Currently Viewing:
The American Journal of Managed Care Special Issue: Health Information Technology
Improving Adherence to Cardiovascular Disease Medications With Information Technology
William M. Vollmer, PhD; Ashli A. Owen-Smith, PhD; Jeffrey O. Tom, MD, MS; Reesa Laws, BS; Diane G. Ditmer, PharmD; David H. Smith, PhD; Amy C. Waterbury, MPH; Jennifer L. Schneider, MPH; Cyndee H. Yonehara, BS; Andrew Williams, PhD; Suma Vupputuri, PhD; and Cynthia S. Rand, PhD
Currently Reading
Information Retrieval Pathways for Health Information Exchange in Multiple Care Settings
Patrick Kierkegaard, PhD; Rainu Kaushal, MD, MPH; and Joshua R. Vest, PhD, MPH
Leveraging EHRs to Improve Hospital Performance: The Role of Management
Julia Adler-Milstein, PhD; Kirstin Woody Scott, MPhil; and Ashish K. Jha, MD, MPH
Electronic Alerts and Clinician Turnover: The Influence of User Acceptance
Sylvia J. Hysong, PhD; Christiane Spitzmuller, PhD; Donna Espadas, BS; Dean F. Sittig, PhD; and Hardeep Singh, MD, MPH
Cost Implications of Human and Automated Follow-up in Ambulatory Care
Eta S. Berner, EdD; Jeffrey H. Burkhardt, PhD; Anantachai Panjamapirom, PhD; and Midge N. Ray, MSN, RN
Primary Care Capacity as Insurance Coverage Expands: Examining the Role of Health Information Technology
Renuka Tipirneni, MD, MSc; Ezinne G. Ndukwe, MPH; Melissa Riba, MS; HwaJung Choi, PhD; Regina Royan, MPH; Danielle Young, MPH; Marianne Udow-Phillips, MHSA; and Matthew M. Davis, MD, MAPP
Adoption of Electronic Prescribing for Controlled Substances Among Providers and Pharmacies
Meghan Hufstader Gabriel, PhD; Yi Yang, MD, PhD; Varun Vaidya, PhD; and Tricia Lee Wilkins, PharmD, PhD
Health Information Exchange and the Frequency of Repeat Medical Imaging
Joshua R. Vest, PhD, MPH; Rainu Kaushal, MD, MPH; Michael D. Silver, MS; Keith Hentel, MD, MS; and Lisa M. Kern, MD
Information Technology and Hospital Patient Safety: A Cross-Sectional Study of US Acute Care Hospitals
Ajit Appari, PhD; M. Eric Johnson, PhD; and Denise L. Anthony, PhD
Automated Detection of Retinal Disease
Lorens A. Helmchen, PhD; Harold P. Lehmann, MD, PhD; and Michael D. Abràmoff, MD, PhD
Trending Health Information Technology Adoption Among New York Nursing Homes
Erika L. Abramson, MD, MS; Alison Edwards, MS; Michael Silver, MS; Rainu Kaushal, MD, MPH; and the HITEC investigators
Electronic Health Record Availability Among Advanced Practice Registered Nurses and Physicians
Janet M. Coffman, PhD, MPP, MA; Joanne Spetz, PhD; Kevin Grumbach, MD; Margaret Fix, MPH; and Andrew B. Bindman, MD
The Value of Health Information Technology: Filling the Knowledge Gap
Robert S. Rudin, PhD; Spencer S. Jones, PhD; Paul Shekelle, MD, PhD; Richard J. Hillestad, PhD; and Emmett B. Keeler, PhD
Overcoming Barriers to a Research-Ready National Commercial Claims Database
David Newman, JD, PhD; Carolina-Nicole Herrera, MA; and Stephen T. Parente, PhD
The Effects of Health Information Technology Adoption and Hospital-Physician Integration on Hospital Efficiency
Na-Eun Cho, PhD; Jongwha Chang, PhD; and Bebonchu Atems, PhD

Information Retrieval Pathways for Health Information Exchange in Multiple Care Settings

Patrick Kierkegaard, PhD; Rainu Kaushal, MD, MPH; and Joshua R. Vest, PhD, MPH
Healthcare professionals used a complex combination of information retrieval pathways for health information exchange to obtain clinical information from external organizations.
  1. 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.
  2. 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
  3. 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).
  4. 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.
Emergency Departments

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.


