eastern Tennessee. Practice descriptionThe pharmacy offers medication reconciliation services via HIE access, as well as other clinical pharmacy services. The average number of prescriptions filled weekly is 1900, and staffing included 3.5 full-time-equivalent (FTE) pharmacists, and 7 FTE technicians. Practice innovationHIE integration within the workflow of the pharmacy was used to enhance existing patient care services, such as medication distribution, drug use review, medication therapy management, and immunizations, as well as to implement a novel transitional care service. EvaluationA mixed-methods design was used to explore HIE workflow. Data collection included a pharmacist and pharmacy technician perceptions survey, mapping steps involved in HIE use in workflow via a think-aloud protocol, and quantitatively reporting the number and type of discordant medications found on medication reconciliation. ResultsIn total, 25 patients qualified for the medication reconciliation intervention and data collection. All 25 patients (100%) had at least 1 discordant medication. HIE access was used for 60% of patients. Community pharmacists were confident in their abilities to perform medication reconciliation and were able to perform the medication reconciliation with the use of the HIE within their workflow, albeit with some reported barriers. The average time spent per patient for HIE-facilitated transitional care was 21 minutes. ConclusionIntegration and utilization of an HIE within the workflow for the purposes of patient care service delivery in the community pharmacy is feasible, but not without limitations. Such HIE utilization and extended access to the patient’s clinical picture may represent a scalable method to enhance currently delivered pharmacist services.

Use patterns of health information exchange systems and admission decisions: Reductionistic and configurational approaches

BackgroundResearch that endeavors to identify the value of electronic health information exchange (HIE) systems to the healthcare industry and, specifically, to clinical decision making is often inconclusive or theory-based. Studies seeking to identify how clinical decisions relate to patterns of actual HIE use, often by analyzing system log files, generally rely on dichotomous distinctions between system use and no-use, disregard the availability of information in the system, and control for few user characteristics. ObjectiveWe aim at empirically exploring the associations between use patterns of HIE systems and subsequent clinical decisions on the basis of broad definitions of use patterns, available information, and control variables. MethodsWe examine the decision to admit critically-ill patients either to the intensive care unit (ICU) or to another ward at a busy emergency department in the period 2010–2012. Using HIE log files, use patterns are characterized by the variables of number of users, volume, diversity, granularity, duration, and content. We test the association between HIE use patterns and the admission decision, after controlling for multiple demographic, clinical, physician, and situational variables and for available HIE information. This association is examined by taking a reductionistic approach that focuses on independent use variables and a configurational approach that focuses on use profiles. ResultsFive use profiles were identified, the largest of which (46.95% of encounters) described basic HIE access. ICU admission is more probable when the HIE system is perused by multiple users (odds increase by 31%) and when use profiles include prolonged screen viewing (odds increase by 159%) or access to diverse and multiple types of information, specifically on test results, procedures, and previous encounters. DiscussionReductionistic and configurational approaches yield complementary insights, which advance the understanding of how actual HIE use is associated with clinical decision making. The study shows that congruent profiles of HIE use enhance the predictability of the admission decision beyond what can be explained by independent variables of HIE use.

The financial impact of health information exchange on emergency department care

ObjectiveTo examine the financial impact health information exchange (HIE) in emergency departments (EDs).Materials and MethodsWe studied all ED encounters over a 13-month period in which HIE data were accessed in all major emergency departments Memphis, Tennessee. HIE access encounter records were matched with similar encounter records without HIE access. Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms. Our estimates employed generalized estimating equations for logistic regression models adjusted for admission type, length of stay, and Charlson co-morbidity index. Marginal probabilities were used to calculate changes in outcome variables and their financial consequences.ResultsHIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied. In 11 EDs directly accessing HIE data only through a secure Web browser, access was associated with a decrease in hospital admissions (adjusted odds ratio (OR)=0.27; p<0001). In a 12th ED relying more on print summaries, HIE access was associated with a decrease in hospital admissions (OR=0.48; p<0001) and statistically significant decreases in head CT use, body CT use, and laboratory test ordering.DiscussionApplied only to the study population, HIE access was associated with an annual cost savings of $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions.ConclusionAccess to additional clinical data through HIE in emergency department settings is associated with net societal saving.

