Factors motivating and affecting health information exchange usage

Objective

Health information exchange (HIE) is the process of electronically sharing patient-level information between providers. However, where implemented, reports indicate HIE system usage is low. The aim of this study was to determine the factors associated with different types of HIE usage.

Design

Cross-sectional analysis of clinical data from emergency room encounters included in an operational HIE effort linked to system user logs using crossed random-intercept logistic regression.

Measurements

Independent variables included factors indicative of information needs. System usage was measured as none, basic usage, or a novel pattern of usage.

Results

The system was accessed for 2.3% of all encounters (6142 out of 271 305). Novel usage patterns were more likely for more complex patients. The odds of HIE usage were lower in the face of time constraints. In contrast to expectations, system usage was lower when the patient was unfamiliar to the facility.

Limitations

Because of differences between HIE efforts and the fact that not all types of HIE usage (ie, public health) could be included in the analysis, results are limited in terms of generalizablity.

Conclusions

This study of actual HIE system usage identifies patients and circumstances in which HIE is more likely to be used and factors that are likely to discourage usage. The paper explores the implications of the findings for system redesign, information integration across exchange partners, and for meaningful usage criteria emerging from provisions of the Health Information Technology for Economic & Clinical Health Act.     

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

Background

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.

Objective

To follow the development of new consumer portal technologies, and to identify barriers and facilitators to patient access to HIE data.

Methods

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.

Results

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.

Conclusions

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.     

Characteristics associated with Regional Health Information Organization viability

Objective

Regional Health Information Organizations (RHIOs) will likely play a key role in our nation''s effort to catalyze health information exchange. Yet we know little about why some efforts succeed while others fail. We sought to identify factors associated with RHIO viability.

Design

Using data from a national survey of RHIOs that we conducted in mid-2008, we examined factors associated with becoming operational and factors associated with financial viability. We used multivariate logistic regression models to identify unique predictors.

Measurements

We classified RHIOs actively facilitating data exchange as operational and measured financial viability as the percent of operating costs covered by revenue from participants in data exchange (0–24%, 25–74%, 75–100%). Predictors included breadth of participants, breadth of data exchanged, whether the RHIO focused on a specific population, whether RHIO participants had a history of collaborating, and sources of revenue during the planning phase.

Results

Exchanging a narrow set of data and involving a broad group of stakeholders were independently associated with a higher likelihood of being operational. Involving hospitals and ambulatory physicians, and securing early funding from participants were associated with a higher likelihood of financial viability, while early grant funding seemed to diminish the likelihood.

Conclusion

Finding ways to help RHIOs become operational and self-sustaining will bolster the current approach to nationwide health information exchange. Our work suggests that convening a broad coalition of stakeholders to focus on a narrow set of data is an important step in helping RHIOs become operational. Convincing stakeholders to financially commit early in the process may help RHIOs become self-sustaining.     

Behavioral health providers' beliefs about health information exchange: a statewide survey

Objective

To assess behavioral health providers'' beliefs about the benefits and barriers of health information exchange (HIE).

Methods

Survey of a total of 2010 behavioral health providers in a Midwestern state (33% response rate), with questions based on previously reported open-ended beliefs elicitation interviews.

Results

Factor analysis resulted in four groupings: beliefs that HIE would improve care and communication, add cost and time burdens, present access and vulnerability concerns, and impact workflow and control (positively and negatively). A regression model including all four factors parsimoniously predicted attitudes toward HIE. Providers clustered into two groups based on their beliefs: a majority (67%) were positive about the impact of HIE, and the remainder (33%) were negative. There were some professional/demographic differences between the two clusters of providers.

Discussion

Most behavioral health providers are supportive of HIE; however, their adoption and use of it may continue to lag behind that of medical providers due to perceived cost and time burdens and concerns about access to and vulnerability of information.     

