Intelligent health in the IS area: A literature review and research agenda

As the global demand for healthcare services continues to grow, improving the efficiency and effectiveness of the healthcare ecosystem has become a pressing concern. Information systems are transforming the healthcare delivery process, shifting the focus of healthcare services from passive disease treatment to proactive health prevention and the healthcare management model from hospital-centric to patient-centric. This study focuses on reviewing research in IS journals on the topic of e-health and is dedicated to constructing a theoretical model of intelligent health to provide a research basis for future discussions in this field. In addition, as the innovation of intelligent healthcare services has led to changes in its elements (e.g., an increase in the number of stakeholders), there is an urgent need to sort out and analyze the existing research.

Assessing the impact of health information exchange on hospital data breach risk

OBJECTIVE

Widespread electronic health information exchange (HIE) across hospitals remains an important policy goal for reducing costs and improving the quality of care. Meanwhile, cybersecurity incidents are a growing threat to hospitals. The relationship between the electronic sharing of health information and cybersecurity incidents is not well understood. The objective of this study was to empirically examine the impact of hospitals' HIE engagement on their data breach risk.

MATERIALS AND METHODS

A balanced panel dataset included 4,936 US community hospitals spanning the period 2010-2017, which was assembled by linking the American Hospital Association annual survey database and the Information Technology (IT) supplement, and the Department of Health and Human Services reports of health data breaches. The relationship between HIE engagement and hospital data breaches was modeled using a difference-in-differences specification controlling for time-varying hospital characteristics.

RESULTS

The percentage of hospitals electronically exchanging information has more than tripled (from 18% to 68%) from 2010 to 2017. Hospital data breaches increased concurrently, largely due to the rise in hacking and unauthorized access. HIE engagement was associated with a 0.672 percentage point increase in the probability of an IT breach three years after the engagement. Hospitals actively engaging in a health information organization and exchanging data with outside providers were associated with a higher risk of IT related breaches in the long run; however, hospitals actively engaging in HIE and exchanging data with inside providers were not associated with any significant risk of IT related breaches.

DISCUSSION

Over time, the increasing amount and complexity of patient information being exchanged can create challenges for cybersecurity if data protection is not up to date. Additionally, data security depends on the weakest link of HIE, and providers with fewer resources for data governance and infrastructure are more vulnerable to data breaches.

CONCLUSION

Moving toward widespread health information exchange has important cybersecurity implications that can significantly impact both patients and healthcare organizations.

Value Implications of Sourcing Electronic Health Records: The Role of Physician Practice Integration

Should hospitals source electronic health records (EHR) systems from a single vendor or multiple vendors to deliver high-value care? We study hospitals’ EHR sourcing strategies based on their degree of integration with physician practices and its impact on the value of healthcare delivered. We propose a novel framework to define healthcare value as the extent to which a hospital effectively expends clinical resources to deliver services that improve patient outcomes. Drawing on modular systems and transaction cost economics theories, we propose a moderated-mediation model that explores the pathways through which EHR sourcing strategies can create value in healthcare. We test our research hypotheses on a large, longitudinal sample of U.S. hospitals and observe that hospitals with EHR configurations closer to single sourcing strategies exhibit greater health information sharing compared with hospitals with multisourced EHR systems. Furthermore, we find that hospital-physician practice integration moderates the impact of single sourcing on health information sharing, which in turn, improves value. Specifically, tighter integration between hospitals and physician practices can create greater value if it is aligned with hospitals’ EHR sourcing strategies. As the healthcare industry moves toward value-based payment reform, our findings provide a useful roadmap to practitioners and policy makers to improve the performance of hospitals and healthcare providers.

History: Rajiv Kohli, Senior Editor; Sunil Wattal, Associate Editor.

Funding: I.R. Bardhan thanks the Foster Parker Centennial Professorship and the Dean’s Research Excellence Grant at the McCombs School of Business at UT Austin for generous financial support. C. Bao thanks the Spears Fellowship at Oklahoma State University for financial support.

Supplemental Material: The online appendix is available at https://doi.org/10.1287/isre.2022.1183 .

Association between state-level malpractice environment and clinician electronic health record (EHR) time

OBJECTIVE

Clinicians spend significant time working in the electronic health record (EHR). The US is an outlier in EHR time, suggesting that EHR-related work may be driven in part by the legal environment and threat of malpractice. To assess this, we evaluate the association between state-level malpractice climate and clinician time spent in the EHR.

