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

eHealth implementation in Europe: a scoping review on legal, ethical, financial, and technological aspects

Background

The evolution of eHealth development has shifted from standalone tools to comprehensive digital health environments, fostering data exchange among diverse stakeholders and systems. Nevertheless, existing research and implementation frameworks have primarily emphasized technological and organizational aspects of eHealth implementation, overlooking the intricate legal, ethical, and financial considerations. It is essential to discover what legal, ethical, financial, and technological challenges should be considered to ensure successful and sustainable implementation of eHealth.

Objective

This review aims to provide insights into barriers and facilitators of legal, ethical, financial, and technological aspects for successful implementation of complex eHealth technologies, which impacts multiple levels and multiple stakeholders.

Methods

A scoping review was conducted by querying PubMed, Scopus, Web of Science, and ACM Digital Library (2018-2023) for studies describing the implementation process of eHealth technologies that facilitate data exchange. Studies solely reporting clinical outcomes or conducted outside Europe were excluded. Two independent reviewers selected the studies. A conceptual framework was constructed through axial and inductive coding, extracting data from literature on legal, ethical, financial, and technological aspects of eHealth implementation. This framework guided systematic extraction and interpretation.

Results

The search resulted in 7.308 studies that were screened for eligibility, of which 35 (0.48%) were included. Legal barriers revolve around data confidentiality and security, necessitating clear regulatory guidelines. Ethical barriers span consent, responsibility, liability, and validation complexities, necessitating robust frameworks. Financial barriers stem from inadequate funding, requiring (commercial) partnerships and business models. Technological issues include interoperability, integration, and malfunctioning, necessitating strategies for enhancing data reliability, improving accessibility, and aligning eHealth technology with existing systems for smoother integration.

Conclusions

This research highlights the multifaceted nature of eHealth implementation, encompassing legal, ethical, financial, and technological considerations. Collaborative stakeholder engagement is paramount for effective decision-making and aligns with the transition from standalone eHealth tools to integrated digital health environments. Identifying suitable stakeholders and recognizing their stakes and values enriches implementation strategies with expertise and guidance across all aspects. Future research should explore the timing of these considerations and practical solutions for regulatory compliance, funding, navigation of responsibility and liability, and business models for reimbursement strategies.

Regulations and Funding to Create Enterprise Architecture for a Nationwide Health Data Ecosystem

The COVID-19 pandemic highlighted the United States' lack of a nationwide infrastructure for collecting, sharing, and using health data, especially for secondary uses (e.g., population health management and public health). The federal government is taking several important steps to upgrade the nation's health data ecosystem-notably, the Centers for Disease Control and Prevention's Data Modernization Initiative and the Office of the National Coordinator for Health Information Technology's Trusted Exchange Framework and Common Agreement. However, substantial barriers remain. Inconsistent regulations, infrastructure, and governance across federal and state levels and between states significantly impede the exchange and analysis of health data. Siloed systems and insufficient funding block effective integration of clinical, public health, and social determinants data within and between states. In this analytic essay, we propose strategies to develop a nationwide health data ecosystem. We focus on providing federal guidance and incentives to develop state-designated entities responsible for the collection, integration, and analysis of clinical, public health, social determinants of health, claims, administrative, and other relevant data. These recommendations include a regulatory clearinghouse, federal guidance, model legislation and templated regulation, funding to incentive enterprise architecture, regulatory sandboxes, and a 3-pronged research agenda. (Am J Public Health. 2024;114(2):209-217. https://doi.org/10.2105/AJPH.2023.307477).

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

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

Adoption and use of various health information exchange methods for sending inside health information in US hospitals

BACKGROUND

Hospitals may adopt various information transmission methods to participate in health information exchange (HIE) programs. However, even if they adopt multiple mechanisms, they may not actively use all of them to send inside information. This study analyzes the frequently used methods for sending data and the common barriers blocking sending practices in hospital settings.

METHODS

Our sample included 3,015 community hospitals that reported their methods of sending patient health information in the 2019 American Hospital Association Information Technology Supplement Survey. The relationship between obstacles hospitals experienced and their use of the information-sending method was analyzed by using robust Poisson regression models.

RESULTS

Many-to-many exchanges that involve intermediaries such as a health information service provider (HISP), electronic health record (EHR) vendor-based network, and national network, once adopted, were more often used by hospitals than one-to-one exchange methods such as provider portals and direct access to EHR by login credentials. Hospitals that lacked the technical capability to electronically send patient health information were less likely to use any of the methods (p <.01), while hospitals located in a more concentrated market were more likely to send information to outside providers by using provider portal, interface connection and national network (p <.01).

DISCUSSION

There is still a notable gap between hospitals' adoption and the actual use of different HIE methods to send inside information to outside organizations. Results argue that even if hospitals adopted an HIE method, they might not necessarily participate in the actual sharing of information, and the method may remain unused due to several usage barriers.

CONCLUSION

Hospital and market-level barriers associated with using one-to-one and many-to-many HIE methods for sharing information may affect progress in interoperability. Examining the barriers to using multiple HIE methods and their impact on interoperability could offer implications for health information technology (IT) policy and inform health system leaders.

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

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

Comparison of health information exchange data with self-report in measuring cancer screening

BACKGROUND

Efficient measurement of the receipt of cancer screening has been attempted with electronic health records (EHRs), but EHRs are commonly implemented within a single health care setting. However, health information exchange (HIE) includes EHR data from multiple health care systems and settings, thereby providing a more population-based measurement approach. In this study, we set out to understand the value of statewide HIE data in comparison to survey self-report (SR) to measure population-based cancer screening.