A framework for assessing patient crossover and health information exchange value

Objective

To evaluate the benefit of a health information exchange (HIE) between hospitals, we examine the rate of crossover among neurosurgical inpatients treated at Emory University Hospital (EUH) and Grady Memorial Hospital (GMH) in Atlanta, Georgia. To inform decisions regarding investment in HIE, we develop a methodology analyzing crossover behavior for application to larger more general patient populations.

Design

Using neurosurgery inpatient visit data from EUH and GMH, unique patients who visited both hospitals were identified through classification by name and age at time of visit. The frequency of flow patterns, including time between visits, and the statistical significance of crossover rates for patients with particular diagnoses were determined.

Measurements

The time between visits, flow patterns, and proportion of patients exhibiting crossover behavior were calculated for the total population studied as well as subpopulations.

Results

5.25% of patients having multiple visits over the study period visited the neurosurgical departments at both hospitals. 77% of crossover patients visited the level 1 trauma center (GMH) before visiting EUH.

Limitations

The true patient crossover may be under-estimated because the study population only consists of neurosurgical inpatients at EUH and GMH.

Conclusion

We demonstrate that detailed analysis of crossover behavior provides a deeper understanding of the potential value of HIE.     

Physicians' opinions of a health information exchange

Background

Arizona Medicaid developed a Health Information Exchange (HIE) system called the Arizona Medical Information Exchange (AMIE).

Objective

To evaluate physicians'' perceptions regarding AMIE''s impact on health outcomes and healthcare costs.

Measurements

A focus-group guide was developed and included five domains: perceived impact of AMIE on (1) quality of care; (2) workflow and efficiency; (3) healthcare costs; (4) system usability; and (5) AMIE data content. Qualitative data were analyzed using analytical coding.

Results

A total of 29 clinicians participated in the study. The attendance rate was 66% (N=19) for the first and last month of focus-group meetings and 52% (N=15) for the focus group meetings conducted during the second month. The benefits most frequently mentioned during the focus groups included: (1) identification of “doctor shopping”; (2) averting duplicative testing; and (3) increased efficiency of clinical information gathering. The most frequent disadvantage mentioned was the limited availability of data in the AMIE system.

Conclusion

Respondents reported that AMIE had the potential to improve care, but they felt that AMIE impact was limited due to the data available.     

A Self-scaling,Distributed Information Architecture for Public Health,Research, and Clinical Care

Objective

This study sought to define a scalable architecture to support the National Health Information Network (NHIN). This architecture must concurrently support a wide range of public health, research, and clinical care activities.

Study Design

The architecture fulfils five desiderata: (1) adopt a distributed approach to data storage to protect privacy, (2) enable strong institutional autonomy to engender participation, (3) provide oversight and transparency to ensure patient trust, (4) allow variable levels of access according to investigator needs and institutional policies, (5) define a self-scaling architecture that encourages voluntary regional collaborations that coalesce to form a nationwide network.

Results

Our model has been validated by a large-scale, multi-institution study involving seven medical centers for cancer research. It is the basis of one of four open architectures developed under funding from the Office of the National Coordinator of Health Information Technology, fulfilling the biosurveillance use case defined by the American Health Information Community. The model supports broad applicability for regional and national clinical information exchanges.

Conclusions

This model shows the feasibility of an architecture wherein the requirements of care providers, investigators, and public health authorities are served by a distributed model that grants autonomy, protects privacy, and promotes participation.     

Emergency Physicians’ Perceptions of Health Information Exchange

Background

Health information exchange (HIE) is a potentially powerful technology that can improve the quality of care delivered in emergency departments, but little is known about emergency physicians’ current perceptions of HIE.

Objectives

This study sought to assess emergency physicians’ perceived needs and knowledge of HIE.

Methods

A questionnaire was developed based on heuristics from the literature and implemented in a Web-based tool. The survey was sent as a hyperlink via e-mail to 371 attending emergency physicians at 12 hospitals in New York City.

