Health Information Exchange Organizations Research Articles

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.

Information blocking remains prevalent at the start of 21st Century Cures Act: results from a survey of health information exchange organizations.

Recent policy making aims to prevent health systems, lectronic health record (EHR) vendors, and others from blocking the electronic sharing of patient data necessary for clinical care. We sought to assess the prevalence of information blocking prior to enforcement of these rules. We conducted a national survey of health information exchange organizations (HIEs) to measure the prevalence of information blocking behaviors observed by these third-party entities. Eighty-nine of 106 HIEs (84%) meeting the inclusion criteria responded. The majority (55%) of HIEs reported that EHR vendors at least sometimes engage in information blocking, while 30% of HIEs reported the same for health systems. The most common type of information blocking behavior EHR vendors engaged in was setting unreasonably high prices, which 42% of HIEs reported routinely observing. The most common type of information blocking behavior health systems engaged in was refusing to share information, which 14% of HIEs reported routinely observing. Reported levels of vendor information blocking was correlated with regional competition among vendors and information blocking was concentrated in some geographic regions. Our findings are consistent with early reports, revealing persistently high levels of information blocking and important variation by actor, type of behavior, and geography. These trends reflect the observations and experiences of HIEs and their potential biases. Nevertheless, these data serve as a baseline against which to measure the impact of new regulations and to inform policy makers about the most common types of information blocking behaviors. Enforcement aimed at reducing information blocking should consider variation in prevalence and how to most effectively target efforts.

Diverging views on health information exchange organizations.

IntroductionHealth information exchange (HIE) capabilities meet the demands for a more effective, efficient, and safer health care system. However, organizations and individual providers have pursued different strategies to meet their respective needs for HIE capabilities. Because effective information sharing is necessary to a learning health system, this study sought to explore the perceptions of different approaches' effect on key features of an effective health care system.MethodsAn anonymous web‐based survey was sent to a convenience sample of the membership of the Healthcare Information and Management Systems Society and the Strategic Health Information Exchange Collaborative with knowledge of HIE (n=68). A series of 7‐point Likert‐type items measured perceptions of enterprise health information exchanges (eHIEs) and community health information organizations (cHIOs) in the areas of effect on exchange participation, effect on market dynamics, relationship to DIRECT Secure Messaging and vendor‐mediated exchange, and effect on quality. Also, respondents were asked to rate 13 qualities and services as “more about eHIE” or “more about cHIO.”ResultsRespondents tended to agree on the importance of cHIO and eHIE. Community benefits and support for public health agencies were concepts more often applied to cHIOs.DiscussionThis study affirmed much of the conventional wisdom and anecdotal comments about perceptions of cHIOs and eHIEs. Although the respondents viewed cHIOs and eHIEs differently in terms of broader societal benefit and strategic advantage, nonetheless consistent agreement appeared in areas of importance in relationship to other information sharing strategies and overall effect on the quality of care.

Health Information Exchange Organizations and Their Support for Research: Current State and Future Outlook

Federal investment spurred health information exchange organization (HIO) development and maturation to provide third-party approaches to electronic health information exchange across disparate electronic health record (EHR) systems. By creating opportunities for data aggregation across multiple medical institutions, HIOs also spur research. Using data from a 2015 national web-based survey of HIOs (N = 64), we identified HIOs supporting or not supporting research, and compared characteristics of the 2 groups. We found that 15 (23%) of the 64 HIOs reported supporting research, 30 (47%) reported planning to support research, and 19 (30%) did not support research. Research-supporting HIOs were more likely than nonresearch supporting HIOs to offer advanced functionality, such as allowing users to query and retrieve data from multiple sources. Our study offers encouraging preliminary evidence that HIOs are supporting research, which could offer a solution to current challenges in creating comprehensive longitudinal clinical data sources for research.

