Health Information Exchange Network Research Articles

Interoperability in the Wild: Comparison of Real-World Electronic C-CDA Documents from Two Sources.

Although health information exchange (HIE) networks exist in multiple nations, providers still require access multiple sources to obtain medical records. We sought to measure and compare differences in data presence and concordance across regional HIE and EHR vendor-based networks. Using 1,054 randomly selected patients from a large health system in the US, we generated consolidated clinical document architecture (C-CDA) documents from each network. 778 (74%) patients had at least one C-CDA document present from either source. Among these patients, two-thirds had information in only one source. All documents contained demographics, but less than half of patients had data in clinical data domains. Moreover, data across HIE networks were not concordant. Results suggest that HIE networks have different, likely complementary, data available for the same patient, suggesting the need for better integration and deduplication for national HIE efforts.

Dentists' Information Needs and Opinions on Accessing Patient Information via Health Information Exchange: Survey Study.

The integration of medical and dental records is gaining significance over the past 2 decades. However, few studies have evaluated the opinions of practicing dentists on patient medical histories. Questions remain on dentists' information needs; their perception of the reliability of patient-reported medical history; satisfaction with the available information and the methods to gather this information; and their attitudes to other options, such as a health information exchange (HIE) network, to collect patient medical history. This study aims to determine Indiana dentists' information needs regarding patients' medical information and their opinions about accessing it via an HIE. We administered a web-based survey to Indiana Dental Association members to assess their current medical information-retrieval approaches, the information critical for dental care, and their willingness to access or share information via an HIE. We used descriptive statistics to summarize survey results and multivariable regression to examine the associations between survey respondents' characteristics and responses. Of the 161 respondents (161/2148, 7.5% response rate), 99.5% (n=160) respondents considered patients' medical histories essential to confirm no contraindications, including allergies or the need for antibiotic prophylaxis during dental care and other adverse drug events. The critical information required were medical conditions or diagnosis, current medications, and allergies, which were gathered from patient reports. Furthermore, 88.2% (n=142) of respondents considered patient-reported histories reliable; however, they experienced challenges obtaining information from patients and physicians. Additionally, 70.2% (n=113) of respondents, especially those who currently access an HIE or electronic health record, were willing to use an HIE to access or share their patient's information, and 91.3% (n=147) shared varying interests in such a service. However, usability, data accuracy, data safety, and cost are the driving factors in adopting an HIE. Patients' medical histories are essential for dentists to optimize dental care, especially for those with chronic conditions. In addition, most dentists are interested in using an HIE to access patient medical histories. The findings from this study can provide an alternative option for improving communications between dental and medical professionals and help the health information technology system or tool developers identify critical requirements for more user-friendly designs.

Collaborating for COVID-19: Hospital Health Information Exchange and Public Health Partnership.

Background: The coronavirus disease (COVID-19) pandemic highlighted the need for effective communication and information sharing among health care organizations and public health systems (PHSs). Health information exchange (HIE) plays a vital role in improving quality control and efficiency in hospital settings, particularly in underserved areas. Objective: This study aimed to investigate the variation of HIE availability among hospitals based on their collaboration with the PHS and affiliation with Accountable Care Organizations (ACOs) in 2020, as well as variation by community social determinants of health. Methods: The primary data set used for this study comprised the linked data set of the 2020 American Hospital Association (AHA) Annual Survey and the AHA Information Technology Supplement. The measures used included the hospital's participation in HIE networks, availability of data exchange, and HIE measures during the COVID-19 pandemic, including whether hospitals effectively received electronically transmitted information from outside providers for COVID-19 treatment. Results: The sample size of hospitals ranged from 1,316 to 1,436, depending on different outcomes related to HIE questions. Of the hospitals surveyed, ∼67% reported public health collaboration and ACO affiliation, while 7% reported neither. Hospitals without public health collaboration or ACO affiliation were more likely to be located in underserved areas. Compared with hospitals without public health collaboration or ACO affiliation, hospitals with both were 9% more likely to report the availability of electronically transmitted clinical information from outside providers and to participate in local and national HIE networks. Furthermore, these hospitals were 30% (marginal effect [ME] = 0.30, p < 0.001) more likely to report effective receipt of information from outside providers for COVID-19 treatment and 12% (ME = 0.12, p = 0.02) more likely to always/often receive clinical information for COVID-19 treatment electronically. Conclusions: Hospital collaboration with the PHS and ACO affiliation are associated with greater availability of electronic health data, particularly during the COVID-19 pandemic.

