Health information exchange (HIE) addresses these shortcomings by providing clinicians who are not part of the same organizational entity with the capability to electronically retrieve and share health-related information across regional, community, or organizational boundaries.8-10 Studies have shown that HIE can lead to numerous benefits such as reduced utilization of healthcare services,11 reduced diagnostic testing,12 prescription safety,13 public health support, and cost savings.14-16 Healthcare organizations can engage in HIE using different technological architectures for point-to-point communication (ie, the direct exchange of data between electronic health record [EHR] systems from different vendors) between providers, and under various interorganizational collaborations such as services provided through a single intermediary health information organization.16,17
HIE models vary across the United States, but often involve physicians, hospitals, and other healthcare stakeholders in the community joining a local HIE effort run by a regional health information organization (RHIO)18 or another model for exchange. These include enterprise HIE efforts (ie, an HIE system privately owned, funded, and developed by a single enterprise or organization)19 and vendor-mediated exchange.20,21 In general, RHIOs have emerged as the leading model to facilitate the electronic exchange of information between healthcare organizations.22 