Exploring Business Strategy in Health Information Exchange Organizations

Unlike consumer goods industries, healthcare has been slow to implement technolo gies that support exchange of data in patients' health records. This results in avoid able medication errors, avoidable hospital readmissions, unnecessary duplicate testing, and other inefficient or wasteful practices. Community-based regional health information exchange (HIE) organizations have evolved in response to federal aims to encourage interoperability, yet little is known about their strategic approach. We use the lens of institutional and strategic management theories to empirically explore the differences in business strategies deployed in HIEs that are, to date, financially sustainable versus those that are not. We developed a 20-question survey targeted to CEOs to assess HIE business strategies. Our sample consisted of 60 community-based exchanges distributed throughout the United States, and we achieved a 58% response rate. Questions centered on competitive strategy and financial sustainability. We relied on logistic regression methods to explore relationships between variables. Our regression identified characteristics common to sustainable organizations. We defined sustainability as revenues exceeding operational costs. Seventeen of the 35 organizations (49%) defined themselves as currently sustainable. Focus and cost leadership strategies were significantly associated with sustainability. Growth strate gies, which were much more common than other strategies, were not associated with sustainability. We saw little evidence of a differentiation strategy (i.e., the basis of competition whereby the attributes of a product or service are unmatched by rivals). Most CEOs had a relatively optimistic outlook, with 60% stating they were confident of surviving over the next 5 years; however, nearly 9% of the organizations were in some phase of divestiture or exit from the market. HIEs are evolving differently based on local leadership decisions, yet their strategic approach is isomorphic (or similar). Further insight into successful business strategies could help ensure the long-term survival of HIEs.

Health information exchanges—Unfulfilled promise as a data source for clinical research

ObjectiveTo determine the use of health information exchange organizations (HIEs) to support and conduct clinical research. Materials and methodsThis scoping review included US-based studies published between January 2003 and March 2014 that used data from an HIE to address at least one of three categories of research: clinical or epidemiological research, financial evaluation, or utilization of health services. Eligibility was not restricted to research on HIEs. Studies with research questions outside of the evaluation of HIEs themselves were sought. ResultsEighteen articles met final study inclusion criteria from an initial list of 847 hits. Fifteen studies addressed a clinical or epidemiological research question, 6 addressed a financial consideration, and 8 addressed a utilization issue. Considerable overlap was found among the research categories: 13 articles addressed more than one category. Of the eighteen included studies, only two used HIE data to answer a research objective that was NOT specific to HIE use. Research designs were varied and ranged from observational studies, such as cohort and cross-sectional studies, to randomized trials. The 18 articles represent the involvement of a small number of HIEs; 7 of the studies were from a single HIE. DiscussionThis review demonstrates that HIE-provided information is available and used to answer clinical or epidemiological, financial, or utilization-based research questions; however, the majority of the studies using HIE data are done with the primary goal of evaluating the use and impact of HIEs on health care delivery and outcomes. As HIEs mature and become integrated parts of the health care industry, the authors anticipate that fewer studies will be published that describe or validate the role of HIEs, and more will use HIEs as multi-institutional data sources for conducting clinical research and improving health services and clinical outcomes. ConclusionArticles identified in this review indicate the limited extent that HIE data are being used for clinical research outside of the evaluation of HIEs themselves, as well as the limited number of specific HIEs that are involved in generating published research. Significant barriers exist that prevent HIEs from developing into an invaluable resource for clinical research including technological infrastructure limitations, business processes limiting secondary use of data, and lack of participating provider support. Research to better understand challenges to developing the necessary infrastructure and policies to foster HIE engagement in research would be valuable as HIEs represent an opportunity to engage non-traditional health care provider research partners.

Feasibility of 30-day hospital readmission prediction modeling based on health information exchange data

IntroductionUnplanned 30-day hospital readmission account for roughly $17 billion in annual Medicare spending. Many factors contribute to unplanned hospital readmissions and multiple models have been developed over the years to predict them. Most researchers have used insurance claims or administrative data to train and operationalize their Readmission Risk Prediction Models (RRPMs). Some RRPM developers have also used electronic health records data; however, using health informatics exchange data has been uncommon among such predictive models and can be beneficial in its ability to provide real-time alerts to providers at the point of care. MethodsWe conducted a semi-systematic review of readmission predictive factors published prior to March 2013. Then, we extracted and merged all significant variables listed in those articles for RRPMs. Finally, we matched these variables with common HL7 messages transmitted by a sample of health information exchange organizations (HIO). ResultsThe semi-systematic review resulted in identification of 32 articles and 297 predictive variables. The mapping of these variables with common HL7 segments resulted in an 89.2% total coverage, with the DG1 (diagnosis) segment having the highest coverage of 39.4%. The PID (patient identification) and OBX (observation results) segments cover 13.9% and 9.1% of the variables. Evaluating the same coverage in three sample HIOs showed data incompleteness. DiscussionHIOs can utilize HL7 messages to develop unique RRPMs for their stakeholders; however, data completeness of exchanged messages should meet certain thresholds. If data quality standards are met by stakeholders, HIOs would be able to provide real-time RRPMs that not only predict intra-hospital readmissions but also inter-hospital cases. ConclusionA RRPM derived using HIO data exchanged through may prove to be a useful method to prevent unplanned hospital readmissions. In order for the RRPM derived from HIO data to be effective, hospitals must actively exchange clinical information through the HIO and develop actionable methods that integrate into the workflow of providers to ensure that patients at high-risk for readmission receive the care they need.

