Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries?

OBJECTIVE

Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions.

DATA SOURCE

Medicare Fee-for-Service Data, 2018.

STUDY DESIGN

We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics.

DATA EXTRACTION METHODS

We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason.

PRINCIPAL FINDINGS

In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other.

CONCLUSIONS

There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.

Record linkage for routinely collected health data in an African health information exchange

Introduction

The Patient Master Index (PMI) plays an important role in management of patient information and epidemiological research, and the availability of unique patient identifiers improves the accuracy when linking patient records across disparate datasets. In our environment, however, a unique identifier is seldom present in all datasets containing patient information. Quasi identifiers are used to attempt to link patient records but sometimes present higher risk of over-linking. Data quality and completeness thus affect the ability to make correct linkages.

Aim

This paper describes the record linkage system that is currently implemented at the Provincial Health Data Centre (PHDC) in the Western Cape, South Africa, and assesses its output to date.

Methods

We apply a stepwise deterministic record linkage approach to link patient data that are routinely collected from health information systems in the Western Cape province of South Africa. Variables used in the linkage process include South African National Identity number (RSA ID), date of birth, year of birth, month of birth, day of birth, residential address and contact information. Descriptive analyses are used to estimate the level and extent of duplication in the provincial PMI.

Results

The percentage of duplicates in the provincial PMI lies between 10% and 20%. Duplicates mainly arise from spelling errors, and surname and first names carry most of the errors, with the first names and surname being different for the same individual in approximately 22% of duplicates. The RSA ID is the variable mostly affected by poor completeness with less than 30% of the records having an RSA ID.The current linkage algorithm requires refinement as it makes use of algorithms that have been developed and validated on anglicised names which might not work well for local names. Linkage is also affected by data quality-related issues that are associated with the routine nature of the data which often make it difficult to validate and enforce integrity at the point of data capture.

Survey of Information Exchange and Advanced Use of Other Health Information Technology in Primary Care Settings: Capabilities In and Outside of the Safety Net

BACKGROUND

Advanced use of health information technology (IT) functionalities can support more comprehensive, coordinated, and patient-centered primary care services. Safety net practices may benefit disproportionately from these investments, but it is unclear whether IT use in these settings has kept pace and what organizational factors are associated with varying use of these features.

OBJECTIVE

The aim was to estimate advanced use of health IT use in safety net versus nonsafety net primary care practices. We explore domains of patient engagement, population health management (decision support and registries), and electronic information exchange. We examine organizational characteristics that may differentially predict advanced use of IT across these settings, with a focus on health system ownership and/or membership in an independent practice network as key factors that may indicate available incentives and resources to support these efforts.

RESEARCH DESIGN

We conduct cross-sectional analysis of a national survey of physician practices (n=1776). We use logistic regression to predict advanced IT use in each of our domains based on safety net status and other organizational characteristics. We then use interaction models to assess whether ownership or network membership moderate the relationship between safety net status and advanced use of health IT.

RESULTS

Health IT use was common across primary care practices, but advanced use of health IT functionalities ranged only from 30% to 50% use. Safety net settings have kept pace with adoption of features for patient engagement and population management, yet lag in information exchange capabilities compared with nonsafety net practices (odds ratio=0.52 for federally qualified health centers, P<0.001; odds ratio=0.66 for other safety net, P=0.03). However, when safety net practices are members of a health system or practice network, health IT capabilities are comparable to nonsafety net sites.

CONCLUSIONS

All outpatient settings would benefit from improved electronic health record usability and implementation support that facilitates advanced use of health IT. Safety net practices, particularly those without other sources of centralized support, need targeted resources to maintain equitable access to information exchange capabilities.

Leveraging a health information exchange for analyses of COVID-19 outcomes including an example application using smoking history and mortality

Understanding sociodemographic, behavioral, clinical, and laboratory risk factors in patients diagnosed with COVID-19 is critically important, and requires building large and diverse COVID-19 cohorts with both retrospective information and prospective follow-up. A large Health Information Exchange (HIE) in Southeast Texas, which assembles and shares electronic health information among providers to facilitate patient care, was leveraged to identify COVID-19 patients, create a cohort, and identify risk factors for both favorable and unfavorable outcomes. The initial sample consists of 8,874 COVID-19 patients ascertained from the pandemic's onset to June 12th, 2020 and was created for the analyses shown here. We gathered demographic, lifestyle, laboratory, and clinical data from patient's encounters across the healthcare system. Tobacco use history was examined as a potential risk factor for COVID-19 fatality along with age, gender, race/ethnicity, body mass index (BMI), and number of comorbidities. Of the 8,874 patients included in the cohort, 475 died from COVID-19. Of the 5,356 patients who had information on history of tobacco use, over 26% were current or former tobacco users. Multivariable logistic regression showed that the odds of COVID-19 fatality increased among those who were older (odds ratio = 1.07, 95% CI 1.06, 1.08), male (1.91, 95% CI 1.58, 2.31), and had a history of tobacco use (2.45, 95% CI 1.93, 3.11). History of tobacco use remained significantly associated (1.65, 95% CI 1.27, 2.13) with COVID-19 fatality after adjusting for age, gender, and race/ethnicity. This effort demonstrates the impact of having an HIE to rapidly identify a cohort, aggregate sociodemographic, behavioral, clinical and laboratory data across disparate healthcare providers electronic health record (HER) systems, and follow the cohort over time. These HIE capabilities enable clinical specialists and epidemiologists to conduct outcomes analyses during the current COVID-19 pandemic and beyond. Tobacco use appears to be an important risk factor for COVID-19 related death.

Integrating Wikipedia editing into health professions education: a curricular inventory and review of the literature

INTRODUCTION

Wikipedia is an online encyclopedia read by millions seeking medical information. To provide health professions students with skills to critically assess, edit, and improve Wikipedia's medical content, a skillset aligned with evidence-based medicine (EBM), Wikipedia courses have been integrated into health professions schools' curriculum. This literature review and curricular inventory of Wikipedia educational initiatives provides an overview of current approaches and identifies directions for future initiatives and research.

METHODS

Five databases were searched for articles describing educational interventions to train health professional students to edit Wikipedia. Course dashboards, maintained by Wiki Education (Wiki Edu), were searched for curricular materials. From these sources, key details were extracted and synthesized, including student and instructor type, course content, educational methods, and student outcomes.

RESULTS

Six articles and 27 dashboards reported courses offered between 2015 and 2019. Courses were predominantly offered to medical and nursing students. Instructors delivered content via videos, live lectures, and online interactive modules. Course content included logistics of Wikipedia editing, EBM skills, and health literacy. All courses included assignments requiring students to edit Wikipedia independently or in groups. Limited details on assessment of student learning were available.

DISCUSSION

A small but growing number of schools are training health professions education students to improve Wikipedia's medical content. Course details are available on Wiki Edu dashboards and, to a lesser extent, in peer-reviewed publications. While more needs to be done in conducting and sharing assessment of student learning, integrating Wikipedia into health professions education has potential to facilitate learning of EBM and communication skills, improve Wikipedia's online content, and engage students with an autonomous environment while learning. Future considerations should include a thorough assessment of student learning and practices, a final review of student edits to ensure they follow Wikipedia's guidelines and are written in clear language, and improved sharing of teaching resources by instructors.

