The impact of interoperability of electronic health records on ambulatory physician practices: a discrete-event simulation study

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.

Perceived Impact of Digital Health Maturity on Patient Experience, Population Health, Health Care Costs, and Provider Experience: Mixed Methods Case Study

BACKGROUND

Health care organizations understand the importance of new technology implementations; however, the best strategy for implementing successful digital transformations is often unclear. Digital health maturity assessments allow providers to understand the progress made toward technology-enhanced health service delivery. Existing models have been criticized for their lack of depth and breadth because of their technology focus and neglect of meaningful outcomes.

OBJECTIVE

We aimed to examine the perceived impacts of digital health reported by health care staff employed in health care organizations across a spectrum of digital health maturity.

METHODS

A mixed methods case study was conducted. The digital health maturity of public health care systems (n=16) in Queensland, Australia, was examined using the quantitative Digital Health Indicator (DHI) self-assessment survey. The lower and upper quartiles of DHI scores were calculated and used to stratify sites into 3 groups. Using qualitative methods, health care staff (n=154) participated in interviews and focus groups. Transcripts were analyzed assisted by automated text-mining software. Impacts were grouped according to the digital maturity of the health care worker's facility and mapped to the quadruple aims of health care: improved patient experience, improved population health, reduced health care cost, and enhanced provider experience.

RESULTS

DHI scores ranged between 78 and 193 for the 16 health care systems. Health care systems in the high-maturity category (n=4, 25%) had a DHI score of ≥166.75 (the upper quartile); low-maturity sites (n=4, 25%) had a DHI score of ≤116.75 (the lower quartile); and intermediate-maturity sites (n=8, 50%) had a DHI score ranging from 116.75 to 166.75 (IQR). Overall, 18 perceived impacts were identified. Generally, a greater number of positive impacts were reported in health care systems of higher digital health maturity. For patient experiences, higher maturity was associated with maintaining a patient health record and tracking patient experience data, while telehealth enabled access and flexibility across all digital health maturity categories. For population health, patient journey tracking and clinical risk mitigation were reported as positive impacts at higher-maturity sites, and telehealth enabled health care access and efficiencies across all maturity categories. Limited interoperability and organizational factors (eg, strategy, policy, and vision) were universally negative impacts affecting health service delivery. For health care costs, the resource burden of ongoing investments in digital health and a sustainable skilled workforce was reported. For provider experiences, the negative impacts of poor usability and change fatigue were universal, while network and infrastructure issues were negative impacts at low-maturity sites.

CONCLUSIONS

This is one of the first studies to show differences in the perceived impacts of digital maturity of health care systems at scale. Higher digital health maturity was associated with more positive reported impacts, most notably in achieving outcomes for the population health aim.

A Predictive Decision Analytics Approach for Primary Care Operations Management: A Case Study of Double-Booking Strategy Design and Evaluation

Primary care plays a vital role for individuals and families in accessing care, keeping well, and improving quality of life. However, the complexities and uncertainties in the primary care delivery system (e.g., patient no-shows/walk-ins, staffing shortage, COVID-19 pandemic) have brought significant challenges in its operations management, which can potentially lead to poor patient outcomes and negative primary care operations (e.g., loss of productivity, inefficiency). This paper presents a decision analytics approach developed based on predictive analytics and hybrid simulation to better facilitate management of the underlying complexities and uncertainties in primary care operations. A case study was conducted in a local family medicine clinic to demonstrate the use of this approach for patient no-show management. In this case study, a patient no-show prediction model was used in conjunction with an integrated agent-based and discrete-event simulation model to design and evaluate double-booking strategies. Using the predicted patient no-show information, a prediction-based double-booking strategy was created and compared against two other strategies, namely random and designated time. Scenario-based experiments were then conducted to examine the impacts of different double-booking strategies on clinic's operational outcomes, focusing on the trade-offs between the clinic productivity (measured by daily patient throughput) and efficiency (measured by visit cycle and patient wait time for doctor). The results showed that the best productivity-efficiency balance was derived under the prediction-based double-booking strategy. The proposed hybrid decision analytics approach has the potential to better support decision-making in primary care operations management and improve the system's performance. Further, it can be generalized in the context of various healthcare settings for broader applications.