Usage and effect of health information exchange: a systematic review.

Health information exchange (HIE) is increasing in the United States, and it is incentivized by government policies. To systematically review and evaluate evidence of the use and effect of HIE on clinical care. Selected databases from 1 January 2003 to 31 May 2014. English-language hypothesis-testing or quantitative studies of several types of data exchange among unaffiliated organizations for use in clinical care that addressed health outcomes, efficiency, utilization, costs, satisfaction, HIE usage, sustainability, and attitudes or barriers. Data extraction was done in duplicate. Low-quality evidence from 12 hypothesis-testing studies supports an effect of HIE use on reduced use or costs in the emergency department. Direct evidence that HIEs were used by providers was reported in 21 studies involving 13 distinct HIE organizations, 6 of which were located in New York, and generally showed usage in less than 10% of patient encounters. Findings from 17 studies of sustainability suggest that approximately one quarter of existing HIE organizations consider themselves financially stable. Findings from 38 studies about attitudes and barriers showed that providers, patients, and other stakeholders consider HIE to be valuable, but barriers include technical and workflow issues, costs, and privacy concerns. Publication bias, possible selective reporting of outcomes, and a dearth of reporting on context and implementation processes. Health information exchange use probably reduces emergency department usage and costs in some cases. Effects on other outcomes are unknown. All stakeholders claim to value HIE, but many barriers to acceptance and sustainability exist. A small portion of operational HIEs have been evaluated, and more research is needed to identify and understand success factors. U.S. Department of Veterans Affairs. (PROSPERO registration number: CRD42014007469).

Consumer-mediated health information exchanges: The 2012 ACMI debate

The American College of Medical Informatics (ACMI) sponsors periodic debates during the American Medical Informatics Fall Symposium to highlight important informatics issues of broad interest. In 2012, a panel debated the following topic: “Resolved: Health Information Exchange Organizations Should Shift Their Principal Focus to Consumer-Mediated Exchange in Order to Facilitate the Rapid Development of Effective, Scalable, and Sustainable Health Information Infrastructure.” Those supporting the proposition emphasized the need for consumer-controlled community repositories of electronic health records (health record banks) to address privacy, stakeholder cooperation, scalability, and sustainability. Those opposing the proposition emphasized that the current healthcare environment is so complex that development of consumer control will take time and that even then, consumers may not be able to mediate their information effectively. While privately each discussant recognizes that there are many sides to this complex issue, each followed the debater’s tradition of taking an extreme position in order emphasize some of the polarizing aspects in the short time allotted them. In preparing this summary, we sought to convey the substance and spirit of the debate in printed form. Transcripts of the actual debate were edited for clarity, and appropriate supporting citations were added for the further edification of the reader.

Patient-Consent Tools Are Available

Federal health officials have developed videos and other tools to gain patient consent for sharing medical information electronically. While state laws and regulations create a patchwork of different requirements for when patient consent is required to release information for treatment, federal officials are encouraging physicians to develop a “meaningful consent” process that includes education about how the information is shared, gives patients time to review the educational materials, and allows them to change or revoke their consent at any time. The effort deals specifically with information shared through health information exchange organizations and is available at www.healthit.gov/providers-professionals/patient-consent-electronic-health-information-exchange/econsent-toolkit. “As patients become more engaged in their health care, it's vitally important that they understand more about various aspects of their choices when it relates to sharing their health in the electronic health information exchange environment,” Joy Pritts, ONC's chief privacy officer in the Office of the National Coordinator for Health Information Technology, said in a statement.

