The American Journal of Managed Care Special Issue: Health Information Technology
Information Retrieval Pathways for Health Information Exchange in Multiple Care Settings
- RHIO-pull: clinicians actively use a RHIO-managed Web-query portal to retrieve information from other healthcare organizations participating in the local RHIO effort. Authorized system users “pulled” patient information by logging into the portal and searching for such information. The query-based HIE systems were independent of the practices’ or hospitals’ EHRs and were available in all 3 communities.
- RHIO-push: RHIOs facilitate the automatic delivery of Continuity of Care Documents (CCDs)—an electronic document exchange standard for clinical documents, or other defined sets of electronic message standards designed to facilitate the data exchange of a clinical document between EHRs from different vendors. This method also included instances of DIRECT project services, if they were provided by the RHIO. DIRECT is a federal project designed to facilitate the sharing of single-patient information between provider EHRs on a point-to-point basis.23
- Alternate-pull: clinicians manually retrieve clinical data from external organizations using a non–RHIO-related exchange service. Examples include providers with read-only privileges to the local hospital’s information systems (ie, providers use a login and password to remotely access laboratory and radiology data from another organization).
- Alternate-push: clinical data are automatically delivered to the healthcare organization using non-RHIO services. Examples include vendor-mediated exchanges in which laboratory reports from specialists are automatically delivered to a PCP’s system. Instances of DIRECT protocol usage that were not RHIO-facilitated were included in this category. These information retrieval pathways are resources in addition to each organization’s internal information systems, such as an EHR, picture archiving and communication system (PACS), or laboratory information system. Table 3 outlines, by care setting, the favored methodologies used by healthcare professionals to retrieve information.
For healthcare professionals working in EDs, their first choice for seeking information was using their own EHR and other hospital-based systems. Generally, interviewees thought going to their own systems was “a lot easier” and that their systems were fairly comprehensive and up to date. For example, radiology data was often retrieved through a hospital’s PACS, were because “[it] has everything that the patient has had done.” One Community C clinician noted, “Our EHR is where I get my lab results on a daily basis.”
There were some exceptions. When healthcare professionals needed “historical data,” wanted to “compare patient’s labs prior,” or if all other internal information gathering approaches had been exhausted, they would use RHIO-pull. In the ED, RHIO-pull was used to obtain additional radiology information. A clinician in Community B noted that the ability to retrieve images and reports was particularly useful when she knew the patient had sought care in other hospitals. Similarly, RHIO-pull was the only option to obtain prior laboratory data; it was commonly used for comparing historical laboratory values with current test values. In all communities, RHIO-pull was used to retrieve data for medication reconciliation or in response to patients exhibiting drug-seeking behavior. For example, a Community Clinician reported he would pull data “when I questioned a patient’s use of medications.”
Primary Care Practices
Healthcare professionals at PCPs used a combination of information retrieval pathways for HIE. In general, clinicians preferred to have clinical data automatically transferred into their EHRs from external organizations, via RHIO-push, because it did not interfere with their natural work flow. In comparison, RHIO-pull was less preferred because it led to inconveniences and work flow disruptions due the additional time and effort required to access and find data in the RHIO-managed Web-query portal. One clinician said, “We get CCDs through [RHIO]. We can access [RHIO-managed Web-query portal], although we don’t do that very much just because it really disrupts the work flow.” Some clinicians used both RHIO-push and RHIO-pull depending on the situation. One staff member said “We’ll use the Web portal depending on what we get from the CCD. Sometimes it’s easier to go to the Web portal. Sometimes it’s easier to do the CCD...”
Because RHIO-push used CCDs, it was the primary mechanism used to procure medication and laboratory information from external sources. However, RHIO-push still presented challenges. For example, interviewees said that when data are pushed into their systems, time is required for interpretation. They said, too, that the amount of information delivered to the practice was substantial and “a little intimidating.” Also, because of the format of the CCD and the amount of information each document contained, several interviewees used the RHIO-pull or Alternate-pull. One clinician noted, “Say they had an x-ray done at [local hospital]. We can go directly to [their PACS] and get that a little quicker than you could [if you went] through the entire CCD.” Providers also reported that technical challenges sometimes caused them to use RHIO-pull, because they “cannot parse an x-ray or an x-ray report into the system.” Lastly, regardless of method of delivery, data still had to be checked for accuracy: “[If] a patient says they have an allergy, but the CCD says they don’t, you’re going to listen to the patient.”