Evaluation of a Health Information Exchange System for Geriatric Health Care in Rural Areas: Development and Technical Acceptance Study

Background

Patients of geriatrics are often treated by several health care providers at the same time. The spatial, informational, and organizational separation of these health care providers can hinder the effective treatment of these patients.

Objective

This study aimed to develop a regional health information exchange (HIE) system to improve HIE in geriatric treatment. This study also evaluated the usability of the regional HIE system and sought to identify barriers to and facilitators of its implementation.

Methods

The development of the regional HIE system followed the community-based participatory research approach. The primary outcomes were the usability of the regional HIE system, expected implementation barriers and facilitators, and the quality of the developmental process. Data were collected and analyzed using a mixed methods approach.

Results

A total of 3 focus regions were identified, 22 geriatric health care providers participated in the development of the regional HIE system, and 11 workshops were conducted between October 2019 and September 2020. In total, 12 participants responded to a questionnaire. The main results were that the regional HIE system should support the exchange of assessments, diagnoses, medication, assistive device supply, and social information. The regional HIE system was expected to be able to improve the quality and continuity of care. In total, 5 adoption facilitators were identified. The main points were adaptability of the regional HIE system to local needs, availability to different patient groups and treatment documents, web-based design, trust among the users, and computer literacy. A total of 13 barriers to adoption were identified. The main expected barriers to implementation were lack of resources, interoperability issues, computer illiteracy, lack of trust, privacy concerns, and ease-of-use issues.

Conclusions

Participating health care professionals shared similar motivations for developing the regional HIE system, including improved quality of care, reduction of unnecessary examinations, and more effective health care provision. An overly complicated registration process for health care professionals and the patients’ free choice of their health care providers hinder the effectiveness of the regional HIE system, resulting in incomplete patient health information. However, the web-based design of the system bridges interoperability problems that exist owing to the different technical and organizational structures of the health care facilities involved. The regional HIE system is better accepted by health care professionals who are already engaged in an interdisciplinary, geriatric-focused network. This might indicate that pre-existing cross-organizational structures and processes are prerequisites for using HIE systems. The participatory design supports the development of technologies that are adaptable to regional needs. Health care providers are interested in participating in the development of an HIE system, but they often lack the required time, knowledge, and resources.

Association of Hospital Interoperable Data Sharing With Alternative Payment Model Participation

Importance

Interoperable patient data exchange across hospitals remains an important policy goal for reducing costs and improving the quality of care. Congress designated 2018 as the goal for nationwide interoperability, and policy makers hoped that aligning financial incentives via alternative payment models (APMs) would help achieve that goal.

Objective

To measure interoperability progress since 2014, assess the association between alternative payment model participation and hospital engagement in interoperable data sharing from 2014 to 2018, and evaluate hospital-reported barriers to interoperability in 2018.

Design Setting and Participants

This cohort study included nonfederal acute care hospitals in the US from January 2014 to December 2018 that responded to the American Hospital Association Annual Survey. Data were analyzed from October 2019 through March 2021.

Exposures

Participation in an APM, including accountable care organizations, bundled payments, or patient-centered medical homes.

Main Outcomes and Measures

Hospital engagement in all 4 domains of interoperability: finding/querying for data, sending data electronically, receiving data electronically, and integrating electronic patient data from external care delivery organizations.

Results

The sample included 3928 hospitals in the US from January 2014 to December 2018. Progress across interoperability domains was uneven, 2430 (88.3%) hospitals sending and 2115 (76.9%) receiving patient data electronically in 2018. However, only 1249 (45.4%) hospitals engaged in all 4 domains of interoperability in 2018, and growth between 2014 and 2018 was slow. There was no evidence that participation in APMs was associated with interoperability, with multivariate models suggesting that participation in an APM was associated with only a non-statistically significant 1-percentage point increase in interoperability engagement (β = 0.01; 95% CI, -0.01 to 0.03). The most commonly cited barrier to interoperability was challenges associated with sharing data across different electronic health record vendors.