Identification of Hypertension in Electronic Health Records Through Computable Phenotype Development and Validation for Use in Public Health Surveillance: Retrospective Study.

Electronic health record (EHR) systems are widely used in the United States to document care delivery and outcomes. Health information exchange (HIE) networks, which integrate EHR data from the various health care providers treating patients, are increasingly used to analyze population-level data. Existing methods for population health surveillance of essential hypertension by public health authorities may be complemented using EHR data from HIE networks to characterize disease burden at the community level. We aimed to derive and validate computable phenotypes (CPs) to estimate hypertension prevalence for population-based surveillance using an HIE network. Using existing data available from an HIE network, we developed 6 candidate CPs for essential (primary) hypertension in an adult population from a medium-sized Midwestern metropolitan area in the United States. A total of 2 independent clinician reviewers validated the phenotypes through a manual chart review of 150 randomly selected patient records. We assessed the precision of CPs by calculating sensitivity, specificity, positive predictive value (PPV), F1-score, and validity of chart reviews using prevalence-adjusted bias-adjusted κ. We further used the most balanced CP to estimate the prevalence of hypertension in the population. Among a cohort of 548,232 adults, 6 CPs produced PPVs ranging from 71% (95% CI 64.3%-76.9%) to 95.7% (95% CI 84.9%-98.9%). The F1-score ranged from 0.40 to 0.91. The prevalence-adjusted bias-adjusted κ revealed a high percentage agreement of 0.88 for hypertension. Similarly, interrater agreement for individual phenotype determination demonstrated substantial agreement (range 0.70-0.88) for all 6 phenotypes examined. A phenotype based solely on diagnostic codes possessed reasonable performance (F1-score=0.63; PPV=95.1%) but was imbalanced with low sensitivity (47.6%). The most balanced phenotype (F1-score=0.91; PPV=83.5%) included diagnosis, blood pressure measurements, and medications and identified 210,764 (38.4%) individuals with hypertension during the study period (2014-2015). We identified several high-performing phenotypes to identify essential hypertension prevalence for local public health surveillance using EHR data. Given the increasing availability of EHR systems in the United States and other nations, leveraging EHR data has the potential to enhance surveillance of chronic disease in health systems and communities. Yet given variability in performance, public health authorities will need to decide whether to seek optimal balance or declare a preference for algorithms that lean toward sensitivity or specificity to estimate population prevalence of disease.

Electronic connectivity between hospital pairs: impact on emergency department-related utilization.

To use more precise measures of which hospitals are electronically connected to determine whether health information exchange (HIE) is associated with lower emergency department (ED)-related utilization. We combined 2018 Medicare fee-for-service claims to identify beneficiaries with 2 ED encounters within 30days, and Definitive Healthcare and AHA IT Supplement data to identify hospital participation in HIE networks (HIOs and EHR vendor networks). We determined whether the 2 encounters for the same beneficiary occurred at: the same organization, different organizations connected by HIE, or different organizations not connected by HIE. Outcomes were: (1) whether any repeat imaging occurred during the second ED visit; (2) for beneficiaries with a treat-and-release ED visit followed by a second ED visit, whether they were admitted to the hospital after the second visit; (3) for beneficiaries discharged from the hospital followed by an ED visit, whether they were admitted to the hospital. In adjusted mixed effects models, for all outcomes, beneficiaries returning to the same organization had significantly lower utilization compared to those going to different organizations. Comparing only those going to different organizations, HIE was not associated with lower levels of repeat imaging. HIE was associated with lower likelihood of hospital admission following a treat-and-release ED visit (1.83 percentage points [-3.44 to -0.21]) but higher likelihood of admission following hospital discharge (2.78 percentage points [0.48-5.08]). Lower utilization for beneficiaries returning to the same organization could reflect better access to information or other factors such as aligned incentives. HIE is not consistently associated with utilization outcomes reflecting more coordinated care in the ED setting.