Sociotechnical challenges to developing technologies for patient access to health information exchange data

Providing patients with access to their medical data is widely expected to help educate and empower them to manage their own health. Health information exchange (HIE) infrastructures could potentially help patients access records across multiple healthcare providers. We studied three HIE organizations as they developed portals to give consumers access to HIE data previously exchanged only among healthcare organizations. To follow the development of new consumer portal technologies, and to identify barriers and facilitators to patient access to HIE data. Semistructured interviews of 15 key informants over a 2-year period spanning the development and early implementation of three new projects, coded according to a sociotechnical framework. As the organizations tried to develop functionality that fully served the needs of both providers and patients, plans were altered by technical barriers (primarily related to data standardization) and cultural and legal issues surrounding data access. Organizational changes also played an important role in altering project plans. In all three cases, patient access to data was significantly scaled back from initial plans. This prospective study revealed how sociotechnical factors previously identified as important in health information technology success and failure helped to shape the evolution of three novel consumer informatics projects. Barriers to providing patients with seamless access to their HIE data were multifactorial. Remedies will have to address technical, organizational, cultural, and other factors.

State and Local Health Agency Engagement in HIE: A Cross-Sectional Survey

A survey of state and local agencies characterizes relationships with health information exchange organizations. Few agencies are engaged in HIE, except where CDC has made strategic investments.

A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use

To receive financial incentives for meaningful use of electronic health records, physicians and hospitals will need to engage in health information exchange (HIE). For most providers, joining regional organizations that support HIE is the most viable approach currently available. To assess the state of HIE in the United States through regional health information organizations (RHIOs). Survey. All RHIOs in the United States. 179 U.S.-based RHIOs that facilitated HIE as of December 2009. Number of operational RHIOs, the subset of operational RHIOs that supported stage 1 meaningful use, and the subset that supported robust HIE; number of ambulatory practices and hospitals participating in RHIOs; and number of financially viable RHIOs. Of 197 potential RHIOs, 179 (91%) reported their status and 165 (84%) returned completed surveys. Of these, 75 RHIOs were operational, covering approximately 14% of U.S. hospitals and 3% of ambulatory practices. Thirteen RHIOs supported stage 1 meaningful use (covering 3% of hospitals and 0.9% of practices), and none met an expert-derived definition of a comprehensive RHIO. Overall, 50 of 75 RHIOs (67%) did not meet the criteria for financial viability. Survey data were self-reported. The sample may not have included all HIE efforts, particularly those of individual providers who set up their own data-exchange agreements. These findings call into question whether RHIOs in their current form can be self-sustaining and effective in helping U.S. physicians and hospitals engage in robust HIE to improve the quality and efficiency of care. Office of the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services.

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.

E Health Records and Information Exchange

E Health Records and Information Exchange

Developing data content specifications for the Nationwide Health Information Network Trial Implementations

In 2007, the Department of Health and Human Services commissioned the Nationwide Health Information Network (NHIN) Trial Implementations project to demonstrate the secure exchange of data among health information exchange organizations around the country. The project's Core Services Content Work Group (CSCWG) developed the content specifications for the project. The CSCWG developed content specifications for a summary patient record and for eight use cases that were implemented in demonstration events in 2008. The CSCWG developed tools to represent the specifications and facilitate implementation. The experience revealed that, in general, the Health Information Technology Standards Panel (HITSP) constructs served as a suitable starting point for the development of content specifications for interoperability. The ability to adhere to specified terminologies still presents significant challenges. This paper describes the process of developing the content specifications and lessons learned.

Biomedical informatics and outcomes research: enabling knowledge-driven health care.

At its core, the practice of medicine is an information-intensive endeavor. Most of what physicians do involves the collection, review, and management of information. Examples of such activities include obtaining and recording patient information, consulting colleagues, reading the scientific literature, planning diagnostic procedures, devising strategies for patient care, interpreting tests, and conducting research. The ever-increasing biomedical knowledge base that must be considered to deliver optimal patient care only adds to the challenges facing medicine today. Successfully addressing these challenges to deliver the best health care possible requires not only the existence of valid and generalizable data sets derived from systematic basic, clinical, and epidemiological research efforts but also the ability to apply the knowledge derived from these research efforts at the point of care. It is easy to understand, therefore, why the field of biomedical informatics, a field that is concerned with collecting, managing, and optimally using information in health care and biomedicine, is critical to the current and future practice of medicine and the study of healthcare outcomes that result from such practice.1,2 Biomedical informatics approaches and related health information technology (health IT) platforms are key to enabling knowledge-driven healthcare and practice improvement initiatives based on a solid research foundation. Similar biomedical informatics approaches and resources are also critical to advancing outcomes research. Indeed, such technologies such as electronic health records (EHRs), clinical data repositories, and research-specific data management systems are already transforming the way we practice medicine and conduct research. This transformation is being further advanced by federally directed funding and research infrastructure development efforts.3,4 In the sections that follow, we provide an overview of how biomedical informatics and health IT processes and tools can affect the conduct of research and the delivery of evidence-based health care from our perspective. Given the current state of development …