METHODS

A statewide survey was conducted among residents in Indiana who had been seen at an ambulatory or inpatient clinical setting in the past year. Measured cancer screening tests included colonoscopy and fecal immunochemical test (FIT) for colorectal cancer, human papilloma virus (HPV) and Pap tests for cervical cancer, and mammogram for breast cancer. For each screening test, the self-reported response for receipt of the screening (yes/no) and 'time since last screening' were compared with the corresponding information from patient HIE to evaluate the concordance between the two measures.

RESULTS

Gwet's AC for HIE and self-report of screening receipt ranged from 0.24-0.73, indicating a fair to substantial concordance. For the time since receipt of last screening test, the Gwet's AC ranged from 0.21-0.90, indicating fair to almost perfect concordance. In comparison with SR data, HIE data provided relatively more additional information about laboratory-based tests: FIT (19% HIE alone vs. 4% SR alone) and HPV tests (27% HIE alone vs. 12% SR alone) and less additional information about procedures: colonoscopy (8% HIE alone vs. 23% SR alone), Pap test (13% HIE alone vs. 19% SR alone), or mammography (9% HIE alone vs. 10% SR alone).

CONCLUSION

Studies that use a single data source should consider the type of cancer screening test to choose the optimal data collection method. HIE and self-report both provided unique information in measuring cancer screening, and the most robust measurement approach involves collecting screening information from both HIE and patient self-report.

Transforming Health Data to Actionable Information: Recent Progress and Future Opportunities in Health Information Exchange

OBJECTIVES

Provide a systematic review of literature pertaining to health information exchange (HIE) since 2018. Summarize HIE-associated literature for most frequently occurring topics, as well as within the context of the COVID-19 pandemic and health equity. Finally, provide recommendations for how HIE can advance the vision of a digital healthcare ecosystem.

METHODS

A computer program was developed to mediate a literature search of primary literature indexed in MEDLINE that was: (1) indexed with "Health Information Exchange" MeSH descriptor as a major topic; and (2) published between January 2018 and December 2021. Frequency of MeSH descriptors was then used to identify and to rank topics associated with the retrieved literature. COVID-19 literature was identified using the general COVID-19 PubMed Clinical Query filter. Health equity literature was identified using additional MeSH descriptor-based searches. The retrieved literature was then reviewed and summarized.

RESULTS

A total of 256 articles were retrieved and reviewed for this survey. The major thematic areas summarized were: (1) Information Dissemination; (2) Delivery of Health Care; (3) Hospitals; (4) Hospital Emergency Service; (5) COVID-19; (6) Health Disparities; and (7) Computer Security and Confidentiality. A common theme across all areas examined for this survey was the maturity of HIE to support data-driven healthcare delivery. Recommendations were developed based on opportunities identified across the reviewed literature.

CONCLUSIONS

HIE is an essential advance in next generation healthcare delivery. The review of the recent literature (2018-2021) indicates that successful HIE improves healthcare delivery, often resulting in improved health outcomes. There remain major opportunities for expanded use of HIE, including the active engagement of clinical and patient stakeholders. The maturity of HIE reflects the maturity of the biomedical informatics and health data science fields.

Sociodemographic characteristics differ across routine adult vaccine cohorts: An All of Us descriptive study

BACKGROUND

The National Institutes of Health All of Us (AoU) Research Program is currently building a database of 1million+ adult subjects. With it, we describe the characteristics of those with documented vaccinations.

OBJECTIVES

To describe the sociodemographic, health status, and lifestyle factors associated with vaccinations.

METHODS

This is a retrospective study involving data from the AoU program (R2020Q4R2, N = 315,297). Five vaccine cohorts [influenza, hepatitis B (HBV), pneumococcal <65 years old, pneumococcal ≥65 years old, and human papillomavirus (HPV)] were generated based on vaccination history. The influenza cohort comprised participants with documented influenza vaccinations in electronic health records (EHRs) from September 2017 to May 2018. Other vaccine cohorts comprised participants with ≥1 lifetime record(s) of vaccination documented in the EHR by December 2018. The vaccine cohorts were compared to the overall AoU cohort. Descriptive statistics were generated using EHR- and survey-based sociodemographic, health, and lifestyle information. The SAMBA (0.9.0) R package was utilized to adjust for EHR selection and outcome misclassification biases to infer sources of disparity for pneumococcal vaccinations in older adults.

RESULTS

Cohort counts were as follows: influenza (n = 15,346), HBV (n = 6323), pneumococcal <65 (n = 15,217), pneumococcal ≥65 (n = 15,100), and HPV (n = 2125). All vaccine cohorts had higher proportions of White and non-Hispanic/Latino participants compared to the overall AoU cohort. The largest differences were found in pneumococcal age ≥65, with 80.2% White participants compared to 52.9% in the overall study population. Multivariable analysis revealed that race/ethnic disparities in pneumococcal vaccination among older adults were explained by biological sex, income, health insurance, and education-related variables.

CONCLUSION

Racial, ethnic, education, and income characteristics differ across the vaccine cohorts among AoU participants. These findings inform future utilization of large health databases in vaccine epidemiology research and emphasize the need for more targeted interventions that address differences in vaccine uptake.