Social media as a tool for scientific updating at the time of COVID pandemic: Results from a national survey in Italy

In the face of the rapid evolution of the COVID-19 pandemic, healthcare professionals on the frontline are in urgent need of frequent updates in the accomplishment of their practice. Hence, clinicians started to search for prompt, valid information on sources that are parallel to academic journals. Aim of this work is to investigate the extent of this phenomenon. We administered an anonymous online cross-sectional survey to 645 Italian clinicians. Target of the survey were all medical figures potentially involved in the management of COVID-19 cases. 369 questionnaires were returned. 19.5% (n = 72) of respondents were younger than 30 years-old; 49,3% (n = 182) worked in Infectious Diseases, Internal Medicine or Respiratory Medicine departments, 11.5% (n = 42) in Intensive Care Unit and 7.4% (n = 27) were general practitioner. 70% (n = 261) of respondents reported that their use of social media to seek medical information increased during the pandemic. 39.3% (n = 145) consistently consulted Facebook groups and 53.1% (n = 196) Whatsapp chats. 47% (n = 174) of respondents reported that information shared on social media had a consistent impact on their daily practice. In the present study, we found no difference in social media usage between age groups or medical specialties. Given the urgent need for scientific update during the present pandemic, these findings may help understanding how clinicians access new evidences and implement them in their daily practice.

Evaluation of a health information exchange system for microcephaly case-finding - New York City, 2013-2015

Background

Birth defects surveillance in the United States is conducted principally by review of routine but lagged reporting to statewide congenital malformations registries of diagnoses by hospitals or other health care providers, a process that is not designed to rapidly detect changes in prevalence. Health information exchange (HIE) systems are well suited for rapid surveillance, but information is limited about their effectiveness at detecting birth defects. We evaluated HIE data to detect microcephaly diagnosed at birth during January 1, 2013–December 31, 2015 before known introduction of Zika virus in North America.

Methods

Data from an HIE system were queried for microcephaly diagnostic codes on day of birth or during the first two days after birth at three Bronx hospitals for births to New York City resident mothers. Suspected cases identified by HIE data were compared with microcephaly cases that had been identified through direct inquiry of hospital records and confirmed by chart abstraction in a previous study of the same cohort.

Results

Of 16,910 live births, 43 suspected microcephaly cases were identified through an HIE system compared to 67 confirmed cases that had been identified as part of the prior study. A total of 39 confirmed cases were found by both studies (sensitivity = 58.21%, 95% CI: 45.52–70.15%; positive predictive value = 90.70%, 95% CI: 77.86–97.41%; negative predictive value = 99.83%, 95% CI: 99.76–99.89% for HIE data).

Conclusion

Despite limitations, HIE systems could be used for rapid newborn microcephaly surveillance, especially in the many jurisdictions where more labor-intensive approaches are not feasible. Future work is needed to improve electronic medical record documentation quality to improve sensitivity and reduce misclassification.

Communication and information exchange between primary healthcare employees and volunteers - Challenges, needs and possibilities for technology support

In light of the challenges posed by an ageing population and tighter public budgets, governments worldwide are seeking innovative ways of improving health service delivery. Volunteers can contribute to such improvement, but this requires effective coordination and communication between volunteers and healthcare employees. In this case study, conducted in two Norwegian municipalities during September-October 2017, the aim was to understand how collaboration and coordination is carried out between several stakeholders: volunteers, volunteer family members of healthcare service users and healthcare employees. Our results show that daily cooperation was largely unsystematic, and stakeholders employed various informal communication procedures. Recruitment of volunteers was based on word of mouth and was coordinated by telephone and email. All processes were paper based, including contracting and confidential agreements. This unsystematic approach resulted in uncoordinated activities characterised by time-consuming processes, with no quality assurance. We concluded that stakeholders would benefit from a technology solution that supports more systematic processes of recruitment, management and monitoring. This article outlines the challenges and needs for information exchange and communication between stakeholders. Furthermore, it describes possible functionality in a digital system that can address these needs, and hence improve coordination, quality of services and resource use.

Centre for Youth Research and Practice: Social Impact Assessment Results

Purpose: This article outlines the objective and structure of the Center for Youth Research and Practice (CYRP), its contributions toward youth research and practices, importance of the linkages that the CYRP has cultivated between research and practice, the facilitation of knowledge exchange with local and global institutions and professionals, and its role in future endeavors.Method: A social impact assessment has been implemented to address the intervention and the outcome based on the contributions of the CYRP to youth research and practices.Results: From this, the work of the CYRP on youth research and practices is concluded to have significant social impacts at the individual, social, organizational, and global levels. The work has found that the quality of life, self-esteem, involvement in society, empowerment through social capacity building, organizational development, and providing an international hub are crucial for youth development and wellbeing.Discussion: Hitherto, the CYRP has published over a hundred journal articles and held nearly 200 events including training courses, workshops, seminars and a conference. Over 6000 participants have taken part in these events and more than 60 institutions have collaborated with the CYRP to exchange knowledge on youth research and practices. The work of the CYRP as a whole has facilitated the participation of different individuals and organizations. In essence, the work of the CYRP has provided important grounds to initiate its role as an international hub as the CYRP is now considered as a center of significance in youth research and practices for Chinese societies in the East Asia region.

Advancing laboratory medicine in hospitals through health information exchange: a survey of specialist physicians in Canada

BACKGROUND

Laboratory testing occupies a prominent place in health care. Information technology systems have the potential to empower laboratory experts and to enhance the interpretation of test results in order to better support physicians in their quest for better and safer patient care. This study sought to develop a better understanding of which laboratory information exchange (LIE) systems and features specialist physicians are using in hospital settings to consult their patients' laboratory test results, and what benefit they derive from such use.

METHODS

As part of a broader research program on the use of health information exchange systems for laboratory medicine in Quebec, Canada, this study was designed as on online survey. Our sample is composed of 566 specialist physicians working in hospital settings, out of the 1512 physicians who responded to the survey (response rate of 17%). Respondents are representative of the targeted population of specialist physicians in terms of gender, age and hospital location.

RESULTS

We first observed that 80% of the surveyed physicians used the province-wide interoperable electronic health records (iEHR) system and 93% used a laboratory results viewer (LRV) to consult laboratory test results and most (72%) use both systems to retrieve lab results. Next, our findings reveal important differences in the capabilities available in each type of system and in the use of these capabilities. Third, there are differences in the nature of the perceived benefits obtained from the use of each of these two systems. Last, the extent of use of an LRV is strongly influenced by the IT artefact itself (i.e., the hospital's LRV available capabilities) while the use of the provincial iEHR system is influenced by its organizational context (i.e. the hospital's size and location).

CONCLUSIONS

The main contribution of this study lies in its insights into the role played by context in shaping physicians' choices about which laboratory information exchange systems to adopt and which features to use, and the different perceptions they have about benefits arising from such use. One related implication for practice is that success of LIE initiatives should not be solely assessed with basic usage statistics.