Conclusions and Relevance

In this cohort study of hospital interoperability, fewer than half of US hospitals were engaged in interoperable data exchange in 2018. There was no observable evidence that hospital APM participation was associated with interoperability engagement. Many hospitals report technical and governance challenges to data sharing that are unlikely to be addressed by the alignment of financial incentives alone.

A Scoping Review of Health Information Technology in Clinician Burnout

BACKGROUND

Clinician burnout is a prevalent issue in healthcare, with detrimental implications in healthcare quality and medical costs due to errors. The inefficient use of health information technologies (HIT) is attributed to having a role in burnout.

OBJECTIVE

This paper seeks to review the literature with the following two goals: (1) characterize and extract HIT trends in burnout studies over time, and (2) examine the evidence and synthesize themes of HIT's roles in burnout studies.

METHODS

A scoping literature review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with two rounds of searches in PubMed, IEEE Xplore, ACM, and Google Scholar. The retrieved papers and their references were screened for eligibility by using developed inclusion and exclusion criteria. Data were extracted from included papers and summarized either statistically or qualitatively to demonstrate patterns.

RESULTS

After narrowing down the initial 945 papers, 36 papers were included. All papers were published between 2013 and 2020; nearly half of them focused on primary care (n = 16; 44.4%). The most commonly studied variable was electronic health record (EHR) practices (e.g., number of clicks). The most common study population was physicians. HIT played multiple roles in burnout studies: it can contribute to burnout; it can be used to measure burnout; or it can intervene and mitigate burnout levels.

CONCLUSION

This scoping review presents trends in HIT-centered burnout studies and synthesizes three roles for HIT in contributing to, measuring, and mitigating burnout. Four recommendations were generated accordingly for future burnout studies: (1) validate and standardize HIT burnout measures; (2) focus on EHR-based solutions to mitigate clinician burnout; (3) expand burnout studies to other specialties and types of healthcare providers, and (4) utilize mobile and tracking technology to study time efficiency.

The Effect of Information Technology on the Information Exchange between Laboratories and Ambulatory Care Centers: A Systematic Review

Laboratory services form an integral part of medical care in the decision-making of physicians, including those working at ambulatory care centers. Information exchange is essential between ambulatory care centers and laboratories. Inevitable errors have always existed in the exchange of such information on paper, which can be to some extent avoided by developing appropriate computer-based interfaces. Therefore, this review aimed to examine studies conducted to determine the effect of electronic communication between ambulatory care centers and laboratories. This systematic review was conducted on the basis of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were searched in the PubMed, Embase, Cochrane, and Web of Science, and those written in English and published between 2000 and February 2019 with full texts available were selected. From a total of 3898 papers retrieved from the studied databases, 24 papers were eligible for entering this study after removing similar and nonrelated studies. Electronic exchanges between ambulatory care centers and laboratories can have numerous benefits in terms of financial, organizational, and quality. This evidence for the value of electronic communications is an important factor contributing to its local investment and adoption.

What is Blockchain Technology and its Significance in the Current Healthcare System? A Brief Insight

Background:

The promising eventual fate of blockchain in healthcare has a lot more extensive prospect. Blockchain is a novel structure that gives another design to storage and trade of data among different members of a particular network. In case of a hospital, blockchain takes into consideration the creation of a better treatment structure by the expert doctor in order to arrange the meeting based on the symptoms of patients throughout the world by the electronic system. Blockchain technology is crucial for biomedical and human services applications as social insurance has turned out to be a standout among the most essential rising application areas of the blockchain distributed ledger technology.

Result:

By and large, blockchain is treated as a conveyed record to store social insurance related information for allocation, trading, dissecting, footage, and affirming purposes among accomplices. The advantage of blockchain databases versus traditional dispersed databases is that they are decentralized, permanent, and perfected with advanced digital payment frameworks and hash chain occasion structure. The blockchain code is an unlocked resource and can be utilized, altered, and customized by its clients.

Conclusion:

Nowadays, blockchain is expected to be almost universally adopted across medical organizations around the world. The purpose of this review article is to comprehend the current explored subjects, difficulties, and future headings in regards to blockchain innovation from the specialized perspective in the health care system.