MATERIALS AND METHODS

We use EHR metadata from 351 ambulatory care health systems in the United States using Epic from January-August 2019 combined with state-level data on malpractice incidence and payouts. We used descriptive statistics to measure variation in clinician EHR time, including total EHR time, documentation time per day, and after-hours EHR time per day. Multi-variable regression evaluated the association between clinicians in high malpractice states and EHR use.

RESULTS

We found no association between location in a state in the top-quartile of malpractice payouts and time spent in the EHR per day, time spent in the EHR outside of scheduled hours, or time spent documenting per day, except for a subgroup of the clinicians in the highest malpractice specialties, where there was a small increase in EHR time per day (B = 6.08 min, P < 0.001) and time spent documenting notes (B = 2.77 min, P < 0.001).

DISCUSSION

State-level differences in malpractice incidence are unlikely to be a significant driver of EHR work for most clinicians.

CONCLUSION

Policymakers seeking to address EHR documentation burden should examine burden driven by other socio-technical demands on clinician time, such as billing or quality measurement.

Functional IT Complementarity and Hospital Performance in the United States: A Longitudinal Investigation

For healthcare practitioners and policymakers, one of the most challenging problems is understanding how to implement health information technology (HIT) applications in a way that yields the most positive impacts on quality and cost of care. We identify four clinical HIT functions which we label as order entry and management (OEM), decision support (DS), electronic clinical documentation (ECD), and results viewing (RV). We view OEM and DS as primary clinical functions and ECD and RV as support clinical functions. Our results show that no single combination of applications uniformly improves clinical and experiential quality and reduces cost for all hospitals. Thus, managers must assess which HIT interactions improve which performance metric under which conditions. Our results suggest that synergies can be realized when these systems are implemented simultaneously. Additionally, synergies can occur when support HIT is implemented before primary HIT and irrespective of the order in which primary HITs are implemented. Practitioners should also be aware that the synergistic effects of HITs and their impact on cost and quality are different for chronic and acute diseases. Our key message to top managers is to prioritize different combinations of HIT contingent on the performance variables they are targeting for their hospitals but also to realize that technology may not impact all outcomes.

Interoperability in the era of digital innovation: An information systems research agenda

Digital innovation enables new forms of cyber-physical innovation based on digital business ecosystems. However, the realization of the opportunities arising from such innovation substantially hinges on interoperability, that is, the ability of two or more systems to exchange information and understand that exchanged information. While interoperability is a long-standing topic in research and practice alike and a valuable knowledge base exists, digital innovation poses novel challenges that might not be covered by conventional wisdom. Accordingly, we review the literature and, first, propose an organizing framework for existing interoperability knowledge involving the contextual conditions of low interoperability, the mechanisms to increase interoperability, and the associated outcomes. Second, we use the framework to identify previous research foci in the scholarly discourse about interoperability and to discuss the potential limitations of this past work in light of digital innovation. Third, we propose a research agenda that enables information systems (IS) research to address the identified limitations—involving conceptual, scoping, and methodological issues—and provide specific recommendations on how to address the identified issues in future IS research. Finally, we propose five major research topics for further inquiry by combining the challenges identified in current knowledge with the current shift toward hyper-connected ecosystems underlying digital innovation.

Performance of Accountable Care Organizations: Health Information Technology and Quality–Efficiency Trade-Offs

Under a traditional fee-for-service payment model, healthcare providers typically compromise the quality of care in order to reduce costs. Drawing on data from a national sample of accountable care organizations (ACOs), we study whether financial incentives offered under the Affordable Care Act led to fundamental changes in care delivery. Our research suggests that effective use of health information technology (IT) by ACO providers is critical in balancing competing goals of quality and efficiency. Unlike hospitals that did not participate in value-based care initiatives, ACOs were able to generate better quality outcomes while also improving overall efficiency. Furthermore, ACO providers that used health IT effectively demonstrated better patient health outcomes due to greater information integration with other providers. In other words, ACOs created value by not only reducing the cost of care but also improving patient outcomes simultaneously. Our research provides a roadmap for practitioners to succeed in a value-based healthcare environment and for policy makers to design better incentives to promote interorganizational information sharing across providers. Our findings suggest that healthcare policy needs to incorporate appropriate incentives to foster effective IT use for care coordination between healthcare providers.

