A Survey Of Health Information Exchange Organizations In Advance Of A Nationwide Connectivity Framework

A scoping review of rule-based clinical decision support malfunctions

OBJECTIVE

Conduct a scoping review of research studies that describe rule-based clinical decision support (CDS) malfunctions.

MATERIALS AND METHODS

In April 2022, we searched three bibliographic databases (MEDLINE, CINAHL, and Embase) for literature referencing CDS malfunctions. We coded the identified malfunctions according to an existing CDS malfunction taxonomy and added new categories for factors not already captured. We also extracted and summarized information related to the CDS system, such as architecture, data source, and data format.

RESULTS

Twenty-eight articles met inclusion criteria, capturing 130 malfunctions. Architectures used included stand-alone systems (eg, web-based calculator), integrated systems (eg, best practices alerts), and service-oriented architectures (eg, distributed systems like SMART or CDS Hooks). No standards-based CDS malfunctions were identified. The "Cause" category of the original taxonomy includes three new types (organizational policy, hardware error, and data source) and two existing causes were expanded to include additional layers. Only 29 malfunctions (22%) described the potential impact of the malfunction on patient care.

DISCUSSION

While a substantial amount of research on CDS exists, our review indicates there is a limited focus on CDS malfunctions, with even less attention on malfunctions associated with modern delivery architectures such as SMART and CDS Hooks.

CONCLUSION

CDS malfunctions can and do occur across several different care delivery architectures. To account for advances in health information technology, existing taxonomies of CDS malfunctions must be continually updated. This will be especially important for service-oriented architectures, which connect several disparate systems, and are increasing in use.

The state of health information organizations and plans to participate in the federal exchange framework

In late 2023, the Office of the National Coordinator for Health Information Technology launched the Trusted Exchange Framework and Common Agreement (TEFCA) to enable nationwide health information exchange. Regional, local, and state health information organizations (HIOs) will be key components of nationwide exchange, and TEFCA could broaden HIOs' access to information. However, HIOs can choose whether to participate. We conducted a national survey of HIOs in 2023 to assess their plans to participate in TEFCA and broader measures of maturity. We identified 76 operational HIOs, down from 89 in 2019. These HIOs operated in 47 states and contained over 600 million patient records, indicating some duplication. Sixty-three percent of HIOs planned to participate in TEFCA, up 7 percentage points from 2019, and 32% of HIOs indicated that they did not know if they would participate. Health information organizations already engaged in exchange with other networks were more likely to plan to participate. The most common barrier (44%) was having not developed a strategic plan for TEFCA participation. While TEFCA appears to have successfully engaged the majority of HIOs, achieving nationwide exchange will require policy efforts to either attract the remaining HIOs or ensure that nonparticipating HIOs' providers have another option for TEFCA participation.

Regulations and Funding to Create Enterprise Architecture for a Nationwide Health Data Ecosystem

The COVID-19 pandemic highlighted the United States' lack of a nationwide infrastructure for collecting, sharing, and using health data, especially for secondary uses (e.g., population health management and public health). The federal government is taking several important steps to upgrade the nation's health data ecosystem-notably, the Centers for Disease Control and Prevention's Data Modernization Initiative and the Office of the National Coordinator for Health Information Technology's Trusted Exchange Framework and Common Agreement. However, substantial barriers remain. Inconsistent regulations, infrastructure, and governance across federal and state levels and between states significantly impede the exchange and analysis of health data. Siloed systems and insufficient funding block effective integration of clinical, public health, and social determinants data within and between states. In this analytic essay, we propose strategies to develop a nationwide health data ecosystem. We focus on providing federal guidance and incentives to develop state-designated entities responsible for the collection, integration, and analysis of clinical, public health, social determinants of health, claims, administrative, and other relevant data. These recommendations include a regulatory clearinghouse, federal guidance, model legislation and templated regulation, funding to incentive enterprise architecture, regulatory sandboxes, and a 3-pronged research agenda. (Am J Public Health. 2024;114(2):209-217. https://doi.org/10.2105/AJPH.2023.307477).