Quality of electronic records documenting adverse drug reactions within a hospital setting: identification of discrepancies and information completeness

AIM

Incomplete and incorrect documentation of adverse drug reactions (ADRs) can restrict prescribing choices resulting in suboptimal pharmaceutical care. This study aimed to examine the quality of information held within electronic systems in a hospital setting, to determine the preciseness of ADR documentation, and identify discrepancies where multiple electronic systems are utilised.

METHOD

Over a four-week period, consecutive patients admitted to the general medical ward at the study hospital had their electronic profiles reviewed. Patient demographic information (de-identified), ADR history and discrepancies between information sources (as recorded in all electronic systems utilised at initial prescribing) were recorded and analysed.

RESULTS

Over the four-week period, 332 patient profiles were reviewed, and over 1,200 alerts were identified and analysed (including duplicates of ADR reactions). Of these patients, 151 (45.5%) had at least one documented allergy or intolerance which generated 585 reactions, relating to 526 unique events. A further 151 (45.5%) were classified as having no known (drug) allergies or intolerances; however, 20 (15%) of these patients did have at least one allergy documented in at least one other electronic system. The remaining 30 (9%) patients were classified as having an unknown allergy status and of those nine had allergies documented in at least one other electronic system. Further, most systems contained information duplication, which had not been addressed during the admission process.

CONCLUSION

ADR information was both imprecise and inaccurate, as multiple discrepancies between ADR information recorded in different electronic patient management systems were found to exist. Information sharing between systems needs to be prioritised in order to allow full, accurate and complete ADR information to be collected, stored and utilised; both to reduce current inadequacies and to allow optimal pharmaceutical care.

Health Information Exchange of Medication Lists: Hospital Discharge to Home Healthcare

Nurses report significant gaps in communication among patients discharged from the hospital with home healthcare (HHC) services. The aim of this pilot study was to quantify the contents of HHC admission packets used to guide nurses' first home visit after hospital discharge. We evaluated 20 randomly selected charts of older adults admitted to HHC after a hospitalization for heart failure. Admission packets contained nearly 50 pages of material, which frequently included duplicate documents printed from the hospital-based electronic health record (EHR). Despite the plethora of documents, most packets omitted key information, such as patients' cognitive and functional status, and even discharge summaries, which would be relevant and actionable for HHC nurses. Moreover, admission packets contained multiple, often discordant, EHR-generated medication lists, which makes reconciliation challenging for nurses and puts vulnerable patients at risk for adverse drug events. Overall, there is an urgent need to improve health information exchange between hospitals and HHC agencies, which will simultaneously promote nurse efficiency and patient safety.

Alternative payment models and hospital engagement in health information exchange

OBJECTIVES

To assess whether hospital participation in alternative payment models (APMs) is associated with greater engagement in health information exchange (HIE) along 4 dimensions: volume of patients for whom information is exchanged, diversity of information types, breadth of partner types, and depth of technical approach.

STUDY DESIGN

Pooled, cross-sectional analysis of data on US hospitals from 2014 to 2015.

METHODS

APM participation came from Leavitt Partners data, Medicare public use files, and the American Hospital Association (AHA) Annual Survey. We used Medicare data to measure HIE volume for 798 hospitals attesting to stage 2 Meaningful Use and the AHA Information Technology Supplement to measure HIE diversity, breadth, and depth for 1730 hospitals. We used mixed-effects regression to estimate the association between participation in APMs and each dimension of HIE.

RESULTS

Compared with nonparticipating hospitals, full-year APM participation was associated with lower HIE volume (data were sent for 11 percentage points fewer discharges; P = .003), greater HIE diversity (of 4 data types, 0.3 more were transmitted; P <.001), greater HIE breadth (of 3 partner types, data were sent to 0.3 more; P <.001), and greater HIE depth (the odds of using a push and pull approach were 1.68 times greater; P = .004).

CONCLUSIONS

Our finding that APM participation was associated with greater HIE diversity, breadth, and depth suggests that value-based payment may be spurring improvements in HIE infrastructure. However, our finding that APM participation is associated with lower HIE volume suggests that there may be an incentive to focus HIE investments on a limited number of partners.

Drivers of health information exchange use during postacute care transitions

OBJECTIVES

To characterize the drivers of the use of electronic health information exchange (HIE) by skilled nursing facilities (SNFs) to access patient hospital data during care transitions.

STUDY DESIGN

Explanatory, sequential mixed-methods study. Quantitative data from an audit log captured HIE use by 3 SNFs to retrieve hospitalization information for the 5487 patients discharged to their care between June 2014 and March 2017, along with patient demographic data. Qualitative inquiry included 16 interviews at the discharging hospital and HIE-enabled SNFs.

METHODS

Multivariate probit models determined patient-level factors associated with SNF HIE use. These models informed subsequent in-depth, semistructured interviews to refine our understanding of usage patterns, as well as facilitators of and barriers to use.

RESULTS

HIE was used by SNFs for 46% of patients for whom it was available; 29% of patients had records accessed within 3 days of hospital discharge. Overall HIE use was more likely for new versus returning SNF patients (3.8%; P <.001) and when a patient was discharged from the emergency department rather than an inpatient unit (6.8%; P = .027). HIE use was less likely on weekends (-4.3%; P = .036) and for more complex patients, as measured by length of stay (-0.4% per day; P ≤.001) or number of conditions (-0.3% per diagnosis; P ≤.001). Interviews revealed distinct HIE use cases across SNFs; perceiving ability to access information not otherwise available in paper discharge materials, as well as workflow integration, were critical facilitators of use during transitional care.

CONCLUSIONS

HIE between hospitals and SNFs is underused. A mixed-methods approach is critical to understanding and explaining variation in implementation and use. Creating value requires hospitals and SNFs to codevelop system design, usage guidelines, and workflows that meaningfully integrate HIE into care delivery.

A secure biometrics-based authentication key exchange protocol for multi-server TMIS using ECC

BACKGROUND AND OBJECTIVES

Telecare Medicine Information System (TMIS) enables physicians to efficiently and conveniently make certain diagnoses and medical treatment for patients over the insecure public Internet. To ensure patients securely access to medicinal services, many authentication schemes have been proposed. Although numerous cryptographic authentication schemes for TMIS have been proposed with the aim to ensure data security, user privacy and authentication, various forms of attacks make these schemes impractical.

METHODS

To design a truly secure and practical authentication scheme for TMIS, a new biometrics-based authentication key exchange protocol for multi-server TMIS without sharing the system private key with distributed servers is presented in this work.

RESULTS

Our proposed protocol has perfect security features including mutual authentication, user anonymity, perfect forward secrecy and resisting various well-known attacks, and these security feathers are confirmed by the BAN logic and heuristic cryptanalysis, respectively.

CONCLUSIONS

A secure biometrics-based authentication key exchange protocol for multi-server TMIS is presented in this work, which has perfect security properties including perfect forward secrecy, supporting user anonymity, etc., and can withstand various attacks such as impersonation attack, off-line password guessing attack, etc.. Considering security is the most important factor for an authentication scheme, so our scheme is more suitable for multi-server TMIS.