eHealthChain-a blockchain-based personal health information management system

Medical IoT devices that use miniature sensors to collect patient's bio-signals and connected medical applications are playing a crucial role in providing pervasive and personalized healthcare. This technological improvement has also created opportunities for the better management of personal health information. The Personal Health Information Management System (PHIMS) supports activities such as acquisition, storage, organization, integration, and privacy-sensitive retrieval of consumer's health information. For usability and wide acceptance, the PHIMS should follow the design principles that guarantee privacy-aware health information sharing, individual information control, integration of information obtained from multiple medical IoT devices, health information security, and flexibility. Recently, blockchain technology has emerged as a lucrative option for the management of personal health information. In this paper, we propose eHealthChain-a blockchain-based PHIMS for managing health data originating from medical IoT devices and connected applications. The eHealthChain architecture consists of four layers, which are a blockchain layer for hosting a blockchain database, an IoT device layer for obtaining personal health data, an application layer for facilitating health data sharing, and an adapter layer, which interfaces the blockchain layer with an application layer. Compared to existing systems, eHealthChain provides complete control to the user in terms of personal health data acquisition, sharing, and self-management. We also present a detailed implementation of a Proof of Concept (PoC) prototype of eHealthChain system built using Hyperledger Fabric platform.

Designing Payment Contracts for Healthcare Services to Induce Information Sharing: The Adoption and the Value of Health Information Exchanges (HIEs)

Recent initiatives to improve healthcare quality and reduce costs have centered around payment mechanisms and IT-enabled health information exchanges (HIEs). Such initiatives profoundly influence both providers’ choices in terms of healthcare effort levels and HIE adoption and patients’ choice of providers. Using a game-theoretical model of a healthcare setup, we examine the role of payment models in aligning providers’ and patients’ incentives for realizing socially optimal (i.e., first-best) choices. We show that the traditional fee-for-service (FFS) payment model does not necessarily induce the first-best solution. The pay-for-performance (P4P) model may induce the first-best solution under some conditions if provider switching by patients during a health episode is socially suboptimal, making provider coordination less of an issue. We identify an episode-based payment (EBP) model that can always induce the first-best solution. The proposed EBP model reduces to the P4P model if the P4P model induces the first-best solution. In other cases, the first-best inducing EBP model is multilateral in the sense that the payment to a provider depends not only on the provider’s own efforts and outcomes but also on those of other providers. Furthermore, the payment in this EBP model is sequence dependent in the sense that payment to a provider is contingent upon whether the patient visits a given provider first or second. We show that the proposed EBP model achieves the lowest healthcare cost, not necessarily at the expense of care quality or provider payment, relative to FFS and P4P. Although our proposed contract is complex, it sets an optimality baseline when evaluating simpler contracts and also characterizes aspects of payment that need to be captured for socially desirable actions. We further show that the value of HIEs depends critically on the payment model as well as on the social desirability of patient switching. Under all three payment models, the HIE value is higher when switching by at least some patients is desirable than when switching by any patient is undesirable. Moreover, the HIE value is highest under the FFS model and lowest under the P4P model. Hence, assessing the value of HIEs in isolation from the underlying payment mechanism and patient-switching behavior may result in under- or overestimation of the HIE value. Therefore, as payment models evolve over time, there is a real need to reevaluate the HIE value and the government subsidies that induce providers to adopt HIEs.

A Deep Learning Approach for Recognizing Activity of Daily Living (ADL) for Senior Care: Exploiting Interaction Dependency and Temporal Patterns

Ensuring the health and safety of senior citizens who live alone is a growing societal concern. The Activity of Daily Living (ADL) approach is a common means to monitor disease progression and the ability of these individuals to care for themselves. However, the prevailing sensor-based ADL monitoring systems primarily rely on wearable motion sensors, capture insufficient information for accurate ADL recognition, and do not provide a comprehensive understanding of ADLs at different granularities. Current healthcare IS and mobile analytics research focuses on studying the system, device, and provided services, and is in need of an end-to-end solution to comprehensively recognize ADLs based on mobile sensor data. This study adopts the design science paradigm and employs advanced deep learning algorithms to develop a novel hierarchical, multiphase ADL recognition framework to model ADLs at different granularities. We propose a novel 2D interaction kernel for convolutional neural networks to leverage interactions between human and object motion sensors. We rigorously evaluate each proposed module and the entire framework against state-of-the-art benchmarks (e.g., support vector machines, DeepConvLSTM, hidden Markov models, and topic-modeling-based ADLR) on two real-life motion sensor datasets that consist of ADLs at varying granularities: Opportunity and INTER. Results and a case study demonstrate that our framework can recognize ADLs at different levels more accurately. We discuss how stakeholders can further benefit from our proposed framework. Beyond demonstrating practical utility, we discuss contributions to the IS knowledge base for future design science-based cybersecurity, healthcare, and mobile analytics applications.