Progress In Interoperability: Measuring US Hospitals' Engagement In Sharing Patient Data

Achieving an interoperable health care system remains a top US policy priority. Despite substantial efforts to encourage interoperability, the first set of national data in 2014 suggested that hospitals' engagement levels were low. With 2015 data now available, we examined the first national trends in engagement in four domains of interoperability: finding, sending, receiving, and integrating electronic patient information from outside providers. We found small gains, with 29.7 percent of hospitals engaging in all four domains in 2015 compared to 24.5 percent in 2014. The two domains with the most progress were sending (with an increase of 8.1 percentage points) and receiving (an increase of 8.4 percentage points) information, while there was no change in integrating systems. Hospitals' use for patient care of data from outside providers was low, with only 18.7 percent of hospitals reporting that they "often" used these data. Our results reveal that hospitals' progress toward interoperability is slow and that progress is focused on moving information between hospitals, not on ensuring usability of information in clinical decisions.

Blockchain Technology for Healthcare: Facilitating the Transition to Patient-Driven Interoperability

Interoperability in healthcare has traditionally been focused around data exchange between business entities, for example, different hospital systems. However, there has been a recent push towards patient-driven interoperability, in which health data exchange is patient-mediated and patient-driven. Patient-centered interoperability, however, brings with it new challenges and requirements around security and privacy, technology, incentives, and governance that must be addressed for this type of data sharing to succeed at scale. In this paper, we look at how blockchain technology might facilitate this transition through five mechanisms: (1) digital access rules, (2) data aggregation, (3) data liquidity, (4) patient identity, and (5) data immutability. We then look at barriers to blockchain-enabled patient-driven interoperability, specifically clinical data transaction volume, privacy and security, patient engagement, and incentives. We conclude by noting that while patient-driving interoperability is an exciting trend in healthcare, given these challenges, it remains to be seen whether blockchain can facilitate the transition from institution-centric to patient-centric data sharing.

Human Factors and Simulation in Emergency Medicine

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.

Understanding Emergency Care Delivery Through Computer Simulation Modeling

In 2017, Academic Emergency Medicine convened a consensus conference entitled, "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes." This article, a product of the breakout session on "understanding complex interactions through systems modeling," explores the role that computer simulation modeling can and should play in research and development of emergency care delivery systems. This article discusses areas central to the use of computer simulation modeling in emergency care research. The four central approaches to computer simulation modeling are described (Monte Carlo simulation, system dynamics modeling, discrete-event simulation, and agent-based simulation), along with problems amenable to their use and relevant examples to emergency care. Also discussed is an introduction to available software modeling platforms and how to explore their use for research, along with a research agenda for computer simulation modeling. Through this article, our goal is to enhance adoption of computer simulation, a set of methods that hold great promise in addressing emergency care organization and design challenges.

Development of a gateway for interoperability in community-based care: An empirical study

BACKGROUND

Information and communications technology has attracted attention as a useful way of sharing care records in community-based care. Such information sharing systems, however, imposed the burden of inputting the same records into different information systems due to a lack of interoperability of the systems.

OBJECTIVES

The purpose of this study was to develop a gateway that links information systems and to investigate the functionality and usability of the gateway through an empirical study.

METHODS

We developed a gateway with healthcare and welfare professionals in Kashiwa city, Japan. The gateway system consisted of two sub-systems: a data exchange sub-system and a common sub-system. Regarding the security, we used the transport layer security 1.2 and a public key infrastructure. For document formats, we utilized the health level seven international, extensible markup language, and portable document format. In addition, we performed an empirical study with 11 scenarios of four simulated patients and a questionnaire survey to the professionals.

RESULTS

Professionals of eight occupations participated the empirical study and verified the gateway to link information systems of six vendors. For a questionnaire survey, 32 professionals out of 40 reported that the gateway would eliminate the burden of inputting the same records into different information systems.