Impact of primary to secondary care data sharing on care quality in NHS England hospitals

Health information exchange (HIE) is seen as a key component of effective care but remains poorly evidenced at a health system level. In the UK National Health Service (NHS), the ability to share primary care data with secondary care clinicians is a focus of continued digital investment. In this study, we report the evolution of interoperable technology across a period of rapid digital transformation in NHS England from 2015 to 2019, and test association of primary to secondary care data-sharing capabilities with clinical care quality indicators across all acute secondary care providers (n = 135 NHS Trusts). In multivariable analyses, data-sharing capabilities are associated with reduction in patients breaching an Accident & Emergency (A&E) 4-h decision time threshold, and better patient-reported experience of acute hospital care quality. Using synthetic control analyses, we estimate mean 2.271% (STD+/−3.371) absolute reduction in A&E 4-h decision time breach, 12 months following introduction of data-sharing capabilities. Our findings support current digital transformation programmes for developing regional HIE networks but highlight the need to focus on implementation factors in addition to technological procurement.

Health information exchange network under collaboration, cooperation, and competition: A game-theoretic approach.

Health Information Exchange (HIE) network allows securely accessing and sharing healthcare-related information among healthcare providers (HCPs) and payers. HIE services are provided by a non-profit/profit organizations under several subscription plans options. A few studies have addressed the sustainability of the HIE network such that HIE providers, HCPs, and payers remain profitable in the long term. However, none of these studies addressed the coexistence of multiple HIE providers in the network. Such coexistence may have a huge impact on the behavior of healthcare systems in terms of adoption rate and HIE pricing strategies. In addition, in spite of all the effort to maintain cooperation between HIE providers, there is still a chance of competition among them in the market. Possible competition among service providers leads to many concerns about the HIE network sustainability and behavior. In this study, a game-theoretic approach to model the HIE market is proposed. Game-theory is used to simulate the behavior of the three different HIE network agents in the HIE market: HIE providers, HCPs, and payers. Pricing strategies and adoption decisions are optimized using a Linear Programming (LP) mathematical model. Results show that the relation between HIEs in the market is crucial to HCP/Payer adoption decision specially to small HCPs. A small change in the discount rate proposed by a competitive HIE provider will highly affect the decision of HCP/payers to join the HIE network. Finally, competition opened the opportunity for more HCPs to join the network due to reduced pricing. Furthermore, collaborative HIEs provided better performance compared to cooperative in terms of profit and HCP adoption rate by sharing their overall costs and revenues.

Evolution of Health Information Sharing Between Health Care Organizations: Potential of Nonfungible Tokens

This study attempts to explain the development and progress of the technology used for sharing health information across health care organizations (such as hospitals and physicians' offices). First, we describe the strengths and weaknesses of traditional sharing models, health information exchange (HIE), and blockchain-based HIE. Second, the potential use of nonfungible token (NFT) protocols in HIE models is proposed as the next possible move for information-sharing initiatives in health care. In addition to some potential opportunities and distinguishing features (eg, ownability, verifiability, and incentivization), we identify the uncertainty and risks associated with the application of NFTs, such as the lack of a dedicated regulatory framework for legal ownership of digital patient data. This paper is among the first to discuss the potential of NFTs in health care. The use of NFTs in HIE networks could generate a new stream of research for future studies. This study provides practical insights into how the technological foundations of information-sharing efforts in health care have developed and diversified from earlier forms.

Perspectives on Challenges and Opportunities for Interoperability: Findings From Key Informant Interviews With Stakeholders in Ohio.

Interoperability-the exchange and integration of data across the health care system-remains a challenge despite ongoing policy efforts aimed at promoting interoperability. This study aimed to identify current challenges and opportunities to advancing interoperability across stakeholders. Primary data were collected through qualitative, semistructured interviews with stakeholders (n=24) in Ohio from July to October 2021. Interviewees were sampled using a stratified purposive sample of key informants from 4 representative groups as follows: acute care and children's hospital leaders, primary care providers, behavioral health providers, and regional health information exchange networks. Interviews focused on key informant perspectives on electronic health record implementation, the alignment of public policy with organizational strategy, interoperability implementation challenges, and opportunities for health information technology. The interviews were transcribed verbatim followed by rigorous qualitative analysis using directed content analysis. The findings illuminate themes related to challenges and opportunities for interoperability that align with technological (ie, implementation challenges, mismatches in interoperability capabilities across stakeholders, and opportunities to leverage new technology and integrate social determinants of health data), organizational (ie, facilitators of interoperability and strategic alignment of participation in value-based payment programs with interoperability), and environmental (ie, policy) domains. Interoperability, although technically feasible for most providers, remains challenging for technological, organizational, and environmental reasons. Our findings suggest that the incorporation of end user considerations into health information technology development, implementation, policy, and standard deployment may support interoperability advancement.