Analysis of the behavior change mechanism of township hospital health workers in Hubei Province, China: A cross-sectional study

This study aims to analyze the behavior changes of health workers in township hospitals by exploring their individual service, health information utilization, and health information exchange before and after intervention.A cross-sectional survey was conducted from September, 2016 to December, 2016 in Qianjiang city, Hubei Province, China. A total of 432 township hospital health workers were investigated from 12 township hospitals. t test and chi-square test were adopted in the difference analysis to compare the behavior changes and factors of the control and intervention groups before and after intervention. t test and U test were used to analyze the behaviors and the key impact factors of health workers in township hospitals. The hypothesis test of the behavior changes in the township hospitals were analyzed using the partial least squares (PLS) method.No significant difference was observed between the control and intervention groups of health workers in township hospitals. Significant differences were observed in the behavior attitude (BA), perceived behavior control (PBC), behavior intention (BI), and behaviors of information utilization and exchange in the intervention group. A significant difference was observed in the indicators of subjective norm (SN), BI, and behaviors with respect to information exchange. A large increment was observed in the intervention group. Based on results of PLS, the individual service, health information utilization, and health information exchange established relationships with BA, SN, PBC, and BI to a certain degree.A cause and effect relationship can be observed among BA, SN, PBC, BI, and behaviors of health workers in the township hospitals. BI can promote behavior changes among township hospital health workers. Moreover, different behaviors are demonstrated by different people because of BA, SN, PBC, and BI. The results of this study can contribute to improving the feasibility, pertinence, and effects of health service, and can serve as the guide in understanding health workers' behaviors.

Does participation in health information exchange improve hospital efficiency?

The federal government allocated nearly $30 billion to spur the development of information technology infrastructure capable of supporting the exchange of interoperable clinical data, leading to growth in hospital participation in health information exchange (HIE) networks. HIEs have the potential to improve care coordination across healthcare providers, leading ultimately to increased productivity of health services for hospitals. However, the impact of HIE participation on hospital efficiency remains unclear. This dynamic prompts the question asked by this study: does HIE participation improve hospital efficiency. This study estimates the effect of HIE participation on efficiency using a national sample of 1017 hospitals from 2009 to 2012. Using a two-stage analytic design, efficiency indices were determined using the Malmquist algorithm and then regressed on a set of hospital characteristics. Results suggest that any participation in HIE can improve both technical efficiency change and total factor productivity (TFP). A second model examining total years of HIE participation shows a benefit of one and three years of participation on TFP. These results suggest that hospital investment in HIE participation may be a useful strategy to improve hospital operational performance, and that policy should continue to support increased participation and use of HIE. More research is needed to identify the exact mechanisms through which HIE participation can improve hospital efficiency.

The impact of health information exchange on healthcare quality and cost-effectiveness: A systematic literature review

BACKGROUND AND OBJECTIVE

Health Information Exchange (HIE) is known as a technology that electronically shares all clinical and administrative data throughout healthcare settings. Despite this technology has a great potential in the healthcare industry, there is a limited and sparse evidence of articles which illustrated the impact of HIE on quality of care and cost-effectiveness. This work presents a systematic review that evaluates the impact of HIE on quality and cost-effectiveness, and the rates of HIE adoption and participation in healthcare organizations.

METHODS

We systematically searched all English papers that were indexed in four major databases (Science Direct, PubMed, IEEE and Web of Science) between 2005 and 2016. Consequently, 32 identified papers appeared in 21 international journals and conferences. Eligible studies independently were critically appraised, collected within data extraction form and then thematically analyzed by two reviewers and if necessary, the third author. The selected papers have been classified based on 11 main categories including publication year, journal and conference names, country and study design, types of data exchanged, healthcare levels, disease or disorder, participants in organizations and individuals, settings characteristics and HIE types, the impact of HIE on quality and cost-effectiveness, and the rates of HIE adoption and participation.

RESULTS

Of the 32 articles, 25 studies investigated the financial and clinical impact of HIE. Overwhelmingly, HIE studies have reported positive findings for quality and cost-effectiveness of care. 15 of HIE studies (60%) demonstrated positive financial effects and 16 studies (64%) reported positive effects on quality improvement of patient care. However, the overall quality of the evidences was low. In this regard, cohort study (59.38%) was the most common used study design. Nine studies presented the rates of HIE adoption and participation. The lowest and highest participation rates were 15.7% and 79%, respectively.

CONCLUSIONS

HIE can be considered as a superior potential for healthcare information system, resulting to promote patient care quality and reduce costs related to resource utilization. However, further researches are needed in order to provide a better understanding of this domain and accordingly attain new opportunities to increase users' participation and motivation for successfully adopting this technology.

Understanding the role of health information in patients' experiences: secondary analysis of qualitative narrative interviews with people diagnosed with cancer in Germany

OBJECTIVE

To analyse the role and meaning of health information in individuals' experiences with either breast, colorectal or prostate cancer in order to better understand unmet information needs of people with a cancer diagnosis.

DESIGN

This is a secondary analysis of data from a qualitative interview study including narrative interviews and maximum variation sampling. A thematic analysis was conducted, followed by an in-depth analysis based on the principles of grounded theory.

SETTING

Interviewees were sought across Germany through self-help organisations, primary care clinics, rehabilitation facilities, physicians and other healthcare professionals to develop cancer modules for the website krankheitserfahrungen.de (illness experiences.de).

PARTICIPANTS

Women with a diagnosis of breast cancer, individuals with a diagnosis of colorectal cancer and men with a diagnosis of prostate cancer.

RESULTS

The meaning and role of information in the illness experiences were clearly associated with gaining control in a seemingly uncontrollable situation in which others -people, the disease- take over. Four categories characterise the ways in which information helped interviewees to regain a sense of control following a diagnosis of cancer: 'becoming confident in one's treatment decision', 'taking responsibility for one's situation', 'understanding the consequences of the disease and treatment for one's life', and 'dealing with fear'. There was, however, always a fine line between information seeking and becoming overwhelmed by information.

CONCLUSIONS

Information needs to be understood as a management tool for handling the disease and its (potential) consequences. Patients' unmet needs for information might not be easily solved by a simple increase in the amount of information because emotional support and respect for patient autonomy might also play a role. The evaluation of one's own information behaviour and the information received is closely linked to how the illness unfolds. This makes it challenging to document unmet information needs and satisfaction with information independent of an individual's illness trajectory over time.

Evaluating the Dental Caries-Related Information on Brazilian Websites: Qualitative Study

BACKGROUND

Dental caries is the most common chronic oral disease, affecting 2.4 billion people worldwide who on average have 2.11 decayed, missing, or filled teeth. It impacts the quality of life of patients, socially and economically. However, the comprehension of dental caries may be difficult for most people, as it involves a multifactorial etiology with the interplay between the tooth surface, the dental biofilm, dietary fermentable carbohydrates, and genetic and behavioral factors. Therefore, the production of effective materials addressed to the education and counseling of patients for the prevention of dental caries requires a high level of specialization. In this regard, the dental caries-related contents produced by laypersons and their availability on the Internet may be low-quality information.

OBJECTIVE

The aim of this study was to assess the readability and the quality of dental caries-related information on Brazilian websites.