PCPs had access to many sources of information outside the efforts of the RHIO-based services and used alternate-pull and alternate-push to engage in HIE. Community A had access to a local hospital’s EHR, a laboratory company’s information systems, a hospital’s PACS, vendor-mediated delivery of clinical documents, and access to Surescripts as part of their EHR. Practices in Community B also had access to vendor-mediated document delivery and to a local hospital’s laboratory information system and PACS. Laboratory reports from specialists were an example of vendor-mediated exchange: one clinician said, “When our patients go to see the specialists, we get cc’d labs that are done.”
Remote log-ins, the process by which clinicians are provided with remote access privileges to another organization’s system by using a user name and password, were prevalent for laboratory and radiology data. One clinician said, “I generally go to the source,” and another added, “If we needed to see the images that the different hospital systems have, a PAC system is set up so that’s where we ended up signing in.” Remote logins did frustrate some clinicians who said, “[External organizations] kind of lock everything down where you need 18 steps to get to where you need to go.” In general, when Alternate-pull proved difficult, PCPs would resort to pulling the data from the RHIO-managed Web-based query system. A clinician said, “If I’ve done blood work on somebody, and they’re supposed to send it...sometimes it doesn’t always get sent...So I can go on [RHIO-managed Web-based query system] and look up the results.” Public Health
Healthcare professionals in public health settings relied on the RHIO-pull and Alternate-pull methods for information retrieval. Clinicians regularly used RHIO-pull to retrieve information not available in their own internal systems. For example, a tuberculosis nurse emphasized: “The first thing I usually do is go into the RHIO and get some background on each of the cases that I’ve gotten a report on. I’m looking at chest x-ray results, CAT [computed tomography] scan results, biopsy results, recent clinic notes from a physician [explaining] why they got the test.” Additionally, accessing the RHIO-pull supported efficient work. A case manager said, “It allows us to access radiology reports instead of waiting for the provider...” and another added, “I do obtain those lab reports regularly, and [it] is a huge help to be able to get them as soon as they’re available.”
Alternate-pull methods were predominantly in the form of remote logins to other organizations. This included access to the local hospital and a local radiology group. One nurse said, “Most of the time we can access their imaging online,” and another said, “I will see which lab it came from and I will ordinarily go to the [local hospital EHR].” For imaging, clinicians relied on the Alternate-pull for getting information. One nurse stated, “We’re pretty good about getting the reports and the x-rays sent over from the hospitals. I think the reports are faxed and then the courier brings over the chest x-rays,” and another added, “We have to call and ask them to get us a disk over here or we pick up the disk.”
Healthcare professionals used a complex combination of information retrieval pathways for HIE to obtain clinical information from external organizations. The choice for each approach was setting- and information-specific, but was also highly dynamic across users and their information needs.
Across each clinical site, several general features of information retrieval approach were consistent. First, the organization’s own internal information system (ie, its EHR) was the primary source of information. Second, when the EHR was the focal technology, that resulted in more reliance on “push” methods for the automatic delivery of information, whether it was through RHIO-push or Alternate-push. Data being pushed were not without technical challenges (ie, too much data), but the information was still accessible and stored within the EHR. Third, pull methods were used when the primary information retrieval method failed to meet clinicians’ information needs. Of the 4 information retrieval pathways for HIE, RHIO-pull required the most change to workflows.
These findings imply that HIE models need to support both push and pull methods to meet the very diverse needs of health professionals.17,23 Although levels of usage of each HIE model varied, each type of exchange served a purpose to meet the user’s information needs. This has further relevance for those measuring and evaluating exchange activities. The multiple mechanisms and reasons for exchange suggest somewhat of a substitution effect among systems (eg, Alternate-pull used instead of RHIO-pull). As a result, measuring individual system usage may be inadequate or misleading about the level of HIE adoption. Composite measures of all exchange activity may be more informative.
As multiple HIE models appear to be the reality for the foreseeable future, attempts to centralize data will continue to be a challenge. To make data management easier for providers and organizations, those working to foster the exchange (eg, RHIOs, vendors, and government agencies) can support numerous technological innovations. Given that the EHR is the primary source of information, we suggest that the more the data from the exchange systems are integrated and work flows are harmonized with the EHR, the better.
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