Collaborating for COVID-19: Hospital Health Information Exchange and Public Health Partnership

Background: The coronavirus disease (COVID-19) pandemic highlighted the need for effective communication and information sharing among health care organizations and public health systems (PHSs). Health information exchange (HIE) plays a vital role in improving quality control and efficiency in hospital settings, particularly in underserved areas. Objective: This study aimed to investigate the variation of HIE availability among hospitals based on their collaboration with the PHS and affiliation with Accountable Care Organizations (ACOs) in 2020, as well as variation by community social determinants of health. Methods: The primary data set used for this study comprised the linked data set of the 2020 American Hospital Association (AHA) Annual Survey and the AHA Information Technology Supplement. The measures used included the hospital's participation in HIE networks, availability of data exchange, and HIE measures during the COVID-19 pandemic, including whether hospitals effectively received electronically transmitted information from outside providers for COVID-19 treatment. Results: The sample size of hospitals ranged from 1,316 to 1,436, depending on different outcomes related to HIE questions. Of the hospitals surveyed, ∼67% reported public health collaboration and ACO affiliation, while 7% reported neither. Hospitals without public health collaboration or ACO affiliation were more likely to be located in underserved areas. Compared with hospitals without public health collaboration or ACO affiliation, hospitals with both were 9% more likely to report the availability of electronically transmitted clinical information from outside providers and to participate in local and national HIE networks. Furthermore, these hospitals were 30% (marginal effect [ME] = 0.30, p < 0.001) more likely to report effective receipt of information from outside providers for COVID-19 treatment and 12% (ME = 0.12, p = 0.02) more likely to always/often receive clinical information for COVID-19 treatment electronically. Conclusions: Hospital collaboration with the PHS and ACO affiliation are associated with greater availability of electronic health data, particularly during the COVID-19 pandemic.

Electronic connectivity between hospital pairs: impact on emergency department-related utilization

OBJECTIVE

To use more precise measures of which hospitals are electronically connected to determine whether health information exchange (HIE) is associated with lower emergency department (ED)-related utilization.

MATERIALS AND METHODS

We combined 2018 Medicare fee-for-service claims to identify beneficiaries with 2 ED encounters within 30 days, and Definitive Healthcare and AHA IT Supplement data to identify hospital participation in HIE networks (HIOs and EHR vendor networks). We determined whether the 2 encounters for the same beneficiary occurred at: the same organization, different organizations connected by HIE, or different organizations not connected by HIE. Outcomes were: (1) whether any repeat imaging occurred during the second ED visit; (2) for beneficiaries with a treat-and-release ED visit followed by a second ED visit, whether they were admitted to the hospital after the second visit; (3) for beneficiaries discharged from the hospital followed by an ED visit, whether they were admitted to the hospital.

RESULTS

In adjusted mixed effects models, for all outcomes, beneficiaries returning to the same organization had significantly lower utilization compared to those going to different organizations. Comparing only those going to different organizations, HIE was not associated with lower levels of repeat imaging. HIE was associated with lower likelihood of hospital admission following a treat-and-release ED visit (1.83 percentage points [-3.44 to -0.21]) but higher likelihood of admission following hospital discharge (2.78 percentage points [0.48-5.08]).

DISCUSSION

Lower utilization for beneficiaries returning to the same organization could reflect better access to information or other factors such as aligned incentives.

CONCLUSION

HIE is not consistently associated with utilization outcomes reflecting more coordinated care in the ED setting.

Population-Based Applications and Analytics Using Patient-Reported Outcome Measures

The intersection of big data and artificial intelligence (AI) has resulted in advances in numerous areas, including machine learning, computer vision, and natural language processing. Although there are many potentially transformative applications of AI in health care, including precision medicine, this industry has been slow to adopt these technologies. At the same time, the operations of health care have historically been system-directed and physician-directed rather than patient-centered. The application of AI to patient-reported outcome measures (PROMs), which provide insight into patient-centered health outcomes, could steer research and healthcare delivery toward decisions that optimize outcomes important to patients. Historically, PROMs have only been collected within research registries. However, the increasing availability of PROMs within electronic health records has led to their inclusion in big data ecosystems, where they can inform or be informed by other data elements. The use of big data to analyze PROMs can help establish norms, evaluate data distribution, and determine proportions of patients achieving change or threshold standards. This information can be used for benchmarking, risk adjustment, predictive modeling, and ultimately improving the health of individuals and populations.