Oral Oncolytics: Using Remote Technology to Improve Access, Operational Efficiency, and Satisfaction

Oncology care management via oral oncolytic therapy requires frequent laboratory monitoring for potential toxicities. A lag in these processes can result in treatment delays and care team dissatisfaction. A nurse-led quality improvement project was implemented to streamline processes, clearly define job tasks, and introduce a remote patient-reported symptom monitoring application to improve patient safety, access, operational productivity, and care team satisfaction. Project results included eliminating paper fax distribution, a 97% decrease in time required to process faxed remote laboratory results, and a 78% reduction in mouse clicks to complete laboratory orders and patient correspondence.

FROM SHARING TO SELLING: CHALLENGES AND OPPORTUNITIES OF ESTABLISHING A DIGITAL HEALTH DATA MARKETPLACE USING BLOCKCHAIN TECHNOLOGIES

During the COVID-19 pandemic, we witnessed how sharing of biological and biomedical data facilitated researchers, medical practitioners, and policymakers to tackle the pandemic on a global scale. Despite the growing use of electronic health records (EHRs) by medical practitioners and wearable digital gadgets by individuals, 80% of health and medical data remain unused, adding little value to the work of researchers and medical practitioners. Legislative constraints related to health data sharing, centralized siloed design of traditional data management systems, and most importantly, lack of incentivization models are thought to be the underpinning bottlenecks for sharing health data. With the advent of the General Data Protection Regulation (GDPR) of the European Union (EU) and the development of technologies like blockchain and distributed ledger technologies (DLTs), it is now possible to create a new paradigm of data sharing by changing the incentivization model from current authoritative or altruistic form to a shared economic model where financial incentivization will be the main driver for data sharing. This can be achieved by setting up a digital health data marketplace (DHDM). Here, we review papers that proposed technical models or implemented frameworks that use blockchain-like technologies for health data. We seek to understand and compare different technical challenges associated with implementing and optimizing the DHDM operation outlined in these articles. We also examine legal limitations in the context of the EU and other countries such as the USA to accommodate any compliance requirement for such a marketplace. Last but not least, we review papers that investigated the short-, medium-, and long-term socioeconomic impact of such a marketplace on a wide range of stakeholders.

The Health Care Sector's Experience of Blockchain: A Cross-disciplinary Investigation of Its Real Transformative Potential

BACKGROUND

Academic literature highlights blockchain's potential to transform health care, particularly by seamlessly and securely integrating existing data silos while enabling patients to exercise automated, fine-grained control over access to their electronic health records. However, no serious scholarly attempt has been made to assess how these technologies have in fact been applied to real-world health care contexts.

OBJECTIVE

The primary aim of this paper is to assess whether blockchain's theoretical potential to deliver transformative benefits to health care is likely to become a reality by undertaking a critical investigation of the health care sector's actual experience of blockchain technologies to date.

METHODS

This mixed methods study entailed a series of iterative, in-depth, theoretically oriented, desk-based investigations and 2 focus group investigations. It builds on the findings of a companion research study documenting real-world engagement with blockchain technologies in health care. Data were sourced from academic and gray literature from multiple disciplinary perspectives concerned with the configuration, design, and functionality of blockchain technologies. The analysis proceeded in 3 stages. First, it undertook a qualitative investigation of observed patterns of blockchain for health care engagement to identify the application domains, data-sharing problems, and the challenges encountered to date. Second, it critically compared these experiences with claims about blockchain's potential benefits in health care. Third, it developed a theoretical account of challenges that arise in implementing blockchain in health care contexts, thus providing a firmer foundation for appraising its future prospects in health care.

RESULTS

Health care organizations have actively experimented with blockchain technologies since 2016 and have demonstrated proof of concept for several applications (use cases) primarily concerned with administrative data and to facilitate medical research by enabling algorithmic models to be trained on multiple disparately located sets of patient data in a secure, privacy-preserving manner. However, blockchain technology is yet to be implemented at scale in health care, remaining largely in its infancy. These early experiences have demonstrated blockchain's potential to generate meaningful value to health care by facilitating data sharing between organizations in circumstances where computational trust can overcome a lack of social trust that might otherwise prevent valuable cooperation. Although there are genuine prospects of using blockchain to bring about positive transformations in health care, the successful development of blockchain for health care applications faces a number of very significant, multidimensional, and highly complex challenges. Early experience suggests that blockchain is unlikely to rapidly and radically revolutionize health care.

CONCLUSIONS

The successful development of blockchain for health care applications faces numerous significant, multidimensional, and complex challenges that will not be easily overcome, suggesting that blockchain technologies are unlikely to revolutionize health care in the near future.

Practice and market factors associated with provider volume of health information exchange

OBJECTIVE

To assess the practice- and market-level factors associated with the amount of provider health information exchange (HIE) use.

MATERIALS AND METHODS

Provider and practice-level data was drawn from the Meaningful Use Stage 2 Public Use Files from the Centers for Medicare and Medicaid Services, the Physician Compare National Downloadable File, and the Compendium of US Health Systems, among other sources. We analyzed the relationship between provider HIE use and practice and market factors using multivariable linear regression and compared primary care providers (PCPs) to non-PCPs. Provider volume of HIE use is measured as the percentage of referrals sent with electronic summaries of care (eSCR) reported by eligible providers attesting to the Meaningful Use electronic health record (EHR) incentive program in 2016.

