Use patterns of health information exchange systems and admission decisions: Reductionistic and configurational approaches

The role of information systems in emergency department decision-making-a literature review

OBJECTIVES

Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED.

MATERIALS AND METHODS

We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes.

RESULTS

Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes.

DISCUSSION

Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation.

CONCLUSION

We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.

Trends in user-initiated health information exchange in the inpatient, outpatient, and emergency settings

Prior research on health information exchange (HIE) typically measured provider usage through surveys or they summarized the availability of HIE services in a healthcare organization. Few studies utilized user log files. Using HIE access log files, we measured HIE use in real-world clinical settings over a 7-year period (2011-2017). Use of HIE increased in inpatient, outpatient, and emergency department (ED) settings. Further, while extant literature has generally viewed the ED as the most relevant setting for HIE, the greatest change in HIE use was observed in the inpatient setting, followed by the ED setting and then the outpatient setting. Our findings suggest that in addition to federal incentives, the implementation of features that address barriers to access (eg, Single Sign On), as well as value-added services (eg, interoperability with external data sources), may be related to the growth in user-initiated HIE.

Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine

BACKGROUND

Clinical decision-making (CDM) is an important competency for young doctors especially under complex and uncertain conditions in geriatric emergency medicine (GEM). However, research in this field is characterized by vague conceptualizations of CDM. To evolve and evaluate evidence-based knowledge of CDM, it is important to identify different definitions and their operationalizations in studies on GEM.

OBJECTIVE

A scoping review of empirical articles was conducted to provide an overview of the documented evidence of findings and conceptualizations of CDM in GEM.

METHODS

A detailed search for empirical studies focusing on CDM in a GEM setting was conducted in PubMed, ProQuest, Scopus, EMBASE and Web of Science. In total, 52 publications were included in the analysis, utilizing a data extraction sheet, following the PRISMA guidelines. Reported outcomes were summarized.

RESULTS

Four themes of operationalization of CDM emerged: CDM as dispositional decisions, CDM as cognition, CDM as a model, and CDM as clinical judgement. Study results and conclusions naturally differed according to how CDM was conceptualized. Thus, frailty-heuristics lead to biases in treatment of geriatric patients and the complexity of this patient group was seen as a challenge for young physicians engaging in CDM.

CONCLUSIONS

This scoping review summarizes how different studies in GEM use the term CDM. It provides an analysis of findings in GEM and call for more stringent definitions of CDM in future research, so that it might lead to better clinical practice.

The benefits of health information exchange: an updated systematic review

Objective

Widespread health information exchange (HIE) is a national objective motivated by the promise of improved care and a reduction in costs. Previous reviews have found little rigorous evidence that HIE positively affects these anticipated benefits. However, early studies of HIE were methodologically limited. The purpose of the current study is to review the recent literature on the impact of HIE.

Methods

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct our systematic review. PubMed and Scopus databases were used to identify empirical articles that evaluated HIE in the context of a health care outcome.

Results

Our search strategy identified 24 articles that included 63 individual analyses. The majority of the studies were from the United States representing 9 states; and about 40% of the included analyses occurred in a handful of HIEs from the state of New York. Seven of the 24 studies used designs suitable for causal inference and all reported some beneficial effect from HIE; none reported adverse effects.

Conclusions

The current systematic review found that studies with more rigorous designs all reported benefits from HIE. Such benefits include fewer duplicated procedures, reduced imaging, lower costs, and improved patient safety. We also found that studies evaluating community HIEs were more likely to find benefits than studies that evaluated enterprise HIEs or vendor-mediated exchanges. Overall, these finding bode well for the HIEs ability to deliver on anticipated improvements in care delivery and reduction in costs.

Improving performance in the ED through laboratory information exchange systems

Background

The accessibility of laboratory test results is crucial to the performance of emergency departments and to the safety of patients. This study aims to develop a better understanding of which laboratory information exchange (LIE) systems emergency care physicians (ECPs) are using to consult their patients’ laboratory test results and which benefits they derive from such use.

Methods

A survey of 163 (36%) ECPs in Quebec was conducted in collaboration with the Quebec’s Department of Health and Social Services. Descriptive statistics, chi-square tests, cluster analyses, and ANOVAs were conducted.

Results

The great majority of respondents indicated that they use several LIE systems including interoperable electronic health record (iEHR) systems, laboratory results viewers (LRVs), and emergency department information systems (EDIS) to consult their patients’ laboratory results. Three distinct profiles of LIE users were observed. The extent of LIE usage was found to be primarily determined by the functional design differences between LIE systems available in the EDs. Our findings also indicate that the more widespread LIE usage, the higher the perceived benefits. More specifically, physicians who make extensive use of iEHR systems and LRVs obtain the widest range of benefits in terms of efficiency, quality, and safety of emergency care.