Improving comparability across cognitive training trials for brain aging: A focus on interoperability

Cognitive training may promote healthy brain aging and prevent dementia, but results from individual studies are inconsistent. There are disagreements on how to evaluate cognitive training interventions between clinical and basic scientists. Individual labs typically create their own assessment and training materials, leading to difficulties reproducing methods. Here, we advocate for improved interoperability: the exchange and cooperative development of a consensus for cognitive training design, analysis, and result interpretation. We outline five guiding principles for improving interoperability: (i) design interoperability, developing standard design and analysis models; (ii) material interoperability, promoting sharing of materials; (iii) interoperability incentives; (iv) privacy and security norms, ensuring adherence to accepted ethical standards; and (v) interpretability prioritization, encouraging a shared focus on neurobiological mechanisms to improve clinical relevance. Improving interoperability will allow us to develop scientifically optimized, clinically useful cognitive training programs to slow/prevent brain aging.

HIGHLIGHTS

Interoperability facilitates progress via resource sharing and comparability.Better interoperability is needed in cognitive training for brain aging research.We adapt an interoperability framework to cognitive training research.We suggest five guiding principles for improved interoperability.We propose an open-source pipeline to facilitate interoperability.

Experiences with information blocking in the United States: a national survey of hospitals

OBJECTIVE

The 21st Century Cures Act Final Rule's information blocking provisions, which prohibited practices likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information (EHI), began to apply to a limited set of data elements in April 2021 and expanded to all EHI in October 2022. We sought to describe hospital leaders' perceptions of the prevalence of practices that may constitute information blocking, by actor and hospital characteristics, following the rule's applicability date.

MATERIALS AND METHODS

Cross-sectional analysis of a national survey of hospitals fielded in 2021. The analytic sample included 2092 nonfederal acute care hospitals in the United States. We present descriptive statistics on the perception of the prevalence of information blocking and results of multivariate regression models examining the association between hospital, health information technology (IT) developer and market characteristics and the perception of information blocking.

RESULTS

Overall, 42% of hospitals reported observing some behavior they perceived to be information blocking. Thirty-six percent of responding hospitals perceived that healthcare providers either sometimes or often engaged in practices that may constitute information blocking, while 17% and 19% perceived that health IT developers (such as EHR developers) and State, regional and/or local health information exchanges did the same, respectively. Prevalence varied by health IT developer market share, hospital for-profit status, and health system market share.

CONCLUSIONS AND RELEVANCE

These results support the value of efforts to further reduce friction in the exchange of EHI and support the need for continued observation to provide a sense of the prevalence of information blocking practices and for education and awareness of information blocking regulations.

Perspectives on Challenges and Opportunities for Interoperability: Findings From Key Informant Interviews With Stakeholders in Ohio

BACKGROUND

Interoperability-the exchange and integration of data across the health care system-remains a challenge despite ongoing policy efforts aimed at promoting interoperability.

OBJECTIVE

This study aimed to identify current challenges and opportunities to advancing interoperability across stakeholders.

METHODS

Primary data were collected through qualitative, semistructured interviews with stakeholders (n=24) in Ohio from July to October 2021. Interviewees were sampled using a stratified purposive sample of key informants from 4 representative groups as follows: acute care and children's hospital leaders, primary care providers, behavioral health providers, and regional health information exchange networks. Interviews focused on key informant perspectives on electronic health record implementation, the alignment of public policy with organizational strategy, interoperability implementation challenges, and opportunities for health information technology. The interviews were transcribed verbatim followed by rigorous qualitative analysis using directed content analysis.