METHODS

A total of 75 websites were selected through Google, Bing, Yahoo!, and Baidu. The websites were organized in rankings according to their order of appearance in each one of the 4 search engines. Furthermore, 2 independent examiners evaluated the quality of websites using the DISCERN questionnaire and the Journal of American Medical Association (JAMA) benchmark criteria. The readability of the websites was assessed by the Flesch Reading Ease adapted to Brazilian Portuguese (FRE-BP). In addition, the information presented on the websites was categorized as etiology, prevention, and treatment of dental caries. The statistical analysis was performed using Spearman rank correlation coefficient, Mann-Whitney U test, hierarchical clustering analysis by Ward minimum variance method, Kruskal-Wallis test, and post hoc Dunn test. P<.05 was considered significant.

RESULTS

The Web contents were considered to be of poor quality by DISCERN (mean 33.48, standard deviation, SD 9.06) and JAMA (mean 1.12, SD 0.97) scores, presenting easy reading levels (FRE-BP: mean 62.93, SD 10.15). The rankings of the websites presented by Google (ρ=-.22, P=.08), Baidu (ρ=-.19, P=.53), Yahoo! (ρ=.22, P=.39), and Bing (ρ=-.36, P=.23) were not correlated with DISCERN scores. Moreover, the quality of websites with health- and nonhealth-related authors was similar (P=.27 for DISCERN and P=.47 for JAMA); however, the pages with a greater variety of dental caries information showed significantly higher quality scores than those with limited contents (P=.009).

CONCLUSIONS

On the basis of this sample, dental caries-related contents available on Brazilian websites were considered simple, accessible, and of poor quality, independent of their authorship. These findings indicate the need for the development of specific policies focused on the stimulus for the production and publication of Web health information, encouraging dentists to guide their patients in searching for recommended oral health websites.

What Factors Impact Consumer Perception of the Effectiveness of Health Information Sites? An Investigation of the Korean National Health Information Portal

Lay public's concerns around health and health information are increasing. In response, governments and government agencies are establishing websites to address such concerns and improve health literacy by providing better access to validated health information. Since 2011, the Korean government has constructed the National Health Information Portal (NHIP) website run in collaboration with the Korean Academy of Medical Sciences (KAMS). This study therefore aimed to 1) examine consumer use of NHIP, with respect to the usage patterns, evaluation on health information provided, and perceived effectiveness of the site; and 2) identify factors that may impact perceived effectiveness of the site. An online survey was conducted with 164 NHIP users, recruited through a popup window on the main screen of the portal website from October to November 2015. The significant predicting factors supported by the data include the relevance of health information on the site, the usefulness of information in making health decisions, and the effective visualization of information. These factors can inform future efforts to design more effective health information websites, possibly based on metadata systems, to further advance the lay public's information seeking and health literacy.

Health information exchange policies of 11 diverse health systems and the associated impact on volume of exchange

BACKGROUND

Provider organizations increasingly have the ability to exchange patient health information electronically. Organizational health information exchange (HIE) policy decisions can impact the extent to which external information is readily available to providers, but this relationship has not been well studied.

OBJECTIVE

Our objective was to examine the relationship between electronic exchange of patient health information across organizations and organizational HIE policy decisions. We focused on 2 key decisions: whether to automatically search for information from other organizations and whether to require HIE-specific patient consent.

METHODS

We conducted a retrospective time series analysis of the effect of automatic querying and the patient consent requirement on the monthly volume of clinical summaries exchanged. We could not assess degree of use or usefulness of summaries, organizational decision-making processes, or generalizability to other vendors.

RESULTS

Between 2013 and 2015, clinical summary exchange volume increased by 1349% across 11 organizations. Nine of the 11 systems were set up to enable auto-querying, and auto-querying was associated with a significant increase in the monthly rate of exchange (P = .006 for change in trend). Seven of the 11 organizations did not require patient consent specifically for HIE, and these organizations experienced a greater increase in volume of exchange over time compared to organizations that required consent.

CONCLUSIONS

Automatic querying and limited consent requirements are organizational HIE policy decisions that impact the volume of exchange, and ultimately the information available to providers to support optimal care. Future efforts to ensure effective HIE may need to explicitly address these factors.

State Variation in Electronic Sharing of Information in Physician Offices: United States, 2015

Data from the National Electronic Health Records Survey •In 2015, the percentage of physicians who had electronically sent patient health information ranged from 19.4% in Idaho to 56.3% in Arizona. •In 2015, the percentage of physicians who had electronically received patient health information ranged from 23.6% in Louisiana and Mississippi to 65.5% in Wisconsin. •In 2015, the percentage of physicians who had electronically integrated patient health information from other providers ranged from 18.4% in Alaska to 49.3% in Delaware. •In 2015, the percentage of physicians who had electronically searched for patient health information ranged from 15.1% in the District of Columbia to 61.2% in Oregon. The Health Information Technology for Economic and Clinical Health Act (HITECH) provides financial incentives to eligible providers using a certified electronic health record (EHR) system (1,2). In 2015, 77.9% of office-based physicians had a certified EHR system, up from 74.1% in 2014 (3-5). A federal plan to enhance the nation's health information technology infrastructure was published in 2015 to support information sharing (6,7). Therefore, this report uses the 2015 National Electronic Health Records Survey (NEHRS) to describe the extent to which physicians can electronically send, receive, integrate, and search for patient health information.

Health information exchange systems and length of stay in readmissions to a different hospital

BACKGROUND

Readmission to a different hospital than the original discharge hospital may result in breakdowns in continuity of care. In different-hospital readmissions (DHRs), continuity can be maintained when hospitals are connected through health information exchange (HIE) systems.

OBJECTIVE

To examine whether length of readmission stay (LORS) differs between same-hospital readmissions and DHRs, and whether in DHRs the LORS differs by the availability of HIE.

DESIGN

A retrospective cohort study of all internal medicine 30-day readmissions in 27 Israeli hospitals between January 1, 2010 and December 31, 2010.

SETTING

Clalit Health Services-Israel's largest integrated healthcare provider and payer.

POPULATION

Adult Clalit members (aged 18 and older) with at least 1 readmission during the study period.

METHODS

A multivariate marginal Cox model tested the likelihood for discharge during each readmission day in same-hospital readmissions (SHRs), DHRs with HIE, and DHRs without HIE.

RESULTS

Of the 27,057 readmissions, 3130 (11.6%) were DHRs and 792 where DHRs with HIE in both the index and readmitting hospital. Partial continuity (DHRs with HIE) was associated with decreased likelihood of discharge on any given day compared with full continuity (SHRs) (hazard ratio [HR] = 0.85, 95% confidence interval [CI]: 0.79-0.91). Similar results were obtained for no continuity (DHRs without HIE) versus full continuity (HR = 0.90, 95% CI: 0.86-0.94). The difference between DHRs with and without HIE was not significant.

CONCLUSIONS

The prolonged LORS in DHRs versus SHRs was not mitigated by the existence of HIE systems. Future research is needed to further elucidate the effects of actual use of HIE on length of DHRs. Journal of Hospital Medicine 2016;11:401-406. © 2015 Society of Hospital Medicine.