Results

The response rate was 58% (n = 216). Although 63% said more than one quarter of their patients would benefit from external health information, the barriers to obtain it without HIE are too high—85% said it was difficult or very difficult to obtain external data, taking an average of 66 minutes, 72% said that their attempts fail half of the time, and 56% currently attempt to obtain external data less than 10% of the time. When asked to create a rank-order list, electrocardiograms (ECGs) were ranked the highest, followed by discharge summaries. Respondents also chose images over written reports for ECGs and X-rays, but preferred written reports for advanced imaging and cardiac studies.

Conclusion

There is a strong perceived need for HIE, most respondents were not aware of HIE prior to this study, and there are certain types of data and presentations of data that are preferred by emergency physicians in the New York City region.     

Professional and geographical network effects on healthcare information exchange growth: does proximity really matter?

Background and objective

We postulate that professional proximity due to common patients and geographical proximity among practice locations are significant factors influencing the adoption of health information exchange (HIE) services by healthcare providers. The objective of this study is to investigate the direct and indirect network effects of these drivers on HIE diffusion.

Design

Multi-dimensional scaling and clustering are first used to create different clusters of physicians based on their professional and geographical proximities. Extending the Bass diffusion model to capture direct and indirect network effects among groups, the growth of HIE among these clusters is modeled and studied. The network effects among the clusters are investigated using adoption data over a 3-year period for an HIE based in Western New York.

Measurement

HIE adoption parameters—external sources of influence as well as direct and indirect network coefficients—are estimated by the extended version of the Bass diffusion model.

Results

Direct network effects caused by common patients among physicians are much more influential on HIE adoption as compared with previously investigated social contagion and external factors. Professional proximity due to common patients does influence adoption decisions; geographical proximity is also influential, but its effect is more on rural than urban physicians.

Conclusions

Flow of patients among different groups of physicians is a powerful factor in HIE adoption. Rather than merely following the market trend, physicians appear to be influenced by other physicians with whom they interact with and have common patients.     

Design and development of an international clinical data exchange system: the international layer function of the Dolphin Project

Objective

At present, most clinical data are exchanged between organizations within a regional system. However, people traveling abroad may need to visit a hospital, which would make international exchange of clinical data very useful.

Background

Since 2007, a collaborative effort to achieve clinical data sharing has been carried out at Zhejiang University in China and Kyoto University and Miyazaki University in Japan; each is running a regional clinical information center.

Methods

An international layer system named Global Dolphin was constructed with several key services, sharing patients'' health information between countries using a medical markup language (MML). The system was piloted with 39 test patients.

Results

The three regions above have records for 966 000 unique patients, which are available through Global Dolphin. Data exchanged successfully from Japan to China for the 39 study patients include 1001 MML files and 152 images. The MML files contained 197 free text-type paragraphs that needed human translation.

Discussion

The pilot test in Global Dolphin demonstrates that patient information can be shared across countries through international health data exchange. To achieve cross-border sharing of clinical data, some key issues had to be addressed: establishment of a super directory service across countries; data transformation; and unique one—language translation. Privacy protection was also taken into account. The system is now ready for live use.

Conclusion

The project demonstrates a means of achieving worldwide accessibility of medical data, by which the integrity and continuity of patients'' health information can be maintained.     

Research and applications: Effects of health information exchange adoption on ambulatory testing rates

Objective

To determine the effects of the adoption of ambulatory electronic health information exchange (HIE) on rates of laboratory and radiology testing and allowable charges.

Design

Claims data from the dominant health plan in Mesa County, Colorado, from 1 April 2005 to 31 December 2010 were matched to HIE adoption data on the provider level. Using mixed effects regression models with the quarter as the unit of analysis, the effect of HIE adoption on testing rates and associated charges was assessed.

