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

Associations between Florida counties' COVID-19 case and death rates and meaningful use among Medicaid providers: Cross-sectional ecologic study

Although the Health Information Technology for Economic and Clinical Health (HITECH) Act has accelerated adoption of Electronic Health Records (EHRs) among Medicaid providers, only half achieved Meaningful Use. Furthermore, Meaningful Use' impact on reporting and/or clinical outcomes remains unknown. To address this deficit, we assessed the difference between Medicaid providers who did and did not achieve Meaningful Use regarding Florida county-level cumulative COVID-19 death, case and case fatality rates (CFR), accounting for county-level demographics, socioeconomic and clinical markers, and healthcare environment. We found that cumulative incidence rates of COVID-19 deaths and CFRs were significantly different between the 5025 Medicaid providers not achieving Meaningful Use and the 3723 achieving Meaningful Use (mean 0.8334/1000 population; SD = 0.3489 vs. mean = 0.8216/1000; SD = 0.3227, respectively) (P = .01). CFRs were .01797 and .01781, respectively, P = .04. County-level characteristics independently associated with increased COVID-19 death rates and CFRs include greater concentrations of persons of African American or Black race, lower median household income, higher unemployment, and higher concentrations of those living in poverty and without health insurance (all P < .001). In accordance with other studies, social determinants of health were independently associated with clinical outcomes. Our findings also suggest that the association between Florida counties' public health outcomes and Meaningful Use achievement may have had less to do with using EHRs for reporting of clinical outcomes and more to do with using EHRs for coordination of care-a key measure of quality. The Florida Medicaid Promoting Interoperability Program which incentivized Medicaid providers towards achieving Meaningful Use, has demonstrated success regarding both rates of adoption and clinical outcomes. Because the Program ends in 2021, we support programs such as HealthyPeople 2030 Health IT which address the remaining half of Florida Medicaid providers who have not yet achieved Meaningful Use.

OUP accepted manuscript

Background

Canada has among the highest incidence and prevalence rates of inflammatory bowel disease (IBD) in the world. While access to IBD specialty care can have a direct impact on health-related outcomes, the complexity of accessing IBD specialty care within Canada is not well understood and presents a barrier to implementation and evaluation of IBD specialty care.

Aim

The IBD Summit was held in partnership with Crohn’s & Colitis Canada to identify barriers and facilitators of IBD specialty care by exploring the perceptions and experiences of key stakeholders of IBD care across Canada.

Results

A total of 20 key stakeholders attended, including gastroenterologists, patients, researchers and policymakers. Perceptions and experiences of stakeholders were transcribed, coded and thematically analyzed. Three key categories relating to access to IBD care arose: (1) inadequate system structure, (2) process inefficiencies and (3) using outcomes to guide system change. The IBD Summit identified similar perceptions and experiences among stakeholders and across provinces, highlighting common barriers and facilitators that transcended provincial and health care system boundaries.

Conclusions

Key suggestions identify the clinical importance of comprehensive integrated multidisciplinary care approaches with enhanced communication between patient and health care providers, greater information sharing among team members, streamlined referral and triage processes, and improved incorporation of best practice into clinical care. Stakeholders across Canada and in other countries may benefit from the suggestions presented herein, as well as the successful use of collaborative and inclusive methods of gathering the perceptions and experiences of key stakeholders from diverse backgrounds.

Leveraging electronic health records to improve management of noncommunicable diseases at primary healthcare centres in Saudi Arabia: a qualitative study

Background

Electronic Health Records (EHRs) can contribute to the earlier detection and better treatment of chronic diseases by improving accuracy and accessibility of patient data. The Saudi Ministry of Health (MOH) implemented an EHR system in all primary health care clinics (PHCs) as part of measures to improve their performance in managing chronic disease. This study examined the perspective of physicians on the current scope and content of NCDs management at PHCs including the contribution of the EHR system.

Methods

Semi-structured interviews were conducted with 22 physicians working in chronic disease clinics at PHCs covering a range of locations and clinic sizes. The participants were selected based on their expertise using a combination of purposive and convenience sampling. The interviews were transcribed, analyzed and coded into the key themes.