1. Vest J. Health information exchange: national and international ap- proaches.
Adv Health Care Manag. 2012;12:3-24.

2. Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

3. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.

4. Elder NC, Hickner J. Missing clinical information: the system is down. JAMA. 2005;293(5):617-619.

5. Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical informa- tion during primary care visits. JAMA. 2005;293(5):565-571.

6. Burnett S, Deelchand V, Franklin BD, Moorthy K, Vincent C. Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care. BMC Health Serv Res. 2011;11:114.

7. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication his- tory errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510-515.

8. Rosenfeld S, Koss S, Caruth K, Fuller G. Evolution of State Health Information Exchange/A Study of Vision, Strategy, and Progress. Rockville, MD:The Agency for Healthcare Research and Quality; 2006.

9.The National Alliance for Health InformationTechnology. Report to the Office of the National Coordinator for Health InformationTechnology on Defining Key Health InformationTechnologyTerms. Washington, DC: Office of the National Coordinator for Health Information Technology; 2008.

10. National eHealth Collaborative. Health Information Exchange Roadmap: The Landscape and the Path Forward. Washington, DC: National eHealth Collaborative; 2012.

11. Hripcsak G, Kaushal R, Johnson KB, et al.The United Hospital Fund meeting on evaluating health information exchange. J Biomed Inform. 2007;40(6Suppl):S3-S10.

12. Bailey JE, Wan JY, Mabry LM, et al. Does health information exchange reduce unnecessary neuroimaging and improve quality
of headache care in the emergency department? J Gen Intern Med. 2013;28(2):176-183.

13. Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform. 2007;40(6Suppl):S40-S45.

14. Frisse ME, Holmes RL. Estimated financial savings associated with health information exchange and ambulatory care referral. J Biomed Inform. 2007;40(6 suppl):S27-S32.

15. Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B.The value of health care information exchange and interoperability. Health Aff (Millwood). 2005;Suppl Web Exclusives:W5-10-W5-18.

16. Frisse ME, Johnson KB, Nian H, et al.The financial impact of health information exchange on emergency department care. J Am Med Inform Assoc. 2012;19(3):328-333.

17. Campion TR Jr, Ancker JS, Edwards AM, Patel VN, Kaushal R; HI-TECH Investigators. Push and pull: physician usage of and satisfaction with health information exchange. AMIA Annu Symp Proc. 2012;77-84.

18. Solomon MR. Regional health information organizations: a vehicle for transforming health care delivery? J Med Syst. 2007;31(1):35-47.

19. Harris Healthcare Solutions. Harness the Power of Enterprise HIE. Melbourne, FL: Harris; 2012.

20.WindenTJ, Boland LL, Frey NG, Satterlee PA, Hokanson JS. Care everywhere, a point-to-point HIE tool: utilization and impact on patient care in the ED. Appl Clin Inform. 2014;5(2):388-401.

21. A practical guide to understanding HIE, assessing your readiness and selecting HIE options in Minnesota. website Updated July 2013. Accessed March 23, 2014.

22. Simon SR, Evans JS, Benjamin A, Delano D, Bates DW. Patients’ attitudes toward electronic health information exchange: qualitative study. J Med Internet Res. 2009;11(3):e30.

23. Kuperman GJ. Health-information exchange: why are we doing it, and what are we doing? J Am Med Inform Assoc. 2011;18(5):678-682.

24. Johnson KB, Unertl KM, Chen Q, et al. Health information exchange usage in emergency departments and clinics: the who, what, and why. J Am Med Inform Assoc. 2011;18(5):690-697.

