Health Information Exchange Participation Research Articles

Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries?

Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions. Medicare Fee-for-Service Data, 2018. We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics. We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason. In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other. There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.

Successes and Barriers of Health Information Exchange Participation Across Hospitals in South Carolina From 2014 to 2020: Longitudinal Observational Study.

The 2009 Health Information Technology for Economic and Clinical Health Act sets three stages of Meaningful Use requirements for the electronic health records incentive program. Health information exchange (HIE) technologies are critical in the meaningful use of electronic health records to support patient care coordination. However, HIE use trends and barriers remain unclear across hospitals in South Carolina (SC), a state with the earliest HIE implementation. This study aims to explore changes in the proportion of HIE participation and factors associated with HIE participation, and barriers to exchange and interoperability across SC hospitals. This study derived data from a longitudinal data set of the 2014-2020 American Hospital Association Information Technology Supplement for 69 SC hospitals. The primary outcome was whether a hospital participated in HIE in a year. A cross-sectional multivariable logistic regression model, clustered at the hospital level and weighted by bed size, was used to identify factors associated with HIE participation. The second outcome was barriers to sending, receiving, or finding patient health information to or from other organizations or hospital systems. The frequency of hospitals reporting each barrier related to exchange and interoperability were then calculated. Hospitals in SC have been increasingly participating in HIE, improving from 43% (24/56) in 2014 to 82% (54/66) in 2020. After controlling for other hospital factors, teaching hospitals (adjusted odds ratio [AOR] 3.7, 95% CI 1.0-13.3), system-affiliated hospitals (AOR 6.6, 95% CI 3.2-13.7), and rural referral hospitals (AOR 8.0, 95% CI 1.2-53.4) had higher odds to participate in HIE than their counterparts, whereas critical access hospitals (AOR 0.1, 95% CI 0.02-0.6) were less likely to participate in HIE than their counterparts reimbursed by the prospective payment system. Hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation. Despite the majority of hospitals reporting HIE participation in 2020, barriers to exchange and interoperability remained, including lack of provider contacts (27/40, 68%), difficulty in finding patient health information (27/40, 68%), adapting different vendor platforms (26/40, 65%), difficulty matching or identifying same patients between systems (23/40, 58%), and providers that do not typically exchange patient data (23/40, 58%). HIE participation has been widely adopted in SC hospitals. Our findings highlight the need to incentivize optimization of HIE and seamless information exchange by facilitating and implementing standardization of health information across various HIE systems and by addressing other technical issues, including providing providers' addresses and training HIE stakeholders to find relevant information. Policies and efforts should include more collaboration with vendors to reduce platform compatibility issues and more user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of provider contacts and patient health information.

127 A formative usability evaluation of a community pharmacist-facing health information exchange (HIE) interface

OBJECTIVES/GOALS: To evaluate the usability of a HIE interface design among community pharmacists and technicians to identify opportunities for design improvements METHODS/STUDY POPULATION: Pharmacists and pharmacy technicians employed at Indiana community pharmacies participated in formative usability testing, via a Rapid Usability Evaluation (RUE), with an interactive, PDF prototype of the HIE interface. Participants were video-recorded to capture first impressions on the usability of the HIE prototype via the think aloud technique. Each participant had up to 1 hour to complete 4 clinical scenarios. Afterwards, participants completed the System Usability Scale (SUS; scale 0–100, with 100 being the best) to rate their satisfaction with the HIE prototype. RESULTS/ANTICIPATED RESULTS: Across 3 community pharmacies, 16 individuals participated in usability testing: 8 pharmacists and 8 technicians. The average SUS score for the HIE interface across participants from all sites was 70. Pharmacists on average scored the interface higher than technicians, 74 vs. 65, respectively. Initial findings from one pharmacy revealed that both pharmacists and technicians expressed a desire for improved efficiency (i.e. fewer clicks ) to access HIE data, alternative placement of HIE links within existing systems, and improved navigation to exit HIE links. DISCUSSION/SIGNIFICANCE: Initial results reveal opportunities to improve the HIE interface usability. Findings will inform design improvements to the interface and the creation of a toolkit to support the sustainable and scalable participation in HIE by community pharmacies.