Use of the clinical care classification in South Korean nursing practice: Challenges and opportunities

Background and objectivesA government-driven standardization of nursing terminology including the Clinical Care Classification (CCC) was endorsed in South Korea in 2015, but the number of hospitals who have adopted this standard terminology remains unknown. This study aimed to determine the CCC awareness, adoption, and utilization statuses and its association with patient experience in South Korea. Design, setting, and participantsA nationwide telephone survey was conducted from January 13 to February 12, 2022 among 217 tertiary and secondary hospitals participating in the health information exchange network. The survey questionnaire included 22 items in 3 categories: current status of electronic nursing records, awareness and adoption of standard terminology, and open-ended questions regarding standard usage and dissemination. General characteristics and experience scores of the patients of the surveyed hospitals were collected from the publicly available data sources. Data analysis was performed using descriptive statistics, t-test, and generalized linear regression. Main outcomes and measuresThe rates of awareness and adoption in hospitals to the nursing terminology standard of the CCC were calculated, and the current status of electronic nursing records used in practice was examined. The relationships between CCC awareness and the characteristics of hospitals in their patient experiences of health services were also identified. ResultsThe survey response rate was 24.9 % (54/217). Two out of three hospitals (68.5 %) were aware of the CCC. These hospitals had 800 beds or more, and higher scores for patient experience. CCC awareness was significantly related to increases in the overall scores for patient experiences (t = 2.70, p =.0103), but no significance with sub-score for nursing service (t = 1.23, p =.1594). ConclusionsWith a high adoption rate of electronic medical record systems, two-third hospitals acknowledged their CCC awareness, but were still lagged in adoption and usage of it in practice with operational challenges. The CCC awareness has potential relationships with positive patient experience.

Interoperability in a Post-Roe Era

This Viewpoint proposes a solution to better safeguard reproductive health information in patient records that are now more complete owing to the interoperability of health information exchange networks.

Promising practices and pockets of excellence: Community pharmacists supporting wellness for reproductive-age women.

Promising practices and pockets of excellence: Community pharmacists supporting wellness for reproductive-age women.

Electronic Connectivity Among US Hospitals Treating Shared Patients.

Increasing electronic health information exchange (HIE) between provider organizations is a top policy priority that has been pursued by establishing varied types of networks. To measure electronic connectivity enabled by these networks, including community, electronic health record vendor, and national HIE networks, across US hospitals weighted by the volume of shared patients and identify characteristics that predict connectivity. Cross-sectional analysis of 1721 hospitals comprising 16,344 hospital pairs and 6,492,232 shared patients from 2018 CareSet Labs HOP data and national hospital surveys. Pairs of US acute care hospitals that delivered care to 11 or more of the same fee-for-service Medicare beneficiaries in 2018. Whether a patient was treated by a pair of hospitals connected through participation in the same HIE network ("connected hospitals") or not connected because the hospitals participated in different networks, only 1 participated, or both did not participate. Sixty-four percent of shared patients were treated by connected hospitals. Of the remaining shared patients, 14% were treated by hospital pairs that participated in different HIE networks, 21% by pairs in which only 1 hospital participated in an HIE network, and 2% by pairs in which neither participated. Patients treated by pairs with at least 1 for-profit hospital, and by pairs located in competitive markets, were less likely to be treated by connected hospitals. While the majority of shared patients received care from connected hospitals, remaining gaps could be filled by connecting HIE networks to each other and by incentivizing certain types of hospitals that may not participate because of competitive concerns.

