Public and private sector roles in health information technology policy: Insights from the implementation and operation of exchange efforts in the United States

The complementary nature of query-based and directed health information exchange in primary care practice

OBJECTIVE

Many policymakers and advocates assume that directed and query-based health information exchange (HIE) work together to meet organizations' interoperability needs, but this is not grounded in a substantial evidence base. This study sought to clarify the relationship between the usage of these 2 approaches to HIE.

MATERIALS AND METHODS

System user log files from a regional HIE organization and electronic health record system were combined to model the usage of HIE associated with a patient visit at 3 federally qualified health centers in New York. Regression models tested the hypothesis that directed HIE usage was associated with query-based usage and adjusted for factors reflective of the FITT (Fit between Individuals, Task & Technology) framework. Follow-up interviews with 8 key informants helped interpret findings.

RESULTS

Usage of query-based HIE occurred in 3.1% of encounters and directed HIE in 23.5%. Query-based usage was 0.6 percentage points higher when directed HIE provided imaging information, and 4.8 percentage points higher when directed HIE provided clinical documents. The probability of query-based HIE was lower for specialist visits, higher for postdischarge visits, and higher for encounters with nurse practitioners. Informants used query-based HIE after directed HIE to obtain additional information, support transitions of care, or in cases of abnormal results.

DISCUSSION

The complementary nature of directed and query-based HIE indicates that both HIE functionalities should be incorporated into EHR Certification Criteria.

CONCLUSIONS

Quantitative and qualitative findings suggest that directed and query-based HIE exist in a complementary manner in ambulatory care settings.

Challenges for developing health-care knowledge in the digital age

Purpose

Health-care knowledge is dispersed among different departments in a health care organization, which makes it difficult at times to provide quality care services to patients. Therefore, this study aims to identify the main challenges in adopting health information technology (HIT).

Design/methodology/approach

This study surveyed 148 stakeholders in 4 key categories [patients, health-care providers, United Arab Emirates (UAE) citizens and foresight experts] to identify the challenges they face in adopting health care technologies. Responses were analyzed using exploratory (EFA) and confirmatory factor analysis (CFA).

Findings

EFA revealed four key latent factors predicting resistance to HIT adoption, namely, organizational strategy (ORGS); technical barriers; readiness for big data and the internet of things (IoT); and orientation (ORI). ORGS accounted for the greatest amount of variance. CFA indicated that readiness for big data and the IoT was only moderately correlated with HIT adoption, but the other three factors were strongly correlated. Specific items relating to cost, the effectiveness and usability of the technology and the organization were strongly correlated with HIT adoption. These results indicate that, in addition to financial considerations, effective HIT adoption requires ensuring that technologies will be easy to implement to ensure their long-term use.

Research limitations/implications

The results indicate that readiness for big data and the IoT-related infrastructure poses a challenge to HIT adoption in the UAE context. Respondents believed that the infrastructure of big data can be helpful in more efficiently storing and sharing health-care information. On the technological side, respondents felt that they may experience a steep learning curve. Regarding ORI, stakeholders expected many more such initiatives from health-care providers to make it more knowledge-specific and proactive.

Practical implications

This study has implications for knowledge management in the health -care sector for information technologies. The HIT can help firms in creating a knowledge eco-system, which is not possible in a dispersed knowledge environment. The utilization of the knowledge base that emerged from the practices and data can help the health care sector to set new standards of information flow and other clinical services such as monitoring the self-health condition. The HIT can further influence the actions of the pharmaceutical and medical device industry.

Originality/value

This paper highlights the challenges in HIT adoption and the most prominent factors. The conceptual model was empirically tested after the collection of primary data from the UAE using stakeholder theory.

Repurposing Clinical Decision Support System Data to Measure Dosing Errors and Clinician-Level Quality of Care

We aimed to develop and validate an instrument to detect hospital medication prescribing errors using repurposed clinical decision support system data. Despite significant efforts to eliminate medication prescribing errors, these events remain common in hospitals. Data from clinical decision support systems have not been used to identify prescribing errors as an instrument for physician-level performance. We evaluated medication order alerts generated by a knowledge-based electronic prescribing system occurring in one large academic medical center's acute care facilities for patient encounters between 2009 and 2012. We developed and validated an instrument to detect medication prescribing errors through a clinical expert panel consensus process to assess physician quality of care. Six medication prescribing alert categories were evaluated for inclusion, one of which - dose - was included in the algorithm to detect prescribing errors. The instrument was 93% sensitive (recall), 51% specific, 40% precise, 62% accurate, with an F1 score of 55%, positive predictive value of 96%, and a negative predictive value of 32%. Using repurposed electronic prescribing system data, dose alert overrides can be used to systematically detect medication prescribing errors occurring in an inpatient setting with high sensitivity.

Diverging views on health information exchange organizations

INTRODUCTION

Health 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.

METHODS

An 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."

RESULTS

Respondents 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.

DISCUSSION

This 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 (HIE): A literature review, assimilation pattern and a proposed classification for a new policy approach

OBJECTIVES

Literature shows existence of barriers to Healthcare Information Exchange (HIE) assimilation process. A number of studies have considered assimilation of HIE as a whole phenomenon without regard to its multifaceted nature. Thus, the pattern of HIE assimilation in healthcare providers has not been clearly studied due to the effects of contingency factors on different assimilation phases. This study is aimed at defining HIE assimilation phases, recognizing assimilation pattern, and proposing a classification to highlight unique issues associated with HIE assimilation.

METHODS

A literature review of existing studies related to HIE efforts from 2005 was undertaken. Four electronic research databases (PubMed, Web of Science, CINAHL, and Academic Search Premiere) were searched for articles addressing different phases of HIE assimilation process.

RESULTS

Two hundred and fifty-four articles were initially selected. Out of 254, 44 studies met the inclusion criteria and were reviewed. The assimilation of HIE is a complicated and a multi-staged process. Our findings indicated that HIE assimilation process consisted of four main phases: initiation, organizational adoption decision, implementation and institutionalization. The data helped us recognize the assimilation pattern of HIE in healthcare organizations.

CONCLUSIONS

The results provide useful theoretical implications for research by defining HIE assimilation pattern. The findings of the study also have practical implications for policy makers. The findings show the importance of raising national awareness of HIE potential benefits, financial incentive programs, use of standard guidelines, implementation of certified technology, technical assistance, training programs and trust between healthcare providers. The study highlights deficiencies in the current policy using the literature and identifies the "pattern" as an indication for a new policy approach.