Electronic Public Health Registry of Extensively Drug-Resistant Organisms, Illinois, USA

In response to clusters of carbapenem-resistant Enterobacteriaceae (CRE) in Illinois, USA, the Illinois Department of Public Health and the Centers for Disease Control and Prevention Chicago Prevention Epicenter launched a statewide Web-based registry designed for bidirectional data exchange among health care facilities. CRE occurrences are entered and searchable in the system, enabling interfacility communication of patient information. For rapid notification of facilities, admission feeds are automated. During the first 12 months of implementation (November 1, 2013-October 31, 2014), 1,557 CRE reports (≈4.3/day) were submitted from 115 acute care hospitals, 5 long-term acute care hospitals, 46 long-term care facilities, and 7 reference laboratories. Guided by a state and local public health task force of infection prevention specialists and microbiologists and a nonprofit informatics entity, Illinois Department of Public Health deployed a statewide registry of extensively drug-resistant organisms. The legal, technical, and collaborative underpinnings of the system enable rapid incorporation of other emerging organisms.

Exploring Business Strategy in Health Information Exchange Organizations

Unlike consumer goods industries, healthcare has been slow to implement technolo gies that support exchange of data in patients' health records. This results in avoid able medication errors, avoidable hospital readmissions, unnecessary duplicate testing, and other inefficient or wasteful practices. Community-based regional health information exchange (HIE) organizations have evolved in response to federal aims to encourage interoperability, yet little is known about their strategic approach. We use the lens of institutional and strategic management theories to empirically explore the differences in business strategies deployed in HIEs that are, to date, financially sustainable versus those that are not. We developed a 20-question survey targeted to CEOs to assess HIE business strategies. Our sample consisted of 60 community-based exchanges distributed throughout the United States, and we achieved a 58% response rate. Questions centered on competitive strategy and financial sustainability. We relied on logistic regression methods to explore relationships between variables. Our regression identified characteristics common to sustainable organizations. We defined sustainability as revenues exceeding operational costs. Seventeen of the 35 organizations (49%) defined themselves as currently sustainable. Focus and cost leadership strategies were significantly associated with sustainability. Growth strate gies, which were much more common than other strategies, were not associated with sustainability. We saw little evidence of a differentiation strategy (i.e., the basis of competition whereby the attributes of a product or service are unmatched by rivals). Most CEOs had a relatively optimistic outlook, with 60% stating they were confident of surviving over the next 5 years; however, nearly 9% of the organizations were in some phase of divestiture or exit from the market. HIEs are evolving differently based on local leadership decisions, yet their strategic approach is isomorphic (or similar). Further insight into successful business strategies could help ensure the long-term survival of HIEs.

Adoption of Certified Electronic Health Record Systems and Electronic Information Sharing in Physician Offices: United States, 2013 and 2014

Data from the 2014 National Electronic Health Records Survey. In 2014, 74.1% of office-based physicians had a certified electronic health record (EHR) system, up from 67.5% in 2013. The percentage of physicians who had a certified EHR system ranged from 58.8% in Alaska to 88.6% in Minnesota. In 2014, 32.5% of office-based physicians with a certified EHR system were electronically sharing patient health information with external providers. The percentage of physicians with a certified EHR system electronically sharing patient health information with external providers ranged from 17.7% in New Jersey to 58.8% in North Dakota.

The Pilot Evaluation of Using the International Classification for Nursing Practice

International Classification for Nursing Practice (ICNP^®) was developed as the standardized terminology by the International Council of Nursing (ICN) since 1999. It is important to evaluate the applicability of using ICNP^® as the electronic nursing data exchange standardization when adopting in Taiwan. A total of 87% clinical nursing problems could be cross-mapped to DC axis of ICNP^® version 2 in traditional Chinese language (Kappa = .96). Only five nursing problems (following care problem; blood transfusion; potential risk for unstable blood sugar level; hyperbilirubinemia; and caregiver anxiety) couldn't be matched. ICNP^® could mostly support the electronic nursing data exchange standardization. Developing Taiwan-ICNP^® as the local terminology was seemed to be the strategy to create a more adoptive standardization across the country for Taiwan health care data exchange in the future.

A Family Medicine Health Technology Strategy for Achieving the Triple Aim for US Health Care

Health information technology (health IT) and health technology, more broadly, offer tremendous promise for connecting, synthesizing, and sharing information critical to improving health care delivery, reducing health system costs, and achieving personal and community health. While efforts to spur adoption of electronic health records (EHRs) among US practices and hospitals have been highly successful, aspirations for effective data exchanges and translation of data into measureable improvements in health outcomes remain largely unrealized. There are shining examples of health enhancement through new technologies, and the discipline of family medicine is well poised to take advantage of these innovations to improve patient and population health. The Future of Family Medicine led to important family medicine health IT initiatives over the past decade. For example, the American Academy of Family Physicians (AAFP) Center for Health Information Technology and the Robert Graham Center provided important leadership for informing health IT policy and standard-setting, such as the Centers for Medicare and Medicaid Services EHR incentives programs (often referred to as "meaningful use."). As we move forward, there is a need for a new and more comprehensive family medicine strategy for technology. To inform the Family Medicine for America's Health (FMAHealth) initiative, this paper explores strategies and tactics that family medicine could pursue to improve the utility of technology for primary care and to help primary care become a leader in rapid development, testing, and implementation of new technologies. These strategies were also designed with a broader stakeholder audience in mind, intending to reach beyond the work being done by FMAHealth. Specific suggestions include: a shared primary care health IT center, meaningful primary care quality measures and capacity to assess/report them, increased primary care technology research, a national family medicine registry, enhancement of family physicians' technology leadership, and championing patient-centered technology functionality.

An Exponential Increase in Regional Health Information Exchange With Collaborative Policies and Technologies

In the United States, the ability to securely exchange health information between organization has been limited by technical interoperability, patient identity matching, and variable institutional policies. Here, we examine the regional experience in a national health information exchange network by examining clinical data sharing between eleven Northern California organizations using the same health information exchange (HIE) platform between 2013-2014. We identify key policies and technologies that have led to a dramatic increase in health information exchange.

Measuring Population Health Using Electronic Health Records: Exploring Biases and Representativeness in a Community Health Information Exchange

Assessment is a core function of public health. Comprehensive clinical data may enhance community health assessment by providing up-to-date, representative data for use in public health programs and policies, especially when combined with community-level data relevant to social determinants. In this study we examine routinely collected and geospatially-enhanced EHR data to assess population health at various levels of geographic granularity available from a regional health information exchange. We present preliminary findings and discuss important biases in EHR data. Future work is needed to develop methods for correcting for those biases to support routine epidemiology work of public health.

Conceptualizing ‘role’ in patient-engaging e-health: A cross-disciplinary review of the literature

Patient-engaging e-health is promoted as a means to improve care and change the social order of healthcare – most notably the roles of patients and healthcare professionals. Nevertheless, while researchers across various fields expect and praise such changes, these social aspects are rarely addressed rigorously in the literature on the effects of e-health. In this paper we review the scientific literature on patient-engaging e-health, with the purpose of articulating the different ways in which role is conceptualized in the various strands of literature and what explicit and implicit assumptions such conceptualizations entail. We identify three conceptualizations of the concept of role and exemplify the findings proposed by studies that apply each of these. We argue that the identified conceptual differences have implications for what is found to be at stake when using e-health to further the involvement of patients in their own care, and that a more rigorous and reflective approach to the use of concepts with rich intellectual histories, such as that of role, will improve both empirical research in e-health and discussions of implications for practice.