Dynamic decision of health information exchange under different hospital relationships: A differential game approach

A growing number of hospitals implement health information exchange (HIE) to mitigate problems caused by fragmentation of medical information and improve their medical service level as well as their reputation. This paper considers the dynamic HIE process between a Grade-A hospital and a community hospital using the differential game theory, and then analyzes the HIE participation extent as well as hospital profit for the following three types of hospital relationships: independent decision-making (IDM), regional medical informatization (RMI), and government led cooperation (GLC). The results indicate that patient transfer percentage is one of the most important factors influencing HIE decision making, cost sharing and hospital profit. Through a comparative study under different hospital relationships, we find that RMI is a Pareto improvement as compared with IDM, in terms of hospitals' HIE participation extent and profit. Although GLC can bring the largest total profit, the Grade-A hospitals' HIE participation extent is the lowest under GLC.

Patient-Centered Data Home: A Path Towards National Interoperability.

ObjectiveNational interoperability is an agenda that has gained momentum in health care. Although several attempts to reach national interoperability, an alerting system through interconnected network of Health Information Exchange (HIE) organizations, Patient-Centered Data Home (PCDH), has seen preliminary success. The aim was to characterize the PCDH initiative through the Indiana Health Information Exchange's participation in the Heartland Region Pilot, which includes HIEs in Indiana, Ohio, Michigan, Kentucky, and Tennessee.Materials and MethodsAdmission, Discharge, and Transfer (ADT) transactions were collected between December 2016 and December 2017 among the seven HIEs in the Heartland Region. ADTs were parsed and summarized. Overlap analyses and patient matching software were used to characterize the PCDH patients. R software and Microsoft Excel were used to populate descriptive statistics and visualization.ResultsApproximately 1.5 million ADT transactions were captured. Majority of patients were female, ages 56–75 years, and were outpatient visits. Top noted reasons for visit were labs, screening, and abdominal pain. Based on the overlap analysis, Eastern Tennessee HIE was the only HIE with no duplicate service areas. An estimated 80 percent of the records were able to be matched with other records.DiscussionThe high volume of exchange in the Heartland Region Pilot established that PCDH is practical and feasible to exchange data. PCDH has the posture to build better comprehensive medical histories and continuity of care in real time.ConclusionThe value of the data gained extends beyond clinical practitioners to public health workforce for improved interventions, increased surveillance, and greater awareness of gaps in health for needs assessments. This existing interconnection of HIEs has an opportunity to be a sustainable path toward national interoperability.

Association of the Magnitude of Nurses With the Use of Health Information Exchanges: Analyzing the National Health Insurance Claim Data of Hospitals and Clinics in Korea.

BackgroundMany features of health care organizations (HCOs) have been identified to be associated with health information exchange (HIE), but subcategories of organizational factors focusing on nurse workforces still need to be identified. The objective of this study is to investigate the association of number of nurses with HIE use in Korea.MethodsThis study had a retrospective study design and used health insurance claim data from June 1, 2016 to June 30, 2018. The unit of analysis was the HCO, and any health insurance claims having HIE were counted by HCO. There were a total of 1490 HCOs having any HIE and 24 026 HCOs not having HIE. For statistical analysis, two-part model was used: logistic regression for HIE participation and the generalized linear model for the volume of HIE use.ResultsHIE was used by 44.6% of general hospitals, and 8.6% and 5.3% of small hospitals and clinics, respectively. Both HIE use and its volume were significantly positively associated with nurse variables. The use of HIE was significantly positively associated with nurse-to-bed ratio in general hospitals (OR 1.028; 1.016 to 1.041) and in small hospitals (OR 1.021; 1.016 to 1.027), and with the number of nurses (OR 1.041; 1.028 to 1.054) in clinics (P<.001). The volume of HIE use was also positively associated with nurse-to-bed ratio in general hospitals (OR 1.010; 1.004 to 1.017) and in small hospitals (OR 1.014; 1.006 to 1.022), and with the number of nurses (OR 1.055; 1.037 to 1.073) in clinics (P<.01).ConclusionThis study found that there was a low rate of HIE use in small hospitals and clinics. The number of nurses was critically associated with the use of HIE and the volume of HIE claims. HIE policy makers need to be aware of this factor in seeking to accelerate HIE.