Understanding the Decisions and Values of Stakeholders in Health Information Exchanges: Experiences From Massachusetts

We studied how health information exchange systems are established by examining the decisions (and thus, indirectly, the values) of key stakeholders (health care providers) participating in a health information exchange pilot project in 3 Massachusetts communities. Our aim was to understand how these kinds of information exchanges can be made viable. We used semistructured interviews to assess health care providers' decision-making processes in selecting technical architectures and vendors for the pilot projects to uncover their needs, expectations, and motivations. Our interviews indicated that, after extensive evaluations, health care providers in all 3 communities eventually selected a hybrid architecture that included a central data repository. However, the reasons for selecting this architecture varied considerably among the 3 communities, reflecting their particular values. Plans to create a community patient portal also differed across communities. Our findings suggest that, to become established, health information exchange efforts must foster trust, appeal to strategic interests of the medical community as a whole, and meet stakeholder expectations of benefits from quality measurements and population health interventions. If health information exchange organizations cannot address these factors, sustainability will remain precarious.

Government Not Doing Enough to Ensure Medical-Record Privacy

Back to table of contents Previous article Next article Professional NewsFull AccessGovernment Not Doing Enough to Ensure Medical-Record PrivacyMark MoranMark MoranSearch for more papers by this authorPublished Online:7 Nov 2008https://doi.org/10.1176/pn.43.21.0010aThe federal government needs to do more to ensure privacy and confidentiality in any national electronic health information network that is developed.In particular, the Office of the National Coordinator for Health Information Technology needs to develop a process for assessing the myriad privacy concerns of different stakeholders and for determining how all of those concerns will be addressed in an overall strategy for ensuring privacy and confidentiality, according to a report by the Government Accountability Office (GAO) released in September.The Department of Health and Human Services' (HHS) “privacy approach does not include a defined process for assessing and prioritizing the many privacy-related initiatives to ensure that key privacy principles and challenges will be fully and adequately addressed,” according to the report. “As a result, stakeholders may lack the overall policies and guidance needed to assist them in their efforts to ensure that privacy protection measures are consistently built into health information technology programs and applications. Moreover, the department may miss an opportunity to establish the high degree of public confidence and trust needed to help ensure the success of a nationwide health information network.”In January 2007, the GAO issued a report on protecting the privacy of electronic health information that asked HHS to identify milestones and assign responsibility for integrating the outcomes of its privacy-related initiatives, ensure that key privacy principles are addressed, and address key challenges associated with the nationwide exchange of health information.The new GAO report noted that HHS has undertaken some important steps. They include the following:The Healthcare Information Technology Standards Panel defined standards for implementing security features in systems that process personal health information.The panel is a body of the American National Standards Institute. According to the institute's Web site, “The mission of the Healthcare Information Technology Standards Panel is to serve as a cooperative partnership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among health care software applications, as they will interact in a local, regional, and national health information network for the United States.”The Certification Commission for Healthcare Information Technology defined certification criteria that included privacy protections for both outpatient and inpatient electronic health records. The Certification Commission Healthcare Information Technology is a recognized certification body for electronic health records and their networks and an independent, voluntary, private-sector initiative.Initiatives aimed at the state level have convened stakeholders to identify and propose solutions for addressing challenges faced by health information exchange organizations in protecting the privacy of electronic health information.In addition, the secretary of HHS released a federal health information technology strategic plan in June that includes privacy and security objectives, along with strategies and target dates for achieving them.But HHS needs to do more, the GAO said.“In particular, the department has not defined a process for ensuring that all privacy principles and challenges will be fully and adequately addressed,” the GAO stated. “This process would include, for example, steps for ensuring that all stakeholders' contributions to defining privacy-related activities are appropriately considered and that individual inputs to the privacy framework will be effectively assessed and prioritized to achieve comprehensive coverage of all key privacy principles and challenges.“Such a process is important given the large number and variety of activities being undertaken and the many stakeholders contributing to the health information technology initiatives. In particular, the contributing activities involve a wide variety of stakeholders, including federal, state, and private-sector entities.”“HHS Has Taken Important Steps to Address Privacy Principles and Challenges, Although More Work Remains” is posted at<www.gao.gov/new.items/d081138.pdf>. Information about the Certification Commission for Healthcare Information Technology is posted at<www.cchit.org>.▪ ISSUES NewArchived