Assessment of Electronic Health Record Use Between US and Non-US Health Systems

Importance

Understanding how the electronic health record (EHR) system changes clinician work, productivity, and well-being is critical. Little is known regarding global variation in patterns of use.

Objective

To provide insights into which EHR activities clinicians spend their time doing, the EHR tools they use, the system messages they receive, and the amount of time they spend using the EHR after hours.

Design, Setting, and Participants

This cross-sectional study analyzed the deidentified metadata of ambulatory care health systems in the US, Canada, Northern Europe, Western Europe, the Middle East, and Oceania from January 1, 2019, to August 31, 2019. All of these organizations used the EHR software from Epic Systems and represented most of Epic Systems's ambulatory customer base. The sample included all clinicians with scheduled patient appointments, such as physicians and advanced practice practitioners.

Exposures

Clinician EHR use was tracked by deidentified and aggregated metadata across a variety of clinical activities.

Main Outcomes and Measures

Descriptive statistics for clinician EHR use included time spent on clinical activities, note documentation (as measured by the percentage of characters in the note generated by automated or manual data entry source), messages received, and time spent after hours.

Results

A total of 371 health systems were included in the sample, of which 348 (93.8%) were located in the US and 23 (6.2%) were located in other countries. US clinicians spent more time per day actively using the EHR compared with non-US clinicians (mean time, 90.2 minutes vs 59.1 minutes; P < .001). In addition, US clinicians vs non-US clinicians spent significantly more time performing 4 clinical activities: notes (40.7 minutes vs 30.7 minutes; P < .001), orders (19.5 minutes vs 8.75 minutes; P < .001), in-basket messages (12.5 minutes vs 4.80 minutes; P < .001), and clinical review (17.6 minutes vs 14.8 minutes; P = .01). Clinicians in the US composed more automated note text than their non-US counterparts (77.5% vs 60.8% of note text; P < .001) and received statistically significantly more messages per day (33.8 vs 12.8; P < .001). Furthermore, US clinicians used the EHR for a longer time after hours, logging in 26.5 minutes per day vs 19.5 minutes per day for non-US clinicians (P = .01). The median US clinician spent as much time actively using the EHR per day (90.1 minutes) as a non-US clinician in the 99th percentile of active EHR use time per day (90.7 minutes) in the sample. These results persisted after controlling for organizational characteristics, including structure, type, size, and daily patient volume.

Conclusions and Relevance

This study found that US clinicians compared with their non-US counterparts spent substantially more time actively using the EHR for a wide range of clinical activities or tasks. This finding suggests that US clinicians have a greater EHR burden that may be associated with nontechnical factors, which policy makers and health system leaders should consider when addressing clinician wellness.

Does Telemedicine Reduce Emergency Room Congestion? Evidence from New York State

Overcrowding in emergency rooms (ERs) is a common yet nagging problem. It not only is costly for hospitals but also compromises care quality and patient experience. Our paper provides solid evidence that telemedicine can significantly improve ER care delivery, especially in the presence of demand and supply fluctuations. We believe such findings are critical for ERs, due to the special setting of unscheduled arrivals leading to high unpredictability of patient traffic. Additional evidence suggests that the efficiency gained from telemedicine does not come at the expense of lower care quality or higher medical expenditure, which points to telemedicine as a feasible solution to the ER overcrowding problem. For healthcare practitioners, our paper highlights the general applicability of telemedicine through the “hub and spoke” architecture. Besides increasing patients’ access to more immediate care from specialists who were not available otherwise, telemedicine enables flexible resource allocation for any hospitals, regardless of where hospitals are located. Our research also provides ground for policymakers to incentivize hospitals to adopt telemedicine in ER, which we believe is critical given the relatively low adoption rate, the lack of direct evidence on its effectiveness, and the current inflexibility of reimbursement policies regarding the application of ER telemedicine.

Leadership in Integrated Care Networks: A Literature Review and Opportunities for Future Research

Introduction

In many countries, elderly patients with chronic conditions require a web of services delivered by several providers collaborating in inter-organisational networks. In view of their global importance, it is surprising how little we know how these networks are led. Like traditional organisations, networks require leadership to function effectively. This paper reviews central characteristics of leadership in integrated care networks and proposes opportunities for future research.