Enabling health information exchange at a US Poison Control Center.

ObjectiveThe objective of this project was to enable poison control center (PCC) participation in standards-based health information exchange (HIE). Previously, PCC participation was not possible due to software noncompliance with HIE standards, lack of informatics infrastructure, and the need to integrate HIE processes into workflow.Materials and MethodsWe adapted the Health Level Seven Consolidated Clinical Document Architecture (C-CDA) consultation note for the PCC use case. We used rapid prototyping to determine requirements for an HIE dashboard for use by PCCs and developed software called SNOWHITE that enables poison center HIE in tandem with a poisoning information system.ResultsWe successfully implemented the process and software at the PCC and began sending outbound C-CDAs from the Utah PCC on February 15, 2017; we began receiving inbound C-CDAs on October 30, 2018.DiscussionWith the creation of SNOWHITE and initiation of an HIE process for sending outgoing C-CDA consultation notes from the Utah Poison Control Center, we accomplished the first participation of PCCs in standards-based HIE in the US. We faced several challenges that are also likely to be present at PCCs in other states, including the lack of a robust set of patient identifiers to support automated patient identity matching, challenges in emergency department computerized workflow integration, and the need to build HIE software for PCCs.ConclusionAs a multi-disciplinary, multi-organizational team, we successfully developed both a process and the informatics tools necessary to enable PCC participation in standards-based HIE and implemented the process at the Utah PCC.

Does Health Information Exchange Improve Patient Outcomes? Empirical Evidence From Florida Hospitals.

Achieving widespread exchange of health information is a national health policy objective, for it is believed to boost treatment efficiency, reduce health care costs, and improve patient outcomes. We used state-level data for 2011-14 from Florida to examine the relationship between hospitals' participation in health information exchange (HIE) and quality and health outcomes. HIE participation was associated with a decrease in the probability of unplanned, thirty-day readmissions for acute myocardial infarction that was 1.3 percentage points greater than that seen at nonparticipating hospitals. This decrease was driven primarily by reduced readmissions to hospitals other than those that provided initial inpatient treatment. These findings indicate that HIE can be leveraged to improve quality measures targeted by the Hospital Readmissions Reduction Program and may hold promise for achieving broader policy goals.

"Doctors’ Orders or Patients’ Preferences? Examining the Role of Physicians in Patients’ Privacy Decisions on Health Information Exchange Platforms"

Health information exchange (HIE) platforms could increase the efficiency of health care services by enabling providers to instantly access the medical records of their patients. However, these benefits cannot be realized unless patients disclose their information on HIE platforms. We examine actual privacy decisions made by patients on an HIE platform, study the influence of physicians’ recommendations on patients’ decisions, and explore the process through which this effect takes place. By analyzing a unique data set consisting of the privacy decisions of 12,444 patients, we show that contrary to common belief, patients do not simply follow physician recommendations, but rather carefully consider the risks and benefits of providing consent. We show that competition among medical providers does not hinder patient participation in HIEs, but that providers’ decisions to ask for consent are primarily driven by the potential benefits of HIE for themselves and their patients.

Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study

Studying diagnostic error at the population level requires an understanding of how diagnoses change over time. To use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy. Diagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality. Patients (180,337) 18years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013. We identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality. Discordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10-1.11, p < 0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p < 0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89-0.99, p < 0.001). Diagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.

Legal Barriers to the Growth of Health Information Exchange-Boulders or Pebbles?

Although the clinical benefits of exchanging patients' health information electronically across providers have long been recognized, participation in health information exchange (HIE) has lagged behind adoption of electronic health records. Barriers erected by federal and state health information privacy law have been cited as a leading reason for the slow progress. A comprehensive assessment of these issues has not been undertaken for nearly a decade, despite a number of salient legal developments. Analysis of federal and state health information privacy statutes and regulations and secondary materials. Although some legal barriers to HIE persist, many have been ameliorated-in some cases, simply through improved understanding of what the law actually requires. It is now clear that the Health Insurance Portability and Accountability Act presents no obstacles to electronically sharing protected health information for treatment purposes and does not hold providers who properly disclose information liable for privacy breaches by recipients. The failure of federal efforts to establish a unique patient identifier number does slow HIE by inhibiting optimal matching of patient records, but other action to facilitate matching will be taken under the 21st Century Cures Act. The Cures Act also creates the legal architecture to begin to combat "information blocking." Varying patient consent requirements under federal and state law are the most important remaining legal barrier to HIE progress. However, federal rules relating to disclosure of substance-abuse treatment information were recently liberalized, and development of a technical standard, Data Segmentation for Privacy, or DS4P, now permits sensitive data requiring special handling to be segmented within a patient's record. Even with these developments, state-law requirements for patient consent remain daunting to navigate. Although patient consent requirements make HIE challenging, providers' expressed worries about legal barriers to participating in HIE likely primarily reflect concerns that are economically motivated. Lowering the cost of HIE or increasing financial incentives may boost provider participation more than further reducing legal barriers.

A State-wide Health IT Infrastructure for Population Health: Building a Community-wide Electronic Platform for Maryland's All-Payer Global Budget.

Maryland Department of Health (MDH) has been preparing for alignment of its population health initiatives with Maryland’s unique All-Payer hospital global budget program. In order to operationalize population health initiatives, it is required to identify a starter set of measures addressing community level health interventions and to collect interoperable data for those measures. The broad adoption of electronic health records (EHRs) with ongoing data collection on almost all patients in the state, combined with hospital participation in health information exchange (HIE) initiatives, provides an unprecedented opportunity for near real-time assessment of the health of the communities. MDH’s EHR-based monitoring complements, and perhaps replaces, ad-hoc assessments based on limited surveys, billing, and other administrative data. This article explores the potential expansion of health IT capacity as a method to improve population health across Maryland.First, we propose a progression plan for four selected community-wide population health measures: body mass index, blood pressure, smoking status, and falls-related injuries. We then present an assessment of the current and near real-time availability of digital data in Maryland including the geographic granularity on which each measure can be assessed statewide. Finally, we provide general recommendations to improve interoperable data collection for selected measures over time via the Maryland HIE. This paper is intended to serve as a high level guiding framework for communities across the US that are undergoing healthcare transformation toward integrated models of care using universal interoperable EHRs.

Does participation in health information exchange improve hospital efficiency?

The federal government allocated nearly $30 billion to spur the development of information technology infrastructure capable of supporting the exchange of interoperable clinical data, leading to growth in hospital participation in health information exchange (HIE) networks. HIEs have the potential to improve care coordination across healthcare providers, leading ultimately to increased productivity of health services for hospitals. However, the impact of HIE participation on hospital efficiency remains unclear. This dynamic prompts the question asked by this study: does HIE participation improve hospital efficiency. This study estimates the effect of HIE participation on efficiency using a national sample of 1017 hospitals from 2009 to 2012. Using a two-stage analytic design, efficiency indices were determined using the Malmquist algorithm and then regressed on a set of hospital characteristics. Results suggest that any participation in HIE can improve both technical efficiency change and total factor productivity (TFP). A second model examining total years of HIE participation shows a benefit of one and three years of participation on TFP. These results suggest that hospital investment in HIE participation may be a useful strategy to improve hospital operational performance, and that policy should continue to support increased participation and use of HIE. More research is needed to identify the exact mechanisms through which HIE participation can improve hospital efficiency.