An Analysis of Patient Safety Incident Reports Associated with Electronic Health Record Interoperability

Background: With the widespread use of electronic health records (EHRs) for many clinical tasks, interoperability with other health information technology (health IT) is critical for the effective delivery of care. While it is generally recognized that poor interoperability negatively impacts patient care, little is known about the specific patient safety implications. Understanding the patient safety implications will help prioritize interoperability efforts around architectures and standards. Objectives: Our objectives were to (1) identify patient safety incident reports that reflect EHR interoperability challenges with other health IT, and (2) perform a detailed analysis of these reports to understand the health IT systems involved, the clinical care processes impacted, whether the incident occurred within or between provider organizations, and the reported severity of the patient safety events. Methods: From a database of 1.735 million patient safety event (PSE) reports spanning multiple provider organizations, 2625 reports that were indicated as being health IT related by the event reporter were reviewed to identify EHR interoperability related reports. Through a rigorous coding process 209 EHR interoperability related events were identified and coded. Results: The majority of EHR interoperability PSE reports involved interfacing with pharmacy systems (i.e. medication related), followed by laboratory, and radiology. Most of the interoperability challenges in these clinical areas were associated with the EHR receiving information from other health IT systems as opposed to the EHR sending information to other systems. The majority of EHR interoperability challenges were within a provider organization and while many of the safety events reached the patient, only a few resulted in patient harm. Conclusions: Interoperability efforts should prioritize systems in pharmacy, laboratory, and radiology. Providers should recognize the need to improve EHRs interfacing with other health IT systems within their own organization.

Understanding Unintended Consequences and Health Information Technology:. Contribution from the IMIA Organizational and Social Issues Working Group

OBJECTIVE

No framework exists to identify and study unintended consequences (UICs) with a focus on organizational and social issues (OSIs). To address this shortcoming, we conducted a literature review to develop a framework for considering UICs and health information technology (HIT) from the perspective of OSIs.

METHODS

A literature review was conducted for the period 2000- 2015 using the search terms "unintended consequences" and "health information technology". 67 papers were screened, of which 18 met inclusion criteria. Data extraction was focused on the types of technologies studied, types of UICs identified, and methods of data collection and analysis used. A thematic analysis was used to identify themes related to UICs.

RESULTS

We identified two overarching themes. One was the definition and terminology of how people classify and discuss UICs. Second was OSIs and UICs. For the OSI theme, we also identified four sub-themes: process change and evolution, individual-collaborative interchange, context of use, and approaches to model, study, and understand UICs.

CONCLUSIONS

While there is a wide body of research on UICs, there is a lack of overall consensus on how they should be classified and reported, limiting our ability to understand the implications of UICs and how to manage them. More mixed-methods research and better proactive identification of UICs remain priorities. Our findings and framework of OSI considerations for studying UICs and HIT extend existing work on HIT and UICs by focusing on organizational and social issues.

Review of Social and Organizational Issues in Health Information Technology

Objectives

This paper reviews organizational and social issues (OSIs) in health information technology (HIT).

Methods

A review and synthesis of the literature on OSIs in HIT was conducted.

Results

Five overarching themes with respect to OSIs in HIT were identified and discussed: scope and frameworks for defining OSIs in HIT, context matters, process immaturity and complexity, trade-offs will happen and need to be discussed openly, and means of studying OSIs in HIT.

Conclusions

There is a wide body of literature that provides insight into OSIs in HIT, even if many of the studies are not explicitly labelled as such. The two biggest research needs are more explicit and theoretical studies of OSI in HITs and more research on integrating micro and macro perspectives of HIT use in organizations.

Improving diagnostic accuracy using EHR in emergency departments: A simulation-based study

It is widely believed that Electronic Health Records (EHR) improve medical decision-making by enabling medical staff to access medical information stored in the system. It remains unclear, however, whether EHR indeed fulfills this claim under the severe time constraints of Emergency Departments (EDs). We assessed whether accessing EHR in an ED actually improves decision-making by clinicians. A simulated ED environment was created at the Israel Center for Medical Simulation (MSR). Four different actors were trained to simulate four specific complaints and behavior and 'consulted' 26 volunteer ED physicians. Each physician treated half of the cases (randomly) with access to EHR, and their medical decisions were compared to those where the physicians had no access to EHR. Comparison of diagnostic accuracy with and without access showed that accessing the EHR led to an increase in the quality of the clinical decisions. Physicians accessing EHR were more highly informed and thus made more accurate decisions. The percentage of correct diagnoses was higher and these physicians were more confident in their diagnoses and made their decisions faster.