Theory and methods

Analysing 73 studies published in leading academic journals, this paper consolidates research on leadership media, practices, activities and outcomes, covering the network, policy and organisation levels of analysis.

Results

Findings indicate that the field has focused on leadership media and outcomes at the network level. They also suggest that leadership in integrated care networks faces multiple tensions. Future research could usefully provide a fuller picture by examining leadership practices, activities and outcomes at the policy and organisation level, integrating advances in the wider leadership literature.

Discussion and conclusion

These findings contribute to the debate on leadership in integrated care networks. They also inform practice, drawing attention to persistent tensions as a core leadership challenge and offering latest scholarly evidence practitioners can use to reflect on and advance their own leadership practice.

Sharing information electronically with other hospitals is associated with increased sharing of patients

OBJECTIVE

One potential benefit of greater electronic health information exchange is a reduction in the effort required for patients to switch between providers. We therefore assessed whether hospital participation in health information organizations (HIOs) led to increased patient sharing.

DATA SOURCES

Secondary data from 2010 to 2016.

STUDY DESIGN

Using hospital-pair and year fixed effects regression models, we assessed change in patient sharing volume following HIO participation by hospitals and compared the effect by the level of market competition and by hospital size.

DATA EXTRACTION METHODS

We used national data on hospital participation in HIOs from the American Hospital Association Information Technology Supplement and data on the volume of Medicare patients shared between pairs of hospitals from 2010 to 2016.

PRINCIPAL FINDINGS

The volume of patients shared between hospitals increased by 2.6 percent when both hospitals participated in a health information organization (P = .008, 95% CI: 0.7%-4.5%). This increase was greater in competitive markets (3.1 percent increase, P = .03 95% CI: 0.3%-5.9%) and between large hospitals (4.3 percent increase, P = .007 95% CI: 1.2%-7.3%). Participation by only one hospital in a pair had no effect on patient sharing.

CONCLUSIONS

Our results suggest that an important policy goal motivating the investment in health information exchange has been at least partially achieved. However, our results also support hospital concerns about the competitive implications of engaging in health information exchange. HIO participation appears to facilitate patient movement between hospitals, likely by lowering switching costs and resulting in greater competition.

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

Policy Points: Historically, in addition to economic and technical hurdles, state and federal health information privacy laws have been cited as a significant obstacle to expanding electronic health information exchange (HIE) in the United States. Our review finds that over the past decade, several helpful developments have ameliorated the legal barriers to HIE, although variation in states' patient consent requirements remains a challenge. Today, health care providers' complaints about legal obstacles to HIE may be better understood as reflecting concerns about the economic and competitive risks of information sharing.

CONTEXT

Although the clinical benefits of exchanging patients' health information electronically across providers have long been recognized, participation in health information exchange (HIE) has lagged behind adoption of electronic health records. Barriers erected by federal and state health information privacy law have been cited as a leading reason for the slow progress. A comprehensive assessment of these issues has not been undertaken for nearly a decade, despite a number of salient legal developments.

METHODS

Analysis of federal and state health information privacy statutes and regulations and secondary materials.

FINDINGS

Although some legal barriers to HIE persist, many have been ameliorated-in some cases, simply through improved understanding of what the law actually requires. It is now clear that the Health Insurance Portability and Accountability Act presents no obstacles to electronically sharing protected health information for treatment purposes and does not hold providers who properly disclose information liable for privacy breaches by recipients. The failure of federal efforts to establish a unique patient identifier number does slow HIE by inhibiting optimal matching of patient records, but other action to facilitate matching will be taken under the 21st Century Cures Act. The Cures Act also creates the legal architecture to begin to combat "information blocking." Varying patient consent requirements under federal and state law are the most important remaining legal barrier to HIE progress. However, federal rules relating to disclosure of substance-abuse treatment information were recently liberalized, and development of a technical standard, Data Segmentation for Privacy, or DS4P, now permits sensitive data requiring special handling to be segmented within a patient's record. Even with these developments, state-law requirements for patient consent remain daunting to navigate.

CONCLUSIONS

Although patient consent requirements make HIE challenging, providers' expressed worries about legal barriers to participating in HIE likely primarily reflect concerns that are economically motivated. Lowering the cost of HIE or increasing financial incentives may boost provider participation more than further reducing legal barriers.