Local Health Departments' Partners and Challenges in Electronic Exchange of Health Information.

Unprecedented amounts of data are produced by the health care and other sectors, presenting opportunities for local health departments (LHDs) to access these data. LHDs will need to participate in health information exchange (HIE) with a number of partners in order to benefit from these data resources. LHDs' participation in HIEs with specific partners has not been studied. To describe the level of and challenges in LHD participation in HIE with other partners, and variation by LHD population size and governance type. This research uses data from the 2015 Informatics Capacity and Needs Assessment Survey, with a target population of all LHDs in the United States. A representative sample of 650 LHDs was drawn using a stratified random sampling design. A total of 324 completed responses were received with a 50% response rate. Survey data were cleaned, and bivariate comparisons were conducted using χ and Somer's D. Substantial variation existed in LHDs' participation in HIE by type of exchange partner. Although 71% participated in HIE with the state departments of health, only 12% with jail/correctional health, 14% with health or county-based purchasing plans, and 15% with home health agencies. Compared with large LHDs (jurisdiction populations of ≥500 000), smaller LHDs were more likely to participate in HIE with state departments of health, but less likely with other exchange partners. The challenges to HIE participation were technological, and organizational/interorganizational in nature and variation existed by LHDs' population size and governance structure with respect to state authority. Local public health agencies more commonly participate in HIE with some partners, but may need to improve HIE with many others. National strategies targeting an increase in HIE of LHDs may use our findings to focus those initiatives.

Which veterans enroll in a VA health information exchange program?

To characterize patients who voluntarily enrolled in an electronic health information exchange (HIE) program designed to share data between Veterans Health Administration (VHA) and non-VHA institutions. Patients who agreed to participate in the HIE program were compared to those who did not. Patient characteristics associated with HIE enrollment were examined using a multivariable logistic regression model. Variables selected for inclusion were guided by a health care utilization model adapted to explain HIE enrollment. Data about patients' sociodemographics (age, gender), comorbidity (Charlson index score), utilization (primary and specialty care visits), and access (distance to VHA medical center, insurance, VHA benefits) were obtained from VHA and HIE electronic health records. Among 57 072 patients, 6627 (12%) enrolled in the HIE program during its first year. The likelihood of HIE enrollment increased among patients ages 50-64, of female gender, with higher comorbidity, and with increasing utilization. Living in a rural area and being unmarried were associated with decreased likelihood of enrollment. Enrollment in HIE is complex, with several factors involved in a patient's decision to enroll. To broaden HIE participation, populations less likely to enroll should be targeted with tailored recruitment and educational strategies. Moreover, inclusion of special populations, such as patients with higher comorbidity or high utilizers, may help refine the definition of success with respect to HIE implementation.

Can a health information exchange save healthcare costs? Evidence from a pilot program in South Korea