RESULTS

Providers used HIE in 49% of referrals; PCPs used HIE in fewer referrals (43%) than non-PCPs (57%). Provider use of products from EHR vendors was negatively related to HIE use, while use of Athenahealth and Greenway Health products were positively related to HIE use. Providers treating, on average, older patients and greater proportions of patients with diabetes used HIE for more referrals. Health system membership, market concentration, and state HIE consent policy were unrelated to provider HIE use.

DISCUSSION

HIE use during referrals is low among office-based providers with the capability for exchange, especially PCPs. Practice-level factors were more commonly associated with greater levels of HIE use than market-level factors.

CONCLUSION

This furthers the understanding that market forces, like competition, may be related to HIE adoption decisions but are less important for use once adoption has occurred.

The 21st Century Cures Act and Challenges to Adolescent Confidentiality

Confidentiality is an important part of adolescent health care, providing a safe arena for young people to address sensitive health concerns and develop independent relationships with their providers. State and federal laws support a range of adolescent confidentiality protections. However, the full implementation of the 21st Century Cures Act, with the release of all medical records to patients and caregivers, may endanger this expectation of privacy. This policy brief reviews implications of the open notes requirement of the Cures Act, suggests strategies to improve care for adolescent patients, and recommends advocacy to improve the 2020 Final Rule implementation.

Patients' Perceptions of Different Information Exchange Mechanisms: An Exploratory Study in the United States

BACKGROUND

Patients may seek health care services from various providers during treatment. These providers could serve in a network (affiliated) or practice separately (unaffiliated). Thus, using secure and reliable health information exchange (HIE) mechanisms would be critical to transfer sensitive personal health information (PHI) across distances. Studying patients' perceptions and opinions about exchange mechanisms could help health care providers build more complete HIEs' databases and develop robust privacy policies, consent processes, and patient education programs.

OBJECTIVES

Due to the exploratory nature of this study, we aim to shed more light on public perspectives (benefits, concerns, and risks) associated with the four data exchange practices in the health care sector.

METHODS

In this study, we compared public perceptions and expectations regarding four common types of exchange mechanisms used in the United States (i.e., traditional, direct, query-based, patient-mediated exchange mechanisms). Traditional is an exchange through fax, paper mailing, or phone calls, direct is a provider-to-provider exchange, query-based is sharing patient data with a central repository, and patient-mediated is an exchange mechanism in which patients can access data and monitor sharing. Data were collected from 1,624 subjects using an online survey to examine the benefits, risks, and concerns associated with the four exchange mechanisms from patients' perspectives.

RESULTS

Findings indicate that several concerns and risks such as privacy concerns, security risks, trust issues, and psychological risks are raised. Besides, multiple benefits such as access to complete information, communication improvement, timely and convenient information sharing, cost-saving, and medical error reduction are highlighted by respondents. Through consideration of all risks and benefits associated with the four exchange mechanisms, the direct HIE mechanism was selected by respondents as the most preferred mechanism of information exchange among providers. More than half of the respondents (56.18%) stated that overall they favored direct exchange over the other mechanisms. 42.70% of respondents expected to be more likely to share their PHI with health care providers who implemented and utilized a direct exchange mechanism. 43.26% of respondents believed that they would support health care providers to leverage a direct HIE mechanism for sharing their PHI with other providers. The results exhibit that individuals expect greater benefits and fewer adverse effects from direct HIE among health care providers. Overall, the general public sentiment is more in favor of direct data transfer. Our results highlight that greater public trust in exchange mechanisms is required, and information privacy and security risks must be addressed before the widespread implementation of such mechanisms.

CONCLUSION

This exploratory study's findings could be interesting for health care providers and HIE policymakers to analyze how consumers perceive the current exchange mechanisms, what concerns should be addressed, and how the exchange mechanisms could be modified to meet consumers' needs.

Unfulfilled promises of health information exchange: What inhibits ambulatory clinics from electronically sharing health information?

PURPOSE

This study seeks to understand the key inhibitors for health information exchange (HIE) by ambulatory (outpatient) clinics. We examine the key technological, organizational and environmental factors that inhibit an ambulatory clinic from electronically exchanging health information with external clinics and hospitals.

METHODS

We utilize survey data from 1285 ambulatory clinics in the US state of Minnesota. Using logistic regressions, we assess if the ambulatory clinic's HIE with external clinics and external hospitals are associated with fourteen inhibitors from technological, organizational and environmental contexts in which ambulatory clinics operate.

RESULTS

Among the technological inhibitors, we find lack of adequate technological infrastructure, difficulties in integrating external data with electronic medical record systems, and security concerns to inhibit ambulatory clinics' HIE with both clinics and hospitals. Inadequate technical support was a barrier for HIE with hospitals, whereas inadequate training of staff was an inhibitor for clinic-to-clinic HIE. Of the environmental variables, legal concerns and complexity in framing HIE agreements with partners were found to inhibit ambulatory clinics' HIE with both external clinics and hospitals. Lack of partner readiness and ability was an inhibiting factor for clinic-to-hospital HIE whereas issues in patient consent, and problems in choosing the right vendor with a good fit were inhibiting ambulatory clinics' HIE with other clinics. Among the organizational variables, lack of adequate senior leadership support and complexity of workflow changes inhibited clinic-to-clinic health data sharing, whereas unclear return on investment (ROI) for HIE was a deterrent for ambulatory clinics' HIE with hospitals.

CONCLUSIONS

This study throws light on electronic HIE practices and its key inhibitors in ambulatory clinics, an understudied area in digital health. This paper provides unique insights into specific inhibitors that deter clinic-to-clinic health information sharing versus those that affect and clinic-to-hospital health information exchange.