25. Vest JR, Zhao H, Jasperson J, Gamm LD, Ohsfeldt RL. Factors motivating and affecting health information exchange usage. J Am Med Inform Assoc. 2011;18(2):143-149.

26. Unertl KM, Johnson KB, Lorenzi NM. Health information exchange technology on the front lines of healthcare: workflow factors and patterns of use. J Am Med Inform Assoc. 2012;19(3):392-400.

27. Kaelber DC, Waheed R, Einstadter D, Love TE, Cebul RD. Use and perceived value of health information exchange: one public healthcare system’s experience. Am J Manag Care. 2013;19(10 Spec No.): SP337-SP343.

28. Kern LM, Wilcox A, Shapiro J, Dhopeshwarkar RV, Kaushal R. Which components of health information technology will drive financial value? Am J Manag Care.18(8):438-445.

29. Wians FH Jr. Clinical laboratory tests: which, why, and what do the results mean? Lab Med. 2009;40(2):105-113.

30. Gunderman RB.The medical community’s changing vision of the patient: the importance of radiology. Radiology. 2005;234(2):339-342.

31. Healthcare Information & Management Systems Society Health Information Exchange Best PracticesTask Force. Health Information Exchanges: Similarities and Differences. HIMSS HIE Common Practices Survey Results White Paper. Chicago, IL: HIMSS; 2009.

32. Phillips AB, Wilson RV, Kaushal R, Merrill JA; HITECH investigators. Implementing health information exchange for public health reporting: a comparison of decision and risk management of three regional health information organizations in New York state. J Am Med Inform Assoc. 2014;21(e1):e173-e177.

33. Guba EG, LincolnYS. Fourth Generation Evaluation.Thousand Oaks, CA: SAGE Publications, Inc; 1989.

34. Dubé L, Paré G. Rigor in information systems positivist case research: current practices, trends, and recommendations. MIS Quarterly. 2003;27(4):597-635.

35. Crabtree BF, MillerWL. Doing qualitative research:Thousand Oaks, CA: Sage Publications, Inc; 1999.

36. Sadler GR, Lee HC, Lim RS, Fullerton J. Recruitment of hard-to- reach population subgroups via adaptations of the snowball sampling strategy. Nurs Health Sci. 2010;12(3):369-374.

37. Atkinson P, Hammersley M. Ethnography: Principles in Practice. 3rd ed. NewYork, NY: Routledge; 2007.

38. Morse JM.The significance of saturation. Qual Health Res. 1995; 5(2):147-149.

39. Glaser BG, Strauss AL. The Discovery of Grounded Theory; Strategies for Qualitative Research. Chicago, IL: AldineTransaction; 1968.

40. Vest JR, Issel LM, Lee S. Experience of using information systems in public health practice: findings from a qualitative study. Online J Public Health Inform. 2014;5(3):227.

41. Brynjolfsson E.The productivity paradox of information technology. Commun ACM. 1993;36(12):66-77.

42. Bawden D, Robinson L.The dark side of information: overload, anxiety and other paradoxes and pathologies. J Inf Sci. 2009;35(2):180-191.

43. Morrison F, Zimmerman J, Hall M, Chase H, Kaushal R, Ancker JS. Developing an online and in-person HIT workforce training program using a team-based learning approach. AMIA Annu Symp Proc. 2011; 63-71.

44. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406.

45. Alavi M, Leidner DE. Review: knowledge management and knowledge management systems: conceptual foundations and research issues. MIS Quarterly. 2001;25(1):107-136.

46. Guptill J. Knowledge management in health care. J Health Care Finance. 2005;31(3):10-14.

47. Yeager VA, Walker D, Cole E, Mora AM, Diana ML. Factors related to health information exchange participation and use. J Med Sys. 2014;38(8):78.

Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up

Sign In

Not a member? Sign up now!