ObjectiveGovernments and institutions across the world have made efforts to adopt and diffuse the health information exchange (HIE) technology with the expectation that the technology would improve the quality and efficiency of care by allowing providers online access to healthcare information generated by other providers at the point of care. However, evidence concerning the effectiveness of the technology is limited hindering the wide adoption of a HIE. The objective of this study was to assess impacts of a HIE on healthcare utilization and costs of patient episodes at a tertiary care hospital following referrals by clinic physicians. Material/methodsWe studied 1265 HIE and 2702 non-HIE episodes after physicians referred patients from 35 HIE and 59 non-HIE clinics to Seoul National University Bundang Hospital (SNUBH) during a 17-month period from June 2009. We examined 9 measures of healthcare utilization and the magnitude of clinical information exchanged in 4 categories. We estimated the savings resulting from HIE use through linear regression models with dummy variables for HIE participation and patient classification codes controlling the case-mix differences between HIE and non-HIE cases. ResultsThe total charges incurred by the HIE group during episodes at SNUBH were approximately 13% lower (P<0.001), and the charges for clinical laboratory tests, pathological diagnosis, function tests, and diagnostic imaging were 54% (P<0.001), 76% (P<0.001), 73% (P<0.001), and 80% (P<0.001) lower for the HIE group than for the non-HIE group. SNUBH physicians had access to more clinical information for HIE than for non-HIE patients. ConclusionsHIE technology improved physicians’ access to past clinical information, which appeared to reduce diagnostic test utilization and healthcare costs. The payer was the major beneficiary of HIE cost savings whereas providers paid for the technology. Fair allocation of benefits and costs among stakeholders is needed for wide HIE adoption.

Meaningful Use Status and Participation in Health Information Exchange Among New York State Hospitals: A Longitudinal Assessment

Billions of dollars is being utilized to promote electronic health record (EHR) adoption and electronic health information exchange (HIE). Monitoring trends over time is critical to understanding the success of policies initiatives. New York State is a leader in state-based initiatives promoting health information technology (HIT), and its experiences can provide valuable lessons to inform ongoing state and federal efforts. All hospitals in New York State were previously surveyed in 2009 to determine rates of EHR adoption, preparedness to meet meaningful use criteria, and participation in HIE. A follow-up survey was conducted from November 2012 through February 2013 to evaluate progress over time. Responses were received from 129 of 210 hospitals (61% response rate). Some 98% of responding hospitals (n = 126) had implemented or begun implementing an EHR-greater than a fourfold increase in three years. Nearly three-quarters had already attested to Stage 1 meaningful use for Medicaid (74.8%, n = 86) and Medicare (70.8%, n = 85), although only 10.7% (n = 13) anticipated it would be easy to achieve Stage 2 meaningful use. Seventy-nine percent of respondents (n = 92) reported exchanging electronic patient-level clinical data with other partners, and 89.9% (n = 116) reported participation in regional arrangements to share data. Lack of architecture and cost remain major barriers to achieving robust HIE. Although much progress has been made since 2009, careful attention must be paid to helping hospitals meet the stricter Stage 2 meaningful use requirements and to supporting robust HIE to help fulfill HIT's promise of achieving higher-quality, lower-cost health care.

Electronic health information exchange in underserved settings: examining initiatives in small physician practices & community health centers.

BackgroundHealth information exchange (HIE) is an important tool for improving efficiency and quality and is required for providers to meet Meaningful Use certification from the United States Centers for Medicare and Medicaid Services. However widespread adoption and use of HIE has been difficult to achieve, especially in settings such as smaller-sized physician practices and federally qualified health centers (FQHCs). We assess electronic data exchange activities and identify barriers and benefits to HIE participation in two underserved settings.MethodsWe conducted key-informant interviews with stakeholders at physician practices and health centers. Interviews were recorded, transcribed, and then coded in two waves: first using an open-coding approach and second using selective coding to identify themes that emerged across interviews, including barriers and facilitators to HIE adoption and use.ResultsWe interviewed 24 providers, administrators and office staff from 16 locations in two states. They identified barriers to HIE use at three levels—regional (e.g., lack of area-level exchanges; partner organizations), inter-organizational (e.g., strong relationships with exchange partners; achieving a critical mass of users), and intra-organizational (e.g., type of electronic medical record used; integration into organization’s workflow). A major perceived benefit of HIE use was the improved care-coordination clinicians could provide to patients as a direct result of the HIE information. Utilization and perceived benefit of the exchange systems differed based on several practice- and clinic-level factors.ConclusionsThe adoption and use of HIE in underserved settings appears to be impeded by regional, inter-organizational, and intra-organizational factors and facilitated by perceived benefits largely at the intra-organizational level. Stakeholders should consider factors both internal and external to their organization, focusing efforts in changing modifiable factors and tailoring HIE efforts based on all three categories of factors. Collective action between organizations may be needed to address inter-organizational and regional barriers. In the interest of facilitating HIE adoption and use, the impact of interventions at various levels on improving the use of electronic health data exchange should be tested.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-415) contains supplementary material, which is available to authorized users.