Results

Physicians indicated that the availability of the EHR helped organise their work and positively influenced NCDs patient encounters in their PHCs. They emphasised the multiple benefits of EHR in terms of efficiency, including the accuracy of patient documentation and the availability of patient information. Shortcomings identified included the lack of a patient portal to allow patients to access information about their health and lack of capacity to facilitate multi-disciplinary care for example through referral to allied health services. Access to the EHR was limited to MOH primary healthcare centres and clinicians noted that patients also received care in private clinics and hospitals.

Conclusion

While well regarded by clinicians, the EHR system impact on patient care at chronic disease clinics is not being fully realised. Enabling patient access to their EHR would be help promote self-management, a core attribute of effective NCD management. Co-ordination of care is another core attribute and in the Saudi health system with multiple public and private providers, this may be substantially improved if the patients EHR was accessible wherever care was provided. There is also a need for enhanced capacity to support improving patient’s nutrition and physical activity.

Provider participation in the Florida Medicaid Promoting Interoperability program: Practice characteristics, meaning use attestations, and incentive payments

OBJECTIVE

The objective of this study was to quantify the rate of provider participation beyond year 1 incentive in the Florida Medicaid Promoting Interoperability (PI) program, formerly the Electronic Health Record Incentive program, and identify the provider and practice characteristics associated with Meaningful Use attestations.

METHODS AND MATERIALS

We conducted a retrospective cohort study using the 2011-2018 records from the PI program, Provider Participation Database. Bivariate associations between Meaningful Use and categorical and ordinal variables were tested using Chi-square and Mantel-Haenszel Chi-square, respectively, with results informing logistic regressions. Adjusted odds ratios and 95 % confidence intervals are reported.

RESULTS

We found that 42.56 % of Florida Medicaid providers achieved Meaningful Use after receiving first-year incentives. Logistic regression showed that pediatricians represented the largest percentage of providers who achieved Meaningful Use (65.06 %) while dentists had the lowest Meaningful Use (7.78 %). We also found that certain geographic areas and various EHR vendors were associated with higher rates of providers Meaningful Use attestation.

DISCUSSION

Although the PI program successfully influenced the adoption of a basic EHR system, low Meaningful Use attestations have inadvertently created a digital "advanced use" divide among providers who serve large numbers of Medicaid patients. This is concerning because advanced EHR functions are necessary precursors to address unmet socioeconomic needs to reduce health disparities.

CONCLUSION

Florida has distributed over $100 million to Medicaid providers who ultimately did not achieve Meaningful Use after collecting their first-year incentive. Policy interventions that can promote advanced EHR use functions are necessary to optimize technology in low-resourced practice settings where the potential benefits are greater.

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.

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.

A qualitative study of physician perspectives on adaptation to electronic health records

Background

Electronic Health Records (EHRs) have the potential to improve many aspects of care and their use has increased in the last decade. Because of this, acceptance and adoption of EHRs is less of a concern than adaptation to use. To understand this issue more deeply, we conducted a qualitative study of physician perspectives on EHR use to identify factors that facilitate adaptation.

Methods

We conducted semi-structured interviews with 9 physicians across a range of inpatient disciplines at a large Academic Medical Center. Interviews were conducted by phone, lasting approximately 30 min, and were transcribed verbatim for analysis. We utilized inductive and deductive methods in our analysis.

Results

We identified 4 major themes related to EHR adaptation: impact of EHR changes on physicians, how physicians managed these changes, factors that facilitated adaptation to using the EHR and adapting to using the EHR in the patient encounter. Within these themes, physicians felt that a positive mindset toward change, providing upgrade training that was tailored to their role, and the opportunity to learn from colleagues were important facilitators of adaptation.

Conclusions

As EHR use moves beyond implementation, physicians continue to be required to adapt to the technology and to its frequent changes. Our study provides actionable findings that allow healthcare systems to focus on factors that facilitate the adaptation process for physicians.

Key Factors Affecting Ambulatory Care Providers' Electronic Exchange of Health Information With Affiliated and Unaffiliated Partners: Web-Based Survey Study

Background

Despite the potential benefits of electronic health information exchange (HIE) to improve the quality and efficiency of care, HIE use by ambulatory providers remains low. Ambulatory providers can greatly improve the quality of care by electronically exchanging health information with affiliated providers within their health care network as well as with unaffiliated, external providers.