The Role of Telehealth in the Covid-19 Pandemic: A Brazilian Experience

SARS-CoV-2, the virus that causes Covid-19, is the third coronavirus to cause severe disease in humans and to spread globally in the past two decades. In this context, several national public health departments, including the Brazilian Ministry of Health, highlighted what was, until then, considered a support service to the health system: telehealth and telemedicine. We intend to present the actions carried out by a national telehealth service in Brazil, both as a Primary Health Care (PHC) support service to professionals and to patients, as well as discussing the potential to reorganize a health system. This is a prevalence study that summarizes the measures adopted by Brazilian Telehealth Center from the 9th to the 27th epidemiological weeks of 2020 to support the health services of the Brazilian Unified Health System (SUS). There was an increase of 76.8% in the demand for telephone teleconsultations during the evaluated period compared to the same period in 2019, with 28.8% of the entire demand arising from doubts related to Covid-19. The Covid-19 pandemic demanded a quick response, with the organization of materials about the disease, a new team to carry out telemonitoring and teleconsultation activities, in addition to the creation of a manual for teleconsultations in Primary Health Care.

Organizational characteristics and perceptions of clinical event notification services in healthcare settings: a study of health information exchange

OBJECTIVE

Event notification systems are an approach to health information exchange (HIE) that notifies end-users of patient interactions with the healthcare system through real-time automated alerts. We examined associations between organizational capabilities and perceptions of event notification system use.

MATERIALS AND METHODS

We surveyed representatives (n = 196) from healthcare organizations (n = 96) that subscribed to 1 of 3 Health Information Organizations' event notification services in New York City (response rate = 27%). The survey was conducted in Fall 2017 and Winter 2018. Surveys measured respondent characteristics, perceived organizational capabilities, event notification use, care coordination, and care quality. Exploratory factor analysis was used to identify relevant independent and dependent variables. We examined the relationship between organizational capabilities, care coordination, and care quality using multilevel linear regression models with random effects.

RESULTS

Respondents indicated that the majority of their organizations provided follow-up care for emergency department visits (66%) and hospital admissions (73%). Perceptions of care coordination were an estimated 57.5% (β = 0.575; P < 0.001) higher among respondents who reported event notifications fit within their organization's existing workflows. Perceptions of care quality were 46.5% (β = 0.465; P < 0.001) higher among respondents who indicated event notifications fit within existing workflows and 23.8% (β = 0.238; P < 0.01) higher where respondents reported having supportive policies and procedures for timely response and coordination of event notifications.

DISCUSSION AND CONCLUSION

Healthcare organizations with specific workflow processes and positive perceptions of fit are more likely to use event notification services to improve care coordination and care quality. In addition, event notification capacity and patient consent procedures influence how end-users perceive event notification services.

Doctors Routinely Share Health Data Electronically Under HIPAA, and Sharing With Patients and Patients' Third-Party Health Apps is Consistent: Interoperability and Privacy Analysis

Since 2000, federal regulations have affirmed that patients have a right to a complete copy of their health records from their physicians and hospitals. Today, providers across the nation use electronic health records and electronic information exchange for health care, and patients are choosing digital health apps to help them manage their own health and health information. Some doctors and health systems have voiced concern about whether they may transmit a patient's data upon the patient's request to the patient or the patient's health app. This hesitation impedes shared information and care coordination with patients. It impairs patients' ability to use the state-of-the-art digital health tools they choose to track and manage their health. It undermines the ability of patients' family caregivers to monitor health and to work remotely to provide care by using the nearly unique capabilities of health apps on people's smartphones. This paper explains that sharing data electronically with patients and patients' third-party apps is legally consistent under the Health Insurance Portability and Accountability Act (HIPAA) with routine electronic data sharing with other doctors for treatment or with insurers for reimbursement. The paper explains and illustrates basic principles and scenarios around sharing with patients, including patients' third-party apps. Doctors routinely and legally share health data electronically under HIPAA whether or not their organizations retain HIPAA responsibility. Sharing with patients and patients' third-party apps is no different and should be just as routine.

Patient Identification Techniques - Approaches, Implications, and Findings

OBJECTIVES

To identify current patient identification techniques and approaches used worldwide in today's healthcare environment. To identify challenges associated with improper patient identification.

METHODS

A literature review of relevant peer-reviewed and grey literature published from January 2015 to October 2019 was conducted to inform the paper. The focus was on: 1) patient identification techniques and 2) unintended consequences and ramifications of unresolved patient identification issues.

RESULTS

The literature review showed six common patient identification techniques implemented worldwide ranging from unique patient identifiers, algorithmic approaches, referential matching software, biometrics, radio frequency identification device (RFID) systems, and hybrid models. The review revealed three themes associated with unresolved patient identification: 1) treatment, care delivery, and patient safety errors, 2) cost and resource considerations, and 3) data sharing and interoperability challenges.

CONCLUSIONS

Errors in patient identification have implications for patient care and safety, payment, as well as data sharing and interoperability. Different patient identification techniques ranging from unique patient identifiers and algorithms to hybrid models have been implemented worldwide. However, no current patient identification techniques have resulted in a 100% match rate. Optimizing algorithmic matching through data standardization and referential matching software should be studied further to identify opportunities to enhance patient identification techniques and approaches. Further efforts to improve patient identity management include adoption of patients' photos at registration, naming conventions, and standardized processes for recording patients' demographic data attributes.