Does Health Information Exchange Reduce Redundant Imaging? Evidence From Emergency Departments

Broad-based electronic health information exchange (HIE), in which patients' clinical data follow them between care delivery settings, is expected to produce large quality gains and cost savings. Although these benefits are assumed to result from reducing redundant care, there is limited supporting empirical evidence. To evaluate whether HIE adoption is associated with decreases in repeat imaging in emergency departments (EDs). ED discharge data from the State Emergency Department Databases for California and Florida for 2007-2010 were merged with Health Information Management Systems Society data that report hospital HIE participation. Using regression with ED fixed effects and trends, we performed a retrospective analysis of the impact of HIE participation on repeat imaging, comparing 37 EDs that initiated HIE participation during the study period to 410 EDs that did not participate in HIE during the same period. Within 3 common types of imaging tests [computed tomography (CT), ultrasound, and chest x-ray), we defined a repeat image for a given patient as the same study in the same body region performed within 30 days at unaffiliated EDs. In our sample there were 20,139 repeat CTs (representing 14.7% of those cases with CT in the index visit), 13,060 repeat ultrasounds (20.7% of ultrasound cases), and 29,703 repeat chest x-rays (19.5% of x-ray cases). HIE was associated with reduced probability of repeat ED imaging in all 3 modalities: -8.7 percentage points for CT [95% confidence interval (CI): -14.7, -2.7], -9.1 percentage points for ultrasound (95% CI: -17.2, -1.1), and -13.0 percentage points for chest x-ray (95% CI: -18.3, -7.7), reflecting reductions of 44%-67% relative to sample means. HIE was associated with reduced repeat imaging in EDs. This study is among the first to find empirical support for this anticipated benefit of HIE.

Health information exchange among U.S. hospitals: who's in, who's out, and why?

BackgroundA key goal of the 2009 HITECH Act is to ensure broad electronic exchange of clinical data among providers. We sought to assess whether current policy efforts, many of which are being developed by states, appear to be tackling key barriers to hospital participation in health information exchange (HIE). MethodsWe used the most recent national data from the American Hospital Association's IT Supplement to assess U.S. hospital participation in HIE and how participation varies by state. We then examined whether HIE is being pursued by all types of hospitals, or whether specific types of hospitals are not yet engaged. We focused on for-profit hospitals, those with smaller market share, and those in more competitive markets. ResultsWe found that 30% of U.S. hospitals engaged in health information exchange with unaffiliated providers. There was large variation in state-level participation, with some states achieving more than 70% participation (Rhode Island, Delaware and Vermont) and others with minimal participation. In markets where exchange occurred, for-profit hospitals were far less likely to engage in HIE than non-profit hospitals (OR=0.17; p<0.001). Hospitals with a larger market share were more likely to engage in exchange (OR=2.05 for hospitals in the highest relative to the lowest quartile of market share; p<0.001), as were hospitals in less competitive markets (OR=2.15 for hospitals in the most relative to least concentrated market quartile; p=0.04). ConclusionsDespite an uptick in hospital HIE participation since the start of HITECH, the majority of hospitals still do not engage in HIE and there is large state-to-state variation. Specific types of hospitals appear to feel that they are better off not engaging in HIE. ImplicationsStronger policies and incentives may be needed to convince organizations to share their data electronically. Pursuing these is critical to ensuring that the highly anticipated quality and efficiency gains from our large national investment in health information technology are realized.