Health information exchange usage in emergency departments and clinics: the who, what, and why

Health information exchange (HIE) systems are being developed across the nation. Understanding approaches taken by existing successful exchanges can help new exchange efforts determine goals and plan implementations. The goal of this study was to explore characteristics of use and users of a successful regional HIE. We used a mixed-method analysis, consisting of cross-sectional audit log data, semi-structured interviews, and direct observation in a sample of emergency departments and ambulatory safety net clinics actively using HIE. For each site, we measured overall usage trends, user logon statistics, and data types accessed by users. We also assessed reasons for use and outcomes of use. Overall, users accessed HIE for 6.8% of all encounters, with higher rates of access for repeat visits, for patients with comorbidities, for patients known to have data in the exchange, and at sites providing HIE access to both nurses and physicians. Discharge summaries and test reports were the most frequently accessed data in the exchange. Providers consistently noted retrieving additional history, preventing repeat tests, comparing new results to retrieved results, and avoiding hospitalizations as a consequence of HIE access. HIE use in emergency departments and ambulatory clinics was focused on patients where missing information was believed to be present in the exchange and was related to factors including the roles of people with access, the setting, and other site-specific issues that impacted the overall breadth of routine system use. These data should form an important foundation as other sites embark upon HIE implementation.

What Affects Clinicians' Usage of Health Information Exchange?

BACKGROUND: The ability to electronically exchange health information among healthcare providers holds enormous promise to improve care coordination and reduce costs. Provider-to-provider data exchange is an explicit goal of the American Recovery and Reinvestment Act of 2009 and may be essential for the long-term success of the Affordable Care Act of 2010. However, little is known about what factors affect clinicians' usage of health information exchange (HIE) functionality. OBJECTIVE: To identify factors that affect clinicians' HIE usage - in terms of frequency of contributing data to and accessing data from aggregate patient records - and suggest policies for fostering its usage. METHODS: We performed a qualitative study using grounded theory by interviewing clinician-users and HIE staff of one operational HIE which supported aggregate patient record functionality. Fifteen clinicians were interviewed for one hour each about what factors affect their HIE usage. Five HIE staff were asked about technology and training issues to provide context. Interviews were recorded, transcribed and analyzed. Recruitment excluded clinicians with little or no familiarity with the HIE and was restricted to one community and a small number of specialties. RESULTS: Clinicians were motivated to access the HIE by perceived improvements in care quality and time savings, but their motivation was moderated by an extensive list of factors including gaps in data, workflow issues and usability issues. HIE access intensities varied widely by clinician. Data contribution intensities to the HIE also varied widely and were affected by billing concerns and time constraints. CONCLUSIONS: Clinicians, EHR and HIE product vendors and trainers should work toward integrating HIE into clinical workflows. Policies should create incentives for HIE organizations to assist clinicians in using HIE, develop measures of HIE contributions and accesses, and create incentives for clinicians to contribute data to HIEs.

Health Information Exchange and Healthcare Utilization

Health information exchange (HIE) makes previously inaccessible data available to clinicians, resulting in more complete information. This study tested the hypotheses that HIE information access reduced emergency room visits and inpatient hospitalizations for ambulatory care sensitive conditions among medically indigent adults. HIE access was quantified by how frequently system users' accessed patients' data. Encounter counts were modeled using zero inflated binomial regression. HIE was not accessed for 43% of individuals. Patient factors associated with accessed data included: prior utilization, chronic conditions, and age. Higher levels of information access were significantly associated with increased counts of all encounter types. Results indicate system users were more likely to access HIE for patients for whom the information might be considered most beneficial. Ultimately, these results imply that HIE information access did not transform care in the ways many would expect. Expectations in utilization reductions, however logical, may have to be reevaluated or postponed.