Leveraging health information exchange for clinical research: Extreme underreporting of hospital service utilization among patients with substance use disorders

BACKGROUND

Substance use disorders are associated with inefficient and fragmented use of healthcare services. The Chesapeake Regional Information System for Our Patients, Inc. (CRISP) is a Health Information Exchange (HIE) linking disparate systems of care in the mid-Atlantic region.

METHODS

This article describes applications of HIE for tracking hospital service utilization in substance use disorder clinical and services research, drawing upon data from one of the first studies approved to access the CRISP HIE. Participants were 200 medical/surgical inpatients with comorbid opioid, cocaine, and/or alcohol use disorder (45.5 % female; 56.5 % black; 77.5 % opioid use disorder; 42.0 % homeless). This study compared HIE-identified hospital service utilization with conventional methods of participant self-report during in-person research follow-ups (3-, 6-, and 12-months post-discharge) and electronic health record (EHR) review from the hospital system of the index admission.

RESULTS

This sample exhibited high levels of hospital utilization, which would have been underestimated using conventional methods. Relying exclusively on self-report in the 12-month observation period would have identified only 33.8 % of 429 inpatient hospitalizations and 9.0 % of 1,287 ED visits, due to both loss-to-follow-up and failure to report events. Even combining self-report with single-system EHR review identified only 66.2 % of inpatient hospitalizations and 59.8 % of ED visits.

CONCLUSIONS

CRISP HIE data were superior to conventional methods for ascertaining hospital service utilization in this sample of patients exhibiting high-volume and fragmented care. The use of HIE holds implications for improving rigor, safety, and efficiency in research studies.

Addiction Treatment Capacity in Health Centers: The Role of Medicaid Reimbursement and Targeted Grant Funding

OBJECTIVE

Expanding access to addiction screening and treatment in primary care, particularly in underserved communities, is a key part of the fight against the opioid epidemic. This study explored correlates of addiction treatment capacity in federally qualified health centers participating in the Midwest Clinicians' Network (MWCN).

METHODS

Two surveys were fielded to 132 MWCN health centers: the Health Center Survey and the Behavioral Health and Diabetes Provider Survey. A total of 77 centers and 515 primary care clinicians, respectively, responded to the surveys. Data were combined with data from the 2016 Uniform Data System and information about receipt of targeted Health Resources and Services Administration (HRSA) grant funding for addiction treatment capacity. Multivariable models examined associations between Medicaid reimbursement for addiction services, HRSA targeted grant funding, and different types of on-site addiction treatment capacity: psychiatrist and certified addiction counselor staffing, addiction counseling services, and medication-assisted treatment (MAT) for opioid addiction.

RESULTS

Health centers that received Medicaid behavioral health reimbursement were five times as likely as those that did not to offer addiction counseling and to employ certified addiction counselors. Health centers that received targeted HRSA funding for addiction services were more than 20 times as likely as those that did not to provide MAT and more than three times as likely to employ psychiatrists. Training needs and privacy protections on data related to addiction treatment were cited as barriers to building addiction treatment capacity.

CONCLUSIONS

Medicaid funding and targeted grant funding were associated with addiction treatment capacity in health centers.

Balancing health privacy, health information exchange, and research in the context of the COVID-19 pandemic

The novel coronavirus disease 2019 infection poses serious challenges to the healthcare system that are being addressed through the creation of new unique and advanced systems of care with disjointed care processes (eg, telehealth screening, drive-through specimen collection, remote testing, telehealth management). However, our current regulations on the flows of information for clinical care and research are antiquated and often conflict at the state and federal levels. We discuss proposed changes to privacy regulations such as the Health Insurance Portability and Accountability Act designed to let health information seamlessly and frictionlessly flow among the health entities that need to collaborate on treatment of patients and, also, allow it to flow to researchers trying to understand how to limit its impacts.

Opt-in consent policies: potential barriers to hospital health information exchange

OBJECTIVES

To (1) assess whether hospitals in states requiring explicit patient consent ("opt-in") for health information exchange (HIE) are more likely to report regulatory barriers to HIE and (2) analyze whether these policies correlate with hospital volume of HIE.

STUDY DESIGN

Cross-sectional analysis of US nonfederal acute care hospitals in 2016.

METHODS

We combined legal scholarship surveying HIE-relevant state laws with the American Hospital Association Annual Information Technology Supplement for regulatory barriers and hospital characteristics. Data from CMS reports for hospitals attesting to Meaningful Use stage 2 (MU2; renamed "Promoting Interoperability" in 2018) in 2016 captured hospital HIE volume. We used multivariate logistic regression and linear regression to estimate the association of opt-in state consent policies with reported regulatory barriers and HIE volume, respectively.

RESULTS

Hospitals in states with opt-in consent policies were 7.8 percentage points more likely than hospitals in opt-out states to report regulatory barriers to HIE (P = .03). In subgroup analyses, this finding held among hospitals that did not attest to MU2 (7.7 percentage points; P = .02). Among hospitals attesting, we did not find a relationship between opt-in policies and regulatory barriers (8.0 percentage points; P = .13) or evidence of a relationship between opt-in policies and HIE volume (β = 0.56; P = .76).

CONCLUSIONS

Our findings suggest that opt-in consent laws may carry greater administrative burdens compared with opt-out policies. However, less technologically advanced hospitals may bear more of this burden. Furthermore, opt-in policies may not affect HIE volume for hospitals that have already achieved a degree of technological sophistication. Policy makers should carefully consider the incidence of administrative burdens when crafting laws pertaining to HIE.