How Carequality, The Sequoia Project, and eHealth Exchange Support the Interoperable Exchange of Health Data in the USA

Every organization in the health IT industry plays an important role in overcoming barriers to health information exchange in the United States. It is important to understand imaging interoperability in the overall context of Health Information Exchange (HIE). The rapid evolution of storage, bandwidth and network transport technologies has made the handling of imaging data converge with the primarily text-based healthcare data. The radiology community must understand the overall environment and become a tightly integrated part of it. As the health IT ecosystems continue to evolve, it became clear that there would not be a single health information exchange network to service the nation. Rather, like other industries such as telecom and banking, there would be multiple networks that would need to interconnect. To support compliance to interoperability standards and specifications, The Sequoia Project began collaborating with industry to create testing programs and tooling that supports transport, security and content testing requirements for four production testing programs today. These testing programs validate compliance to standards for transport and security as well standards for the payloads such as clinical documents and imaging data. While once operating under the same umbrella, The Sequoia Project, Carequality and eHealth Exchange (https://ehealthexchange.org/) have been separate companies since 2018. Each plays a unique role in helping patient information move where and when it is needed, each working with a framework of standards published by IHE, DICOM, and HL7 to enable health information exchange.

Hemodialysis Record Sharing: Solution for Work Burden Reduction and Disaster Preparedness.

BackgroundAfter the Great East Japan Earthquake in 2011, backup systems for clinical information were launched in Japan. The system in Miyagi Prefecture called the Miyagi Medical and Welfare Information Network (MMWIN) is used as a health information exchange network to share clinical information among various medical facilities for patients who have opted in. Hospitals and clinics specializing in chronic renal failure require patients’ data and records during hemodialysis to facilitate communication in daily clinical activity and preparedness for disasters.ObjectiveThis study aimed to facilitate the sharing of clinical data of patients undergoing hemodialysis among different hemodialysis facilities.MethodsWe introduced a document-sharing system to make hemodialysis reports available on the MMWIN. We also recruited hospitals and clinics to share the hemodialysis reports of their patients and promoted the development of a network between emergency and dialysis clinics.ResultsIn addition to basic patient information as well as information on diagnosis, prescription, laboratory data, hospitalization, allergy, and image data from different facilities, specific information about hemodialysis is available, as well as a backup of indispensable information in preparation for disasters. As of June 1, 2021, 12 clinics and 10 hospitals of 68 dialysis facilities in Miyagi participated in the MMWIN. The number of patients who underwent hemodialysis in Miyagi increased by more than 40%.ConclusionsOur backup system successfully developed a network of hemodialysis facilities. We have accumulated data that are beneficial to prevent the fragmentation of patient information and would be helpful in transferring patients efficiently during unpredictable disasters.

A participatory epidemiological and One Health approach to explore the community's capacity to detect emerging zoonoses and surveillance network opportunities in the forest region of Guinea.

The Ebola virus disease epidemic that threatened West Africa between 2013 and 2016 was of unprecedented health magnitude. After this health crisis, studies highlighted the need to introduce community-based surveillance systems and to adopt a One Health approach. This study aimed to provide preparatory insights for the definition of a community-based surveillance system for emerging zoonoses such as viral hemorrhagic fevers in Guinea. The objective was to explore the disease detection capacity and the surveillance network opportunities at the community level in two pilot areas in the forest region of Guinea, where the epidemic emerged. Based on a participatory epidemiological and One Health approach, we conducted Focus Group Discussions with human, animal and ecosystem health actors. We used a range of participatory tools, included semi-structured interviews, ranking, scoring and flow diagram, to estimate the local knowledge and perception of diseases and clinical signs and to investigate the existing health information exchange network and its related strengths and weaknesses. The results showed that there is heterogeneity in knowledge of diseases and perception of the clinical signs among actors and that there are preferred and more effective health communication channels opportunities. This preparatory study suggests that it is necessary to adapt the case definitions and the health communication channels to the different actors who can play a role in a future community-based surveillance system and provides recommendations for future surveillance activities to be carried out in West Africa.

Identification of barriers affecting the use of health information exchange (HIE) in clinicians' practices: An empirical study in the United States

Health information exchange (HIE) programs as a policy subject in several developed countries can enable sharing of adequate and accurate information across providers and healthcare organizations to improve care coordination. However, besides the expected benefits of participating in HIE in enhancing coordination, reducing costs, and improving patient safety, previous studies report that clinicians' rate of using HIE mechanisms is still low. Insufficient participation of clinicians in data exchange networks can diminish the value of HIE. Based on utility theory, this study aims to identify and categorize barriers associated with the implementation of HIE projects in healthcare organizations and develop a comprehensive model to empirically examine the effects of HIE inhibitors on clinicians' intention to engage in HIE networks. Data was collected using an online survey from 318 clinicians working in different healthcare settings in the United States. Results show that internal inhibitors (including technological and organizational barriers) and external inhibitors (including partners, patients, vendors, and legal barriers) strongly influence clinicians' intention to engage in HIEs. Taking an integrated approach, this study can contribute to the existing literature by providing a more informed way of conceptualizing and explaining HIE adoption in healthcare organizations. The findings can help HIE decision-makers, healthcare organizations, and providers to identify key HIE inhibitors and take corrective actions to address them. Addressing both internal and external inhibitors would increase the likelihood of widespread implementation of HIEs in different healthcare settings and facilitate interoperability and connectivity in regional and community health information networks.