Objective

This study aimed to examine the extent of electronic HIE use by ambulatory clinics with affiliated providers within their health system and with external providers, as well as the key technological, organizational, and environmental factors affecting the extent of HIE use within and outside the health system.

Methods

A Web-based survey of 320 ambulatory care providers was conducted in the state of Illinois. The study examined the extent of HIE usage by ambulatory providers with hospitals, clinics, and other facilities within and outside their health care system–encompassing seven kinds of health care data. Ten factors pertaining to technology (IT [information technology] Compatibility, External IT Support, Security & Privacy Safeguards), organization (Workflow Adaptability, Senior Leadership Support, Clinicians Health-IT Knowledge, Staff Health-IT Knowledge), and environment (Government Efforts & Incentives, Partner Readiness, Competitors and Peers) were assessed. A series of multivariate regressions were used to examine predictor effects.

Results

The 6 regressions produced adjusted R-squared values ranging from 0.44 to 0.63. We found that ambulatory clinics exchanged more health information electronically with affiliated entities within their health system as compared with those outside their health system. Partner readiness emerged as the most significant predictor of HIE usage with all entities. Governmental initiatives for HIE, clinicians’ prior familiarity and knowledge of health IT systems, implementation of appropriate security, and privacy safeguards were also significant predictors. External information technology support and workflow adaptability emerged as key predictors for HIE use outside a clinic’s health system. Differences based on clinic size, ownership, and specialty were also observed.

Conclusions

This study provides exploratory insights into HIE use by ambulatory providers within and outside their health care system and differential predictors that impact HIE use. HIE use can be further improved by encouraging large-scale interoperability efforts, improving external IT support, and redesigning adaptable workflows.

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

Implementation of Health Information Exchange at the Pima County Adult Detention Complex: Lessons Learned

Successful transition of patients between health care entities is difficult. Historically, the process of transitioning individuals through the corrections system with regard to health care was made even more challenging by the limitation of paper records. Recently, the advent of electronic medical records has improved health care nationwide. The use of health information exchange (HIE) systems in areas such as emergency medicine has also impacted patient outcomes. To date, this technology has not been used in the corrections system. Semi-structured interviews were conducted with 12 correctional health care professionals, corrections staff, and public health entities to evaluate the novel implementation of HIE at a local correctional facility. This article describes the challenges and successes that occurred during the implementation and their implications for successful implementations in the future.

Linking the health data system in the U.S.: Challenges to the benefits

In order to improve patient care in the United States there, the government made a mandate called HIE (Health Information Exchange). This order was created from the belief that sharing digital health information between, across, and within health communities will improve one's healthcare experience across their lifespan. Patient health information, i.e. the personal health record, should be shareable between healthcare providers; such as private practice physicians, home health agencies, hospitals and nursing care facilities. Most of the U.S. hospitals now have electronic health records, however, with a lack of standards for structuring health information and unified communication protocols to share health information across providers, only a small percentage of U.S. hospitals engage in computerized HIE. In order to understand barriers and facilitators in the U.S. of HIE adoption, we reviewed the published research literature between 2010 and 2015. Our search yielded 664 articles from Medline, PsychInfo, Global health, InSpec, Scopus and Business Source Complete databases. Thirty-nine articles met our inclusion criteria. This article presents the compiled organizational and end user barriers and facilitators along with suggested methods to achieve continuity of care through HIE.

Integrated precision medicine: the role of electronic health records in delivering personalized treatment

Precision Medicine involves the delivery of a targeted, personalized treatment for a given patient. By harnessing the power of electronic health records (EHRs), we are increasingly able to practice precision medicine to improve patient outcomes. In this article, we introduce the scientific community at large to important building blocks for personalized treatment, such as terminology standards that are the foundation of the EHR and allow for exchange of health information across systems. We briefly review different types of clinical decision support (CDS) and present the current state of CDS, which is already improving the care patients receive with genetic profile-based tailored recommendations regarding diagnostic and treatment plans. We also report on limitations of current systems, which are slowly beginning to integrate new genomic data into patient records but still present many challenges. Finally, we discuss future directions and how the EHR can evolve to increase the capacity of the healthcare system in delivering Precision Medicine at the point of care. WIREs Syst Biol Med 2017, 9:e1378. doi: 10.1002/wsbm.1378 For further resources related to this article, please visit the WIREs website.