Multiple Administrations of Intravenous Thrombolytic Therapy to a Stroke Mimic

BACKGROUND

Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke-stroke mimics-may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low.

CASE REPORT

We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider's workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine.

Reorienting health systems to care for people with HIV beyond viral suppression

The effectiveness of antiretroviral therapy and its increasing availability globally means that millions of people living with HIV now have a much longer life expectancy. However, people living with HIV have disproportionately high incidence of major comorbidities and reduced health-related quality of life. Health systems must respond to this situation by pioneering care and service delivery models that promote wellness rather than mere survival. In this Series paper, we review evidence about the emerging challenges of the care of people with HIV beyond viral suppression and identify four priority areas for action: integrating HIV services and non-HIV services, reducing HIV-related discrimination in health-care settings, identifying indicators to monitor health systems' progress toward new goals, and catalysing new forms of civil society engagement in the more broadly focused HIV response that is now needed worldwide. Furthermore, in the context of an increasing burden of chronic diseases, we must consider the shift that is underway in the HIV field in relation to burgeoning policy and programmatic efforts to promote healthy ageing.

Patient Privacy Perspectives on Health Information Exchange in a Mental Health Context: Qualitative Study

BACKGROUND

The privacy of patients with mental health conditions is prominent in health information exchange (HIE) discussions, given that their potentially sensitive personal health information (PHI) may be electronically shared for various health care purposes. Currently, the patient privacy perspective in the mental health context is not well understood because of the paucity of in-depth patient privacy research; however, the evidence suggests that patient privacy perspectives are more nuanced than what has been assumed in the academic and health care community.

OBJECTIVE

This study aimed to generate an understanding on how patients with mental health conditions feel about privacy in the context of HIE in Canada. This study also sought to identify the factors underpinning their privacy perspectives and explored how their perspectives influenced their attitudes toward HIE.

METHODS

Semistructured interviews were conducted with patients at a Canadian academic hospital for addictions and mental health. Guided by the Antecedent-Privacy Concern-Outcome macro-model, interview transcripts underwent deductive and inductive thematic analyses.

RESULTS

We interviewed 14 participants. Their privacy concerns varied, depending on the participant's privacy experiences and health care perceptions. Media reports of privacy breaches and hackers had little impact on participants' privacy concerns because of a fatalistic belief that privacy breaches are a reality in the digital age. Rather, direct observations and experiences with the mistreatment of PHI in health care settings caused concern. Decisions to trust others with PHI depended on past experiences with the individual (or institution) and health care needs. Participants had little knowledge of patient privacy rights and legislation but were willing to participate in HIE because of perceived individual and societal benefits.

CONCLUSIONS

This study introduces evidence that patients with mental health conditions would support HIE. Participants were pragmatic, supporting HIE because they wanted the best care possible. They also understood that their PHI was critical in supporting the single-payer Canadian health care system. Participant health care experiences informed their privacy perspectives, trust, and PHI sharing attitudes-all accentuating the importance of the patient experience in building trust in HIE. Their lack of knowledge about patient rights and PHI uses highlights the degree of trust they have in the health care system to protect their privacy. These findings suggest that the patient privacy discourse should extend beyond the oft-cited barrier of patient privacy concerns to include discussions about building trust, communicating the benefits of HIE, and improving patient experiences. Although our findings are in the Canadian context, this study highlights the importance of engaging patients in privacy policy discussions, regardless of jurisdiction, to ensure their nuanced perspectives are reflected in policy decisions on their PHI.

Designing a Distributed Ledger Technology System for Interoperable and General Data Protection Regulation-Compliant Health Data Exchange: A Use Case in Blood Glucose Data

Background

Distributed ledger technology (DLT) holds great potential to improve health information exchange. However, the immutable and transparent character of this technology may conflict with data privacy regulations and data processing best practices.

Objective

The aim of this paper is to develop a proof-of-concept system for immutable, interoperable, and General Data Protection Regulation (GDPR)–compliant exchange of blood glucose data.

Methods

Given that there is no ideal design for a DLT-based patient-provider data exchange solution, we proposed two different variations for our proof-of-concept system. One design was based purely on the public IOTA distributed ledger (a directed acyclic graph-based DLT) and the second used the same public IOTA ledger in combination with a private InterPlanetary File System (IPFS) cluster. Both designs were assessed according to (1) data reversal risk, (2) data linkability risks, (3) processing time, (4) file size compatibility, and (5) overall system complexity.

Results

The public IOTA design slightly increased the risk of personal data linkability, had an overall low processing time (requiring mean 6.1, SD 1.9 seconds to upload one blood glucose data sample into the DLT), and was relatively simple to implement. The combination of the public IOTA with a private IPFS cluster minimized both reversal and linkability risks, allowed for the exchange of large files (3 months of blood glucose data were uploaded into the DLT in mean 38.1, SD 13.4 seconds), but involved a relatively higher setup complexity.

Conclusions

For the specific use case of blood glucose explored in this study, both designs presented a suitable performance in enabling the interoperable exchange of data between patients and providers. Additionally, both systems were designed considering the latest guidelines on personal data processing, thereby maximizing the alignment with recent GDPR requirements. For future works, these results suggest that the conflict between DLT and data privacy regulations can be addressed if careful considerations are made regarding the use case and the design of the data exchange system.