Health Interoperability into Practice: Results of the Development of a Consent Form in a Pilot Project in a Health District in São Paulo, Brazil

Interoperability of health information systems is a centerpiece of the "E-Health" Brazilian Ministry of Health strategy. It aims to solve at least partially the health information technology puzzle that we face today. This paper describes a health information exchange pilot project in a health district of the city of São Paulo. It discusses the results of the development of an informed consent form for health information exchange. This consent form showed excellent results, with median application time of 3 minutes and with 97.8% of patients feeling fully clarified. The patients' perception when faced with options of consent to share their data is also described.

Applications of health information exchange information to public health practice

Increased information availability, timeliness, and comprehensiveness through health information exchange (HIE) can support public health practice. The potential benefits to disease monitoring, disaster response, and other public health activities served as an important justification for the US' investments in HIE. After several years of HIE implementation and funding, we sought to determine if any of the anticipated benefits of exchange participation were accruing to state and local public health practitioners participating in five different exchanges. Using qualitative interviews and template analyses, we identified public health efforts and activities that were improved by participation in HIE. HIE supported public health activities consistent with expectations in the literature. However, no single department realized all the potential benefits of HIE identified. These findings suggest ways to improve HIE usage in public health.

Trending health information technology adoption among New York nursing homes

OBJECTIVES

Federal policies are incentivizing hospitals and providers to adopt and meaningfully use electronic health records (EHRs). Nursing homes are not eligible for incentives. However, understanding health information technology (HIT) adoption among nursing homes will be critical to developing HIT policies for this sector. Our objective was to assess the pace of EHR adoption, changes in computerized function adoption, and participation in health information exchange by New York state nursing homes over time.

STUDY DESIGN

We used a repeated, cross-sectional study design.

METHODS

We surveyed all New York state nursing homes between February and May 2013, comparing results to the same survey administered in 2012.

RESULTS

We received responses from 472 of 630 nursing homes (74.9%). Rates of EHR adoption increased from 48.6% to 56.3% (P = .03). Participation in health information exchange remained unchanged (54.5% to 55.3%, P = .8). The top barriers to EHR adoption cited were: a) the initial cost of HIT investment (67.9%, n = 133), b) lack of technical IT staff (46.4%, n = 91), and c) lack of fiscal incentives (45.8%, n = 88). Comparing nursing homes with EHRs in 2012 to nursing homes with EHRs in 2013, the availability of many types of computerized functionalities significantly increased, although no gains were seen for order entry or clinical tools.

CONCLUSIONS

While some gains are being made by nursing homes, HIT adoption generally lags behind that of other sectors. Public policy focusing on building HIT infrastructure is essential to ensure that nursing homes keep up with other healthcare segments.

Health information exchange and the frequency of repeat medical imaging

OBJECTIVES

Medical imaging, which is expensive, is frequently repeated for the same patient within a relatively short period of time due to lack of access to previous images. Health information exchange (HIE) may reduce repeat imaging by facilitating provider access to prior images and reports. We sought to determine the effect of an HIE system on the occurrence of repeat imaging.

STUDY DESIGN AND METHODS

We conducted a cohort study of adult patients who consented to participate in a community-based HIE system in an 11-county region in New York. Using data from 2009-2010, we linked log files of provider HIE usage to administrative claims data from 2 commercial health plans. Using generalized estimation equations, we measured the association between HIE system access and repeat imaging within 90 days.

RESULTS

Of 196,314 patients in the cohort, 34,604 (18%) of patients had at least 1 imaging procedure, which was equivalent to a rate of 28.7 imaging procedures per 100 patients. Overall, 7.7% of images were repeated within 90 days. If the HIE system was accessed within the 90 days following an initial imaging procedure, imaging was significantly less likely to be repeated (5% repeated with HIE access vs 8% repeated without HIE access, P < .001). HIE system access reduced the adjusted odds of a repeat image by 25% (95% CI, 13%-35%).

CONCLUSIONS

Use of the HIE system to access previous patient information was associated with a reduction in repeated imaging.

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

BACKGROUND

Health information exchange (HIE) is an important tool for improving efficiency and quality and is required for providers to meet Meaningful Use certification from the United States Centers for Medicare and Medicaid Services. However widespread adoption and use of HIE has been difficult to achieve, especially in settings such as smaller-sized physician practices and federally qualified health centers (FQHCs). We assess electronic data exchange activities and identify barriers and benefits to HIE participation in two underserved settings.

METHODS

We conducted key-informant interviews with stakeholders at physician practices and health centers. Interviews were recorded, transcribed, and then coded in two waves: first using an open-coding approach and second using selective coding to identify themes that emerged across interviews, including barriers and facilitators to HIE adoption and use.

RESULTS

We interviewed 24 providers, administrators and office staff from 16 locations in two states. They identified barriers to HIE use at three levels-regional (e.g., lack of area-level exchanges; partner organizations), inter-organizational (e.g., strong relationships with exchange partners; achieving a critical mass of users), and intra-organizational (e.g., type of electronic medical record used; integration into organization's workflow). A major perceived benefit of HIE use was the improved care-coordination clinicians could provide to patients as a direct result of the HIE information. Utilization and perceived benefit of the exchange systems differed based on several practice- and clinic-level factors.

CONCLUSIONS

The adoption and use of HIE in underserved settings appears to be impeded by regional, inter-organizational, and intra-organizational factors and facilitated by perceived benefits largely at the intra-organizational level. Stakeholders should consider factors both internal and external to their organization, focusing efforts in changing modifiable factors and tailoring HIE efforts based on all three categories of factors. Collective action between organizations may be needed to address inter-organizational and regional barriers. In the interest of facilitating HIE adoption and use, the impact of interventions at various levels on improving the use of electronic health data exchange should be tested.

Altogether better

The College of Medicine last year gave Altogether Better its top award for innovation. Hosted by South West Yorkshire Partnership NHS Foundation Trust, Altogether Better aims to unlock the power of communities to transform lives, working with community health champions to improve wellbeing.

Care everywhere, a point-to-point HIE tool: utilization and impact on patient care in the ED

BACKGROUND

Emergency departments (EDs) routinely struggle with gaps in information when providing patient care. A point to point health information exchange (HIE) model has the potential to effectively fill those gaps.

OBJECTIVE

To examine the utility, perceived and actual, of a point-to-point HIE tool called Care Everywhere (CE) and its impact on patient care in the ED.

METHODS

This mixed methods study was performed at four large hospital EDs between January 2012 and November 2012. Retrospective data was extracted from the electronic health record (EHR) to evaluate CE utilization since implementation. ED notes data were extracted from ED visits occurring between January 2012 and June 2012 and were reviewed to evaluate the impact of exchanged information on patient care.