Views of patient, healthcare professionals and administrative staff on flow of information and collaboration in a regional health information exchange: a qualitative study

BACKGROUND

Nowadays, patients can be more involved in developing healthcare services with their healthcare professionals. Patient-centred information is a key part of improving regional health information exchange (HIE), giving patients an active role in care management.

AIM

The aim was to get a deeper understanding of the flow of information and collaboration in one hospital district area from the viewpoint of patients, healthcare professionals and administrative staff.

METHODS

The data were collected by themed interviews and analysed using both deductive and inductive content analyses. The interview themes were the flow of information and collaboration after 5 years of HIE usage in one hospital district area in Finland.

FINDINGS

Health information exchange usage had changed the regional flow of information after the 5-year period. The patients were satisfied that their primary care physician was able to access their special care information. The experiences of healthcare professionals and administrative staff also showed that information availability and information exchange had improved regionally. HIE usage was also found to have improved regional collaboration between different organisations in patient health care.

CONCLUSIONS

It was recognised that patients had taken on more responsibility for transferring their follow-up treatment information. Healthcare information exchange between professionals not only improves patient care or patient involvement in their own care, but it also requires that patient self-care or self-care management is integrated into HIE systems to share information not only among professionals, but also between patients and professionals. This information will be used in the development of healthcare systems to meet more the developing of the continuity of care the patient's point of view.

Clinical Data Systems to Support Public Health Practice: A National Survey of Software and Storage Systems Among Local Health Departments

CONTEXT

Numerous software and data storage systems are employed by local health departments (LHDs) to manage clinical and nonclinical data needs. Leveraging electronic systems may yield improvements in public health practice. However, information is lacking regarding current usage patterns among LHDs.

OBJECTIVE

To analyze clinical and nonclinical data storage and software types by LHDs.

DESIGN

Data came from the 2015 Informatics Capacity and Needs Assessment Survey, conducted by Georgia Southern University in collaboration with the National Association of County and City Health Officials.

PARTICIPANTS

A total of 324 LHDs from all 50 states completed the survey (response rate: 50%).

MAIN OUTCOME MEASURES

Outcome measures included LHD's primary clinical service data system, nonclinical data system(s) used, and plans to adopt electronic clinical data system (if not already in use). Predictors of interest included jurisdiction size and governance type, and other informatics capacities within the LHD. Bivariate analyses were performed using χ and t tests.

RESULTS

Up to 38.4% of LHDs reported using an electronic health record (EHR). Usage was common especially among LHDs that provide primary care and/or dental services. LHDs serving smaller populations and those with state-level governance were both less likely to use an EHR. Paper records were a common data storage approach for both clinical data (28.9%) and nonclinical data (59.4%). Among LHDs without an EHR, 84.7% reported implementation plans.

CONCLUSIONS

Our findings suggest that LHDs are increasingly using EHRs as a clinical data storage solution and that more LHDs are likely to adopt EHRs in the foreseeable future. Yet use of paper records remains common. Correlates of electronic system usage emerged across a range of factors. Program- or system-specific needs may be barriers or facilitators to EHR adoption. Policy makers can tailor resources to address barriers specific to LHD size, governance, service portfolio, existing informatics capabilities, and other pertinent characteristics.

Adoption Factors of the Electronic Health Record: A Systematic Review

Background

The Health Information Technology for Economic and Clinical Health (HITECH) was a significant piece of legislation in America that served as a catalyst for the adoption of health information technology. Following implementation of the HITECH Act, Health Information Technology (HIT) experienced broad adoption of Electronic Health Records (EHR), despite skepticism exhibited by many providers for the transition to an electronic system. A thorough review of EHR adoption facilitator and barriers provides ongoing support for the continuation of EHR implementation across various health care structures, possibly leading to a reduction in associated economic expenditures.

Objective

The purpose of this review is to compile a current and comprehensive list of facilitators and barriers to the adoption of the EHR in the United States.