Using Blockchain to Create Transaction Identity for Persons Experiencing Homelessness in America: Policy Proposal

More than 500,000 people experience homelessness in America each day. Local and federal solutions to the problem have had limited success because of the fragmentation of services and lack of valid and timely information. Billions of dollars spent to provide reliable, timely, and actionable information in health care have exposed the difficulty of establishing such a system using the prevalent information technology solutions. However, relying on successful examples of the use of blockchain to help refugee populations and poor farmers internationally, we have partnered to propose an innovative solution to this problem using the case of people experiencing homelessness in Austin, Texas. This paper aims to describe one of the first applications of blockchain technology for addressing homelessness in the United States by creating a digital identity for people experiencing homelessness and engaging emergency medical services and clinical providers. The authors argue that a lack of documentation to prove personal identity and the inability to access own records are major hurdles for empowering persons experiencing homelessness to be resilient and overcome the life challenges they face. Furthermore, it is argued that this lack of information causes misdiagnosis, duplication, and fragmentation in service delivery, which can be potentially addressed by blockchain technology. Further planning for creating a program on the ground with additional funding will demonstrate the results of using blockchain technology to establish digital identity for persons experiencing homelessness.

Five key strategic priorities of integrating patient generated health data into United Kingdom electronic health records

The integration of patient/person generated health data into clinical applications is a key strategic priority internationally. However, despite agreement on the overall direction of travel, there are still a range of challenges that inhibit progress in this area. These include technology-related factors (such as interoperability), use-related factors (such as data overload) and characteristics of the strategic environment (such as existing standards). Building on important policy deliberations from the United States that aim to navigate these challenges, we here apply emerging policy frameworks to the United Kingdom and outline five key priority areas that are intended to help policy makers make important strategic decisions in attempting to integrate patient/person generated data into electronic health records.

Mind the gap: the potential of alternative health information exchange

OBJECTIVES

To determine the proportion of patient transitions that could be connected through 3 proprietary alternatives to open, community-based health information exchange (HIE): HIE between physicians who are part of the same integrated system, use the same electronic health record (EHR), or use an EHR that participates in an EHR vendor alliance.

STUDY DESIGN

Cross-sectional analysis of Medicare patient transitions and physician EHR adoption and organizational affiliation from SK&A.

METHODS

We characterized the percentage of transitions that could be covered by each HIE approach and the degree of redundancy. We then assessed whether coverage opportunities differed by provider type and used multivariate linear regression to estimate the association between physician characteristics and proportion of transitions uncovered by any proprietary approach (ie, requiring an open HIE approach).

RESULTS

Given current EHR adoption and organizational affiliations, 33% of transitions could be covered by proprietary HIE. For the average physician, open methods of HIE would still be needed for 45% of patients treated by other physicians. Physicians who did not use a market-leading EHR, were not members of a large integrated system, and shared patients with a broader network of physicians have the greatest need for open HIE.

CONCLUSIONS

Proprietary approaches to HIE do not eliminate the need for open HIE and may further disadvantage providers in small healthcare organizations using less common EHRs. Ongoing support and innovative value creation within open HIE will likely remain necessary to support HIE by independent physicians. Public efforts to promote interoperability should seek to integrate proprietary models with open HIE.

The Association Between State-Level Health Information Exchange Laws and Hospital Participation in Community Health Information Organizations

Evidence suggests that health information exchange (HIE) is an effective strategy to improve efficiency and quality of care, as well as reduce costs. A complex patchwork of federal and state legislation has developed over time to encourage HIE activity. Hospitals and health systems have adopted various HIE models to meet the requirements of these statutes and regulations. Given the complexity of HIE laws, it is important to understand how these legal levers influence HIE engagement. We combined data from two unique data sources to examine the association between state-level HIE laws and hospital engagement in community HIEs. Our results identified three legal provisions of state laws (HIE authorization, financial & non-financial incentives, opt-out consent) that increased the likelihood of community HIE engagement. Other provisions decreased the likelihood of engagement. This analysis provides foundational evidence about the utility of HIE laws. More research is needed to determine causal relationships.

Hospitals' adoption of intra-system information exchange is negatively associated with inter-system information exchange

Introduction

U.S. policy on interoperable HIT has focused on increasing inter-system (ie, between different organizations) health information exchange. However, interoperable HIT also supports the movement of information within the same organization (ie, intra-system exchange).

Methods

We examined the relationship between hospitals' intra- and inter-system information exchange capabilities among health system hospitals included in the 2010-2014 American Hospital Association's Annual Health Information Technology Survey. We described the factors associated with hospitals that adopted more intra-system than inter-system exchange capability, and explored the extent of new capability adoption among hospitals that reported neither intra- or inter-system information capabilities at baseline.

Results

The prevalence of exchange increased over time, but the adoption of inter-system information exchange was slower; when hospitals adopt information exchange, adoption of intra-system exchange was more common. On average during our study period, hospitals could share 4.6 types of information by intra-system exchange, but only 2.7 types of information by inter-system exchange. Controlling for other factors, hospitals exchanged more types of information in an intra-system manner than inter-system when the number of different inpatient EHR vendors in use in health system is larger.

Conclusion

Consistent with the U.S. goals for more widely accessible patient information, hospitals' ability to share information has increased over time. However, hospitals are prioritizing within-organizational information exchange over exchange between different organizations. If increasing inter-system exchanges is a desired goal, current market incentives and government policies may be insufficient to overcome hospitals' motivations for pursuing an intra-system-information-exchange-first strategy.