Results

Claims submitted by 306 providers in 69 practices for 34 818 patients were analyzed. The rate of testing per provider was expressed as tests per 1000 patients per quarter. For primary care providers, the rate of laboratory testing increased over the time span (baseline 1041 tests/1000 patients/quarter, increasing by 13.9 each quarter) and shifted downward with HIE adoption (downward shift of 83, p<0.01). A similar effect was found for specialist providers (baseline 718 tests/1000 patients/quarter, increasing by 19.1 each quarter, with HIE adoption associated with a downward shift of 119, p<0.01). Even so, imputed charges for laboratory tests did not shift downward significantly in either provider group, possibly due to the skewed nature of these data. For radiology testing, HIE adoption was not associated with significant changes in rates or imputed charges in either provider group.

Conclusions

Ambulatory HIE adoption is unlikely to produce significant direct savings through reductions in rates of testing. The economic benefits of HIE may reside instead in other downstream outcomes of better informed, higher quality care.     

Hospital treatment -is it affordable? A structured cost analysis of vaginal deliveries and planned caesarean sections

Introduction

The analysis of cost effectiveness in hospitals is as difficult as treating the patients properly. We are yet not able to answer the simple question of what costs are caused by a certain diagnosis and its treatment during an average hospital stay.

Methods

To answer some issues of the global problem of cost effectiveness during hospitalisation, we analysed the costs and the cost structure of a normal obstetrical hospital stay during an uncomplicated vaginal delivery and a planned caesarean section. Cost data was collected and summarized from the patients file, the hospital''s computer system gathering all cost centres, known material expenses and expenses of non obstetrical medical services.

Results

For vaginal deliveries/planned caesareans we can calculate with a surplus of about 83 €/1432 €. About 45% of the summarized costs are calculated on a reliable database.

Discussion

The introduction of the DRG based clearing system in Germany has aggravated the discussion on cost effectiveness. Our meticulous work-up of expenses excluded personal precautionary costs and personnel costs of documentation because no tools are described to depict such costs. If we would add these costs to the known expenses of our study, we strongly suspect that hospital treatment of vaginal deliveries or planned caesarean sections is not cost effective.     

Patients with poorly controlled diabetes in primary care: healthcare clinicians' beliefs and attitudes

Objective

To determine doctors'' and nurses'' attitudes and beliefs about treating patients with type 2 diabetes with less than ideal glycaemic control while receiving maximal oral treatment in primary care.

Design

Focus groups.

Setting

Primary care.

Participants

Four focus groups of 23 GPs and practice nurses.

Results

General practice was thought to be the best setting for managing all patients with type 2 diabetes but there were concerns about a lack of resources and unfamiliarity with starting insulin. Issues around compliance were extensively discussed; the “failing diabetic” had dual meanings of failing glycaemic control and failing compliance and effort by both patient and doctor. Although views about insulin therapy differed, patients were understood to be resistant to starting insulin, representing for them a more serious stage of diabetes, with fears of needles and hypoglycaemia.

Conclusion

The role of diabetes specialist nurses working in primary care will be crucial in managing such patients to improve knowledge, for extra resources, for their experience of insulin use, and to change attitudes.     

Mass scale screening of common arboviral infections by an affordable,cost effective RT-PCR method

Objective

To develop a rapid, cost effective RT-PCR method for the mass scale diagnosis of such diseases at the viremia stage to find out the actual disease burden in that area.

Methods

For this purpose, cases with the history of only short febrile illness were considered. Thus 157 samples with the history of dengue/chikungunya like illness and only 58 samples with a history of acute encephalitis syndrome (AES) were selected.

Results

Out of 157 samples, 42 and 74 were detected as dengue and chikungunya, respectively and out of 58 AES cases only 23 could be detected as Japanese encephalitis by this RT-PCR method.

Conclusions

This cost effective RT-PCR method can detect the total positive cases that remain undetected by ELISA method. Moreover, this method is capable to detect the viral RNA from patients'' sera even after the appearance of IgM antibody at one fifth costs as compared with the other commercially available kits.     

The impact of the electronic medical record on structure,process, and outcomes within primary care: a systematic review of the evidence

Background

The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations.

Objective

The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices.

Materials and methods

Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria.