RESULTS

Per focus group discussions, physicians thought the information received via CE was of value to patient care, particularly laboratory results, imaging, medication lists, discharge summaries and ECG interpretations. They feel the greatest impact of HIE is the avoidance of duplicative diagnostic testing and the identification of drug-seeking behavior. Nursing and ancillary staff expressed somewhat less enthusiasm but still felt HIE positively impacted patient care. Over a period of six months, CE was used in approximately 1.46% of ED encounters. A review of ED provider notes over that time period revealed CE use resulted in 560 duplicate diagnostic procedures being avoided and 28 cases of drug seeking behavior identified.

CONCLUSION

Our study provides insight into the perceived value of HIE from the point of view of our ED physicians and staff. It also demonstrates that a point-to-point HIE tool such as Epic System's Care Everywhere has the potential to generate greater efficiencies within the ED and impact to patient care through elimination of duplicative diagnostic imaging or testing and resource utilization associated with those procedures.

Association between use of a health information exchange system and hospital admissions

OBJECTIVE

Relevant patient information is frequently difficult to obtain in emergency department (ED) visits. Improved provider access to previously inaccessible patient information may improve the quality of care and reduce hospital admissions. Health information exchange (HIE) systems enable access to longitudinal, community-wide patient information at the point of care. However, the ability of HIE to avert admissions is not well demonstrated. We sought to determine if HIE system usage is correlated with a reduction in admissions via the ED.

METHODS

We identified 15,645 adults from New York State with an ED visit during a 6-month period, all of whom consented to have their information accessible in the HIE system, and were continuously enrolled in two area health plans. Using claims we determined if the ED encounter resulted in an admission. We used the HIE's system log files to determine usage during the encounter. We determined the association between HIE system use and the likelihood of admission to the hospital from the ED and potential cost savings.

RESULTS

The HIE system was accessed during 2.4% of encounters. The odds of an admission were 30% lower when the system was accessed after controlling for confounding (odds ratio = 0.70; 95%C I= 0.52, 0.95). The annual savings in the sample was $357,000.

CONCLUSION

These findings suggest that the use of an HIE system may reduce hospitalizations from the ED with resultant cost savings. This is an important outcome given the substantial financial investment in interventions designed to improve provider access to patient information in the US.

Can we predict a national profile of non-attendance paediatric urology patients: a multi-institutional electronic health record study

BACKGROUND

Non-attendance at paediatric urology outpatient appointments results in the patient's failure to receive medical care and wastes health care resources.

OBJECTIVE

To determine the utility of using routinely collected electronic health record (EHR) data for multi-centre analysis of variables predictive of patient noshows (NS) to identify areas for future intervention.

METHODS

Data were obtained from Children's Hospital Colorado, Rady Children's Hospital San Diego and University of Virginia Hospital paediatric urology practices, which use the Epic® EHR system. Data were extracted for all urology outpatient appointments scheduled from 1 October 2010 to 30 September 2011 using automated electronic data extraction techniques. Data included appointment type; date; provider type and days from scheduling to appointment. All data were de-identified prior to analysis. Predictor variables identified using χ(2) and analysis of variance were modelled using multivariate logistic regression.

RESULTS

A total of 2994 NS patients were identified within a population of 28,715, with a mean NS rate of 10.4%. Multivariate logistic regression determined that an appointment with mid-level provider (odds ratio (OR) 1.70 95% CI (1.56, 1.85)) and an increased number of days between scheduling and appointment (15-28 days OR 1.24 (1.09, 1.41); 29+ days OR 1.70 (1.53, 1.89)) were significantly associated with NS appointments.

CONCLUSION

We demonstrated sufficient interoperability among institutions to obtain data rapidly and efficiently for use in 1) interventions; 2) further study and 3) more complex analysis. Demographic and potentially modifiable clinic characteristics were associated with NS to the outpatient clinic. The analysis also demonstrated that available data are dependent on the clinical data collection systems and practices.

Health information exchange, system size and information silos

There are many technology platforms that bring benefits only when users share data. In healthcare, this is a key policy issue, because of the potential cost savings and quality improvements from 'big data' in the form of sharing electronic patient data across medical providers. Indeed, one criterion used for federal subsidies for healthcare information technology is whether the software has the capability to share data. We find empirically that larger hospital systems are more likely to exchange electronic patient information internally, but are less likely to exchange patient information externally with other hospitals. This pattern is driven by instances where there may be a commercial cost to sharing data with other hospitals. Our results suggest that the common strategy of using 'marquee' large users to kick-start a platform technology has an important drawback of potentially creating information silos. This suggests that federal subsidies for health data technologies based on 'meaningful use' criteria, that are based simply on the capability to share data rather than actual sharing of data, may be misplaced.

Breast cancer and quality of life: medical information extraction from health forums

Internet health forums are a rich textual resource with content generated through free exchanges among patients and, in certain cases, health professionals. We tackle the problem of retrieving clinically relevant information from such forums, with relevant topics being defined from clinical auto-questionnaires. Texts in forums are largely unstructured and noisy, calling for adapted preprocessing and query methods. We minimize the number of false negatives in queries by using a synonym tool to achieve query expansion of initial topic keywords. To avoid false positives, we propose a new measure based on a statistical comparison of frequent co-occurrences in a large reference corpus (Web) to keep only relevant expansions. Our work is motivated by a study of breast cancer patients' health-related quality of life (QoL). We consider topics defined from a breast-cancer specific QoL-questionnaire. We quantify and structure occurrences in posts of a specialized French forum and outline important future developments.

Use and perceived value of health information exchange: one public healthcare system's experience

OBJECTIVES

To describe health information exchange (HIE) use and providers' perceptions of value in a public healthcare system using a commercial electronic health record (EHR).

STUDY DESIGN

Observational study of HIE implementation and cross-sectional provider survey.

METHODS

We identified characteristics (age, gender, race/ethnicity, insurance type, comorbid conditions) and the care setting (primary care; emergency department [ED] or inpatient care; or specialty care) for patients with and without HIE. Associations between patient characteristics and HIE were examined using a multivariate logistic regression. Provider perceptions were assessed via confidential survey.

RESULTS

During its first 14 months, 11,960 HIEs occurred among 9399 patients. Rates of HIE use were 13/1000 visits overall (20/1000 in primary care, 36/1000 in the ED/inpatient setting, and 5/1000 in specialty settings [P <.001]). Patients with HIE were older, more often female, African American, had more chronic conditions, and more often had Medicaid or Medicare insurance (P <.001). HIE was used least among commercially insured (odds ratio, 0.78, 95% confidence interval,0.73-0.83, compared with uninsured). Among the 18% (74/412) of survey respondents, 93% "disagreed/strongly disagreed" that obtaining consent was difficult and 97% reported no patient refusals. Respondents "agreed/strongly agreed" that HIE fostered more efficient care (93%), saved time (85%), decreased laboratory (84%) and imaging (74%) use, and 15% stated that HIE prevented an unnecessary admission.

CONCLUSION

Early HIE use varied by care setting, patient characteristics, and insurance. Providers perceived HIE acceptable to patients, and helpful in avoiding redundant testing and unnecessary hospitalizations. Lower HIE use among commercially insured patients reinforces concerns that financial incentives may inhibit adoption.