Conclusions

Extensive use of LIE systems allows ECPs to better determine and monitor the health status of their patients, verify their diagnostic assumptions, and apply evidence-based practices in laboratory medicine. But for such benefits to be possible, ECPs must be provided with LIE systems that produce accurate, up-to-date, complete, and easy-to-interpret information.

Characteristics and outcomes of critically-ill medical patients admitted to a tertiary medical center with restricted ICU bed capacity

BACKGROUND

In the emergency department (ED) critically-ill medical patients are treated in the resuscitation room (RR). No studies described the outcomes of critically-ill RR patients admitted to a hospital with low capacity of intensive care unit (ICU) beds.

METHODS

We included all medical patients above 18 who were admitted to a RR of a tertiary hospital during 2011-2012. We conducted multivariate logistic and Cox regressions and propensity score (PS) matched analysis to analyze parameters associated with the study outcomes.

RESULTS

In-hospital mortality rate was 32.4% in ICU admitted patients compared to 52.0% of the non-ICU critically-ill patients (p<0.001). Age above 80, female and recent ED encounters were associated with non-ICU admissions (p<0.05 for all). ICU admission had a statistically significant effect on in-hospital mortality in PS matched analysis (OR 0.36, 95% CI 0.21-0.61). A marginal effect was evident in one-year survival in PS matched landmark analysis (HR 0.50 95% CI 0.23-1.06).

CONCLUSION

ED critically-ill medical patients who were treated in the RR had high mortality rates in an institute with restricted ICU beds availability. However, those who were admitted to an ICU showed prolonged short and perhaps long term survival compared to those who were not.

Balancing volume and duration of information consumption by physicians: The case of health information exchange in critical care

BACKGROUND

The realization of the potential benefits of health information exchange systems (HIEs) for emergency departments (EDs) depends on the way these systems are actually used. The attributes of volume of information and duration of information processing are important for the study of HIE use patterns in the ED, as cognitive load and time constraints may result in a trade-off between these attributes. Experts and non-experts often use different problem-solving strategies, which may be consequential for their system use patterns. Little previous research focuses on the trade-off between volume and duration of system use or on the factors that affect it, including user expertise.

OBJECTIVES

This study aims at exploring the trade-off of volume and duration of use, examining whether this relationship differs between experts and non-experts, and identifying factors that are associated with use patterns characterized by volume and duration.

METHODS

The research objectives are pursued in the context of critically-ill patients, treated at a busy ED in the period 2010-2012. The primary source of internal and external data is an HIE linked to 14 hospitals, over 1300 clinics, and other clinical facilities. We define four use profiles based on the attributes of duration and volume: quick and basic, quick and deep, slow and basic, and slow and deep. The volume and duration of use are computed using HIE log files as the number of screens and the time per screen, respectively. Each session is then classified into a specific profile based on distances from predefined profile centroids. Experts are physicians that are board-certified in emergency medicine. We test the distribution of use profiles and their associations with multiple variables that describe the patient, physician, situation, information available in the HIE system, and use dynamics within the encounter.

RESULTS

The quick and basic profile is the most prevalent. While available admission summaries are associated with quick and basic use, lab and imaging results are associated with slower or deeper use. Physicians who are the first to use the system or are sole users during an encounter are less inclined to quick and deep use. These effects are intensified for experts.

DISCUSSION

A trade-off between volume and duration is identified. While system use is overall similar for experts and non-experts, the circumstances in which a certain profile is more likely to be observed vary across these two groups. Information availability and multiple-physician dynamics within the encounter emerge as important for the prediction of use profiles. The findings of this study provide implications for the design, implementation, and research of HIE use.

A literature review for large-scale health information system project planning, implementation and evaluation

Information technology is perceived as a potential panacea for healthcare organisations to manage pressure to improve services in the face of increased demand. However, the implementation and evaluation of health information systems (HIS) is plagued with problems and implementation shortcomings and failures are rife. HIS implementation is complex and relies on organisational, structural, technological, and human factors to be successful. It also requires reflective, nuanced, multidimensional evaluation to provide ongoing feedback to ensure success. This article provides a comprehensive review of the literature about evaluating and implementing HIS, detailing the challenges and recommendations for both evaluators and healthcare organisations. The factors that inhibit or promote successful HIS implementation are identified and effective evaluation strategies are described with the goal of informing teams evaluating complex HIS.