Results and discussion

The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedian''s framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.     

Life sciences domain analysis model

Objective

Meaningful exchange of information is a fundamental challenge in collaborative biomedical research. To help address this, the authors developed the Life Sciences Domain Analysis Model (LS DAM), an information model that provides a framework for communication among domain experts and technical teams developing information systems to support biomedical research. The LS DAM is harmonized with the Biomedical Research Integrated Domain Group (BRIDG) model of protocol-driven clinical research. Together, these models can facilitate data exchange for translational research.

Materials and methods

The content of the LS DAM was driven by analysis of life sciences and translational research scenarios and the concepts in the model are derived from existing information models, reference models and data exchange formats. The model is represented in the Unified Modeling Language and uses ISO 21090 data types.

Results

The LS DAM v2.2.1 is comprised of 130 classes and covers several core areas including Experiment, Molecular Biology, Molecular Databases and Specimen. Nearly half of these classes originate from the BRIDG model, emphasizing the semantic harmonization between these models. Validation of the LS DAM against independently derived information models, research scenarios and reference databases supports its general applicability to represent life sciences research.

Discussion

The LS DAM provides unambiguous definitions for concepts required to describe life sciences research. The processes established to achieve consensus among domain experts will be applied in future iterations and may be broadly applicable to other standardization efforts.

Conclusions

The LS DAM provides common semantics for life sciences research. Through harmonization with BRIDG, it promotes interoperability in translational science.     

Grid Binary LOgistic REgression (GLORE): building shared models without sharing data

Objective

The classification of complex or rare patterns in clinical and genomic data requires the availability of a large, labeled patient set. While methods that operate on large, centralized data sources have been extensively used, little attention has been paid to understanding whether models such as binary logistic regression (LR) can be developed in a distributed manner, allowing researchers to share models without necessarily sharing patient data.

Material and methods

Instead of bringing data to a central repository for computation, we bring computation to the data. The Grid Binary LOgistic REgression (GLORE) model integrates decomposable partial elements or non-privacy sensitive prediction values to obtain model coefficients, the variance-covariance matrix, the goodness-of-fit test statistic, and the area under the receiver operating characteristic (ROC) curve.

Results

We conducted experiments on both simulated and clinically relevant data, and compared the computational costs of GLORE with those of a traditional LR model estimated using the combined data. We showed that our results are the same as those of LR to a 10⁻¹⁵ precision. In addition, GLORE is computationally efficient.

Limitation

In GLORE, the calculation of coefficient gradients must be synchronized at different sites, which involves some effort to ensure the integrity of communication. Ensuring that the predictors have the same format and meaning across the data sets is necessary.

Conclusion

The results suggest that GLORE performs as well as LR and allows data to remain protected at their original sites.     

Clinical research data warehouse governance for distributed research networks in the USA: a systematic review of the literature

Objective

To review the published, peer-reviewed literature on clinical research data warehouse governance in distributed research networks (DRNs).

Materials and methods

Medline, PubMed, EMBASE, CINAHL, and INSPEC were searched for relevant documents published through July 31, 2013 using a systematic approach. Only documents relating to DRNs in the USA were included. Documents were analyzed using a classification framework consisting of 10 facets to identify themes.

Results

6641 documents were retrieved. After screening for duplicates and relevance, 38 were included in the final review. A peer-reviewed literature on data warehouse governance is emerging, but is still sparse. Peer-reviewed publications on UK research network governance were more prevalent, although not reviewed for this analysis. All 10 classification facets were used, with some documents falling into two or more classifications. No document addressed costs associated with governance.

Discussion

Even though DRNs are emerging as vehicles for research and public health surveillance, understanding of DRN data governance policies and procedures is limited. This is expected to change as more DRN projects disseminate their governance approaches as publicly available toolkits and peer-reviewed publications.

Conclusions

While peer-reviewed, US-based DRN data warehouse governance publications have increased, DRN developers and administrators are encouraged to publish information about these programs.