RESULTS

The findings illuminate themes related to challenges and opportunities for interoperability that align with technological (ie, implementation challenges, mismatches in interoperability capabilities across stakeholders, and opportunities to leverage new technology and integrate social determinants of health data), organizational (ie, facilitators of interoperability and strategic alignment of participation in value-based payment programs with interoperability), and environmental (ie, policy) domains.

CONCLUSIONS

Interoperability, although technically feasible for most providers, remains challenging for technological, organizational, and environmental reasons. Our findings suggest that the incorporation of end user considerations into health information technology development, implementation, policy, and standard deployment may support interoperability advancement.

An overview and policy implications of national nurse identifier systems: A call for unity and integration

There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses' collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers- the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.

Effect of Health Information Exchange Plus a Care Transitions Intervention on Post-Hospital Outcomes Among VA Primary Care Patients: a Randomized Clinical Trial

BACKGROUND

Health information exchange (HIE) notifications when patients experience cross-system acute care encounters offer an opportunity to provide timely transitions interventions to improve care across systems.

OBJECTIVE

To compare HIE notification followed by a post-hospital care transitions intervention (CTI) with HIE notification alone.

DESIGN

Cluster-randomized controlled trial with group assignment by primary care team.

PATIENTS

Veterans 65 or older who received primary care at 2 VA facilities who consented to HIE and had a non-VA hospital admission or emergency department visit between 2016 and 2019.

INTERVENTIONS

For all subjects, real-time HIE notification of the non-VA acute care encounter was sent to the VA primary care provider. Subjects assigned to HIE plus CTI received home visits and telephone calls from a VA social worker for 30 days after arrival home, focused on patient activation, medication and condition knowledge, patient-centered record-keeping, and follow-up.

MEASURES

Primary outcome: 90-day hospital admission or readmission.

SECONDARY OUTCOMES

emergency department visits, timely VA primary care team telephone and in-person follow-up, patients' understanding of their condition(s) and medication(s) using the Care Transitions Measure, and high-risk medication discrepancies.

KEY RESULTS

A total of 347 non-VA acute care encounters were included and assigned: 159 to HIE plus CTI and 188 to HIE alone. Veterans were 76.9 years old on average, 98.5% male, 67.8% White, 17.1% Black, and 15.1% other (including Hispanic). There was no difference in 90-day hospital admission or readmission between the HIE-plus-CTI and HIE-alone groups (25.8% vs. 20.2%, respectively; risk diff 5.6%; 95% CI - 3.3 to 14.5%, p = .25). There was also no difference in secondary outcomes.

CONCLUSIONS

A care transitions intervention did not improve outcomes for veterans after a non-VA acute care encounter, as compared with HIE notification alone. Additional research is warranted to identify transitions services across systems that are implementable and could improve outcomes.

Electronic Connectivity Among US Hospitals Treating Shared Patients

BACKGROUND

Increasing electronic health information exchange (HIE) between provider organizations is a top policy priority that has been pursued by establishing varied types of networks.

OBJECTIVES

To measure electronic connectivity enabled by these networks, including community, electronic health record vendor, and national HIE networks, across US hospitals weighted by the volume of shared patients and identify characteristics that predict connectivity.

RESEARCH DESIGN

Cross-sectional analysis of 1721 hospitals comprising 16,344 hospital pairs and 6,492,232 shared patients from 2018 CareSet Labs HOP data and national hospital surveys.

SUBJECTS

Pairs of US acute care hospitals that delivered care to 11 or more of the same fee-for-service Medicare beneficiaries in 2018.

MEASURES

Whether a patient was treated by a pair of hospitals connected through participation in the same HIE network ("connected hospitals") or not connected because the hospitals participated in different networks, only 1 participated, or both did not participate.

RESULTS

Sixty-four percent of shared patients were treated by connected hospitals. Of the remaining shared patients, 14% were treated by hospital pairs that participated in different HIE networks, 21% by pairs in which only 1 hospital participated in an HIE network, and 2% by pairs in which neither participated. Patients treated by pairs with at least 1 for-profit hospital, and by pairs located in competitive markets, were less likely to be treated by connected hospitals.