Methods

Authors searched Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE, 01/01/2012–09/01/2015, core clinical/academic journals, MEDLINE full text, and evaluated only articles germane to our research objective. Team members selected a final list of articles through consensus meetings (n=31). Multiple research team members thoroughly read each article to confirm applicability and study conclusions, thereby increasing validity.

Results

Group members identified common facilitators and barriers associated with the EHR adoption process. In total, 25 adoption facilitators were identified in the literature occurring 109 times; the majority of which were efficiency, hospital size, quality, access to data, perceived value, and ability to transfer information. A total of 23 barriers to adoption were identified in the literature, appearing 95 times; the majority of which were cost, time consuming, perception of uselessness, transition of data, facility location, and implementation issues.

Conclusions

The 25 facilitators and 23 barriers to the adoption of the EHR continue to reveal a preoccupation on cost, despite incentives in the HITECH Act. Limited financial backing and outdated technology were also common barriers frequently mentioned during data review. Future public policy should include incentives commensurate with those in the HITECH Act to maintain strong adoption rates.

Barriers and facilitators to exchanging health information: a systematic review

OBJECTIVES

We conducted a systematic review of studies assessing facilitators and barriers to use of health information exchange (HIE).

METHODS

We searched MEDLINE, PsycINFO, CINAHL, and the Cochrane Library databases between January 1990 and February 2015 using terms related to HIE. English-language studies that identified barriers and facilitators of actual HIE were included. Data on study design, risk of bias, setting, geographic location, characteristics of the HIE, perceived barriers and facilitators to use were extracted and confirmed.

RESULTS

Ten cross-sectional, seven multiple-site case studies, and two before-after studies that included data from several sources (surveys, interviews, focus groups, and observations of users) evaluated perceived barriers and facilitators to HIE use. The most commonly cited barriers to HIE use were incomplete information, inefficient workflow, and reports that the exchanged information that did not meet the needs of users. The review identified several facilitators to use.

DISCUSSION

Incomplete patient information was consistently mentioned in the studies conducted in the US but not mentioned in the few studies conducted outside of the US that take a collective approach toward healthcare. Individual patients and practices in the US may exercise the right to participate (or not) in HIE which effects the completeness of patient information available to be exchanged. Workflow structure and user roles are key but understudied.

CONCLUSIONS

We identified several facilitators in the studies that showed promise in promoting electronic health data exchange: obtaining more complete patient information; thoughtful workflow that folds in HIE; and inclusion of users early in implementation.

Developing a Workflow Composite Score to Measure Clinical Information Logistics. A Top-down Approach

BACKGROUND

Availability and usage of individual IT applications have been studied intensively in the past years. Recently, IT support of clinical processes is attaining increasing attention. The underlying construct that describes the IT support of clinical workflows is clinical information logistics. This construct needs to be better understood, operationalised and measured.

OBJECTIVES

It is therefore the aim of this study to propose and develop a workflow composite score (WCS) for measuring clinical information logistics and to examine its quality based on reliability and validity analyses.

METHODS

We largely followed the procedural model of MacKenzie and colleagues (2011) for defining and conceptualising the construct domain, for developing the measurement instrument, assessing the content validity, pretesting the instrument, specifying the model, capturing the data and computing the WCS and testing the reliability and validity.

RESULTS

Clinical information logistics was decomposed into the descriptors data and information, function, integration and distribution, which embraced the framework validated by an analysis of the international literature. This framework was refined selecting representative clinical processes. We chose ward rounds, pre- and post-surgery processes and discharge as sample processes that served as concrete instances for the measurements. They are sufficiently complex, represent core clinical processes and involve different professions, departments and settings. The score was computed on the basis of data from 183 hospitals of different size, ownership, location and teaching status. Testing the reliability and validity yielded encouraging results: the reliability was high with r(split-half) = 0.89, the WCS discriminated between groups; the WCS correlated significantly and moderately with two EHR models and the WCS received good evaluation results by a sample of chief information officers (n = 67). These findings suggest the further utilisation of the WCS.

CONCLUSION

As the WCS does not assume ideal workflows as a gold standard but measures IT support of clinical workflows according to validated descriptors a high portability of the WCS to other hospitals in other countries is very likely. The WCS will contribute to a better understanding of the construct clinical information logistics.