Growth in health information exchange with ACO market penetration.

First, to assess whether hospitals expand the network breadth of their health information exchange (HIE) partners after joining an accountable care organization (ACO). Second, to analyze whether this HIE network expansion effect varies across markets with differing levels of ACO penetration. Difference-in-differences analyses of US nonfederal acute care hospitals, 2014-2017. We used data from the American Hospital Association Annual Survey and Information Technology Supplement to measure hospital ACO participation, HIE network breadth (defined as number of different partner types), and ACO market penetration at the hospital referral region level. We implemented a difference-in-differences model to estimate changes in hospitals' HIE network breadth with ACO participation in different years. We estimate these effects combined across all markets and stratified by markets with high and low ACO market penetration. In combined analyses, HIE breadth increased by 0.35 partner types with ACO participation, a 30.7% increase (P < .001). In stratified analyses, this effect was larger for hospitals in high-ACO penetration markets (0.41 partner types, a 32.0% increase; P < .001) and smaller for hospitals in low-ACO penetration markets (0.25 partner types, a 24.8% increase; P < .05). We found dynamic effects of ACO adoption illustrating an immediate effect in high-ACO penetration markets and a 2-year delayed effect in low-ACO penetrationmarkets. Hospitals that joined ACOs increased their HIE breadth, but this effect was heterogenous across markets and across time. Our findings illustrate a "network effect," with large, immediate effects in HIE breadth following ACO participation in high-ACO penetration markets and smaller, delayed effects in low-ACO penetrationmarkets.

A Survey Of Health Information Exchange Organizations In Advance Of A Nationwide Connectivity Framework.

After more than a decade of investment in electronic health information exchange (HIE), the Office of the National Coordinator for Health Information Technology is advancing a national framework-the Trusted Exchange Framework and Common Agreement-to connect islands of electronic data sharing. This national framework creates new potential opportunities and challenges for state and local health information organizations (HIOs). We undertook our sixth national HIO survey to assess the current state of HIOs and to newly examine anticipated responses to the Trusted Exchange Framework and Common Agreement. We identified eighty-nine operational HIOs, down from 106 in 2014. Although more than half of HIOs struggled with financial viability and competition from health information technology vendor-based HIE networks, many are large in scale, offer a breadth of services to diverse participants, and engage in network-to-network connectivity. Looking ahead, 56percent of HIOs planned to participate in the Trusted Exchange Framework and Common Agreement, and 41percent were unsure. As the Trusted Exchange Framework and Common Agreement advances basic network-to-network connectivity, HIOs that have experience with such connectivity while also offering value-added services will be well positioned for sustainability and growth.

Mapping the Landscape of Health Information Exchange (HIE) Networks in the United States

Since the 1990s, there has been ongoing investment in the development of health information exchanges (HIEs) in the United States. However, HIE innovation has diffused throughout the health provider organizations in the country at a disappointingly slow manner. The fact that multiple stakeholder domains (that have often conflicting different policy, technical and social positions) affect HIE innovation constitutes one possible reason for this slow diffusion. Therefore, to understand the diffusion pace, one must account for structural differences in different kinds of HIE networks. However, we lack existing research on this dilemma. In the information systems (IS) discipline, research has focused on individual HIE instantiations. In the health policy domain, research has summarized different forms of HIE networks without applying theoretical lenses to explore structural differences among them. Further, HIE value research lacks consensus on measurement criteria due to these divergent motivations for HIE instantiations. To that end, in this paper, we 1) describe the current HIE network landscape in the United States from an organizational perspective, 2) propose a framework for future research to address structural differences among HIE networks, and 3) demonstrate how network type acts as a boundary condition for measuring exchange behaviors and outcomes.