CONCLUSIONS

While the majority of shared patients received care from connected hospitals, remaining gaps could be filled by connecting HIE networks to each other and by incentivizing certain types of hospitals that may not participate because of competitive concerns.

The Patient Role in a Federal National-Scale Health Information Exchange

The federal Trusted Exchange Framework and Common Agreement (TEFCA) aims to reduce fragmentation of patient records by expanding query-based health information exchange with nationwide connectivity for diverse purposes. TEFCA provides a common agreement and security framework allowing clinicians, and possibly insurance company staff, public health officials, and other authorized users, to query for health information about hundreds of millions of patients. TEFCA presents an opportunity to weave information exchange into the fabric of our national health information economy. We define 3 principles to promote patient autonomy and control within TEFCA: (1) patients can query for data about themselves, (2) patients can know when their data are queried and shared, and (3) patients can configure what is shared about them. We believe TEFCA should address these principles by the time it launches. While health information exchange already occurs on a large scale today, the launch of TEFCA introduces a major, new, and cohesive component of 21st-century US health care information infrastructure. We strongly advocate for a substantive role for the patient in TEFCA, one that will be a model for other systems and policies.

Interoperability in a Post-Roe Era: Sustaining Progress While Protecting Reproductive Health Information

This Viewpoint proposes a solution to better safeguard reproductive health information in patient records that are now more complete owing to the interoperability of health information exchange networks.

A mixed-methods analysis of telehealth implementation in nursing homes amidst the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has forced nursing homes to adapt new models of care in response to the evolving crisis including rapid implementation of telehealth services. The purpose of our study was to investigate implementation of telehealth in nursing homes amidst the COVID-19 pandemic using a human factors model.

METHODS

Using a mixed methods design, we conducted a secondary analysis of data from a national survey of nursing home administrative leaders (n = 204). Using six survey questions, we calculated a total telehealth score (range 0-42). Descriptive statistics and paired sample t-test were used to explore the change in telehealth in two consecutive years (2019-2021). Next, we conducted semi-structured interviews with (n = 21) administrators and clinicians to assess differences in implementation according to extent of telehealth use.

RESULTS

The mean telehealth score in year 1 was 12.11 (SD = 9.85) and year 2 was 19.25 (SD = 11.25). There was a significant difference in telehealth scores from year 1 to year 2 (t = 6.83, p < 0.000). While 64% of nursing homes reported higher telehealth scores in year 2 compared to year 1, over 32% reported a decline. Qualitative analysis revealed facilitators of telehealth including training, use of integrated equipment, having staff present for the visit, and using telehealth for different types of visits. Barriers included using smart phones to conduct the visit, billing, interoperability and staffing.

CONCLUSION

Training, adaptation of work processes to support communication, and restructuring teams and tasks are the result of interactions between system components that could improve usability and sustainability of telehealth in nursing homes.

Hospital's adoption of multiple methods of obtaining outside information and use of that information

OBJECTIVE

Hospitals have multiple methods available to engage in health information exchange (HIE); however, it is not well understood whether these methods are complements or substitutes. We sought to characterize patterns of adoption of HIE methods and examine the association between these methods and increased availability and use of patient information.

MATERIALS AND METHODS

Cross-sectional analysis of 3208 nonfederal acute care hospitals in the 2019 American Hospital Association Information Technology Supplement.

RESULTS

The median hospital obtained outside information through 4 methods. Hospitals that obtained data through a regional HIE organization were 2.2 times more likely to also obtain data via Direct using a health information service provider (HISP) than hospitals that did not (P < .001). Hospitals in a single electronic health record (EHR) vendor network were no more or less likely to participate in a HISP or HIE. Six of 7 methods were associated with greater information availability. Only 4 of 7 methods (portals, interfaces, single vendor networks and multi-vendor networks but not access to outside EHR, regional exchange or Direct using a HISP) were associated with more frequent use of information, and single vendor networks were most strongly associated with more frequent use (odds ratio = 4.7, P < .001).

DISCUSSION

Adoption of some methods was correlated, indicating complementary use. Few methods were negatively correlated, indicating limited competition. Although information availability was common, low correlation with use indicated that challenges related to integration may be slowing use of information.

CONCLUSION

Complementarities between methods, and the role of integration in supporting information use, indicate the potential value of efforts aimed at ensuring exchange methods work well together, such as the Trusted Exchange Framework and Common Agreement.

Patient-Centered Data Home: A Path Towards National Interoperability

Objective

National interoperability is an agenda that has gained momentum in health care. Although several attempts to reach national interoperability, an alerting system through interconnected network of Health Information Exchange (HIE) organizations, Patient-Centered Data Home (PCDH), has seen preliminary success. The aim was to characterize the PCDH initiative through the Indiana Health Information Exchange's participation in the Heartland Region Pilot, which includes HIEs in Indiana, Ohio, Michigan, Kentucky, and Tennessee.

Materials and Methods

Admission, Discharge, and Transfer (ADT) transactions were collected between December 2016 and December 2017 among the seven HIEs in the Heartland Region. ADTs were parsed and summarized. Overlap analyses and patient matching software were used to characterize the PCDH patients. R software and Microsoft Excel were used to populate descriptive statistics and visualization.

Results

Approximately 1.5 million ADT transactions were captured. Majority of patients were female, ages 56–75 years, and were outpatient visits. Top noted reasons for visit were labs, screening, and abdominal pain. Based on the overlap analysis, Eastern Tennessee HIE was the only HIE with no duplicate service areas. An estimated 80 percent of the records were able to be matched with other records.

Discussion

The high volume of exchange in the Heartland Region Pilot established that PCDH is practical and feasible to exchange data. PCDH has the posture to build better comprehensive medical histories and continuity of care in real time.

Conclusion

The value of the data gained extends beyond clinical practitioners to public health workforce for improved interventions, increased surveillance, and greater awareness of gaps in health for needs assessments. This existing interconnection of HIEs has an opportunity to be a sustainable path toward national interoperability.

Progress toward Digital Transformation in an Evolving Post-acute Landscape

Digitization has been a central pillar of structural investments to promote organizational capacity for transformation, and yet skilled nursing facilities (SNFs) and other post-acute providers have been excluded and/or delayed in benefitting from the past decade of substantial public and private sector investment in information technology (IT). These settings have limited internal capacity and resources to invest in digital capabilities on their own, propagating a limited infrastructure that may only further sideline SNFs and their role in an ever-evolving healthcare landscape that needs to be focused on age-friendly, high-value care. Meaningful progress will require continuous refinement of supportive policy, financial investment, and scalable organizational best practices specific to the SNF context. In this essay, we lay out an action agenda to move from age-agnostic to age-friendly digital transformation. Key to the value proposition of these efforts is a focus on interoperability- the seamless exchange of electronic health information across settings that is critical for care coordination and for providers to have the information they need to make safe and appropriate care decisions. Interoperability is not synonymous with digital transformation, but a foundational building block for its potential. We characterize the current state of digitization in SNFs in the context of key health IT policy advancements over the past decade, identifying ongoing and emergent policy work where the digitization needs of SNFs and other post-acute settings can be better addressed. We also discuss accompanying implementation considerations and strategies for optimally translating policy efforts into impactful practice change across an ever-evolving post-acute landscape. Acting on these insights at the policy and practice level provides cautious optimism that nursing home care – and care for older adults across the care continuum – may benefit more equitably from the promise of future digitization.

Rapid adoption of electronic health record and health information exchange among assisted living communities, 2010-2018

Adoption of electronic health records (EHRs) and health information exchange (HIE) is a key tool to improving the quality of care in assisted living communities (ALC). We examined whether EHRs were being used in ALC to support HIE in 2010 and 2018. We found that adoption of EHR and HIE functions increased substantially over the study period. However, adoption of HIE functions lagged significantly behind EHR functions in both 2010 and 2018 and was accompanied by growing disparities in the adoption of EHR functions among smaller, nonchain, and for-profit communities. To improve the quality of care for this important and growing population, targeted policies are needed to support the adoption of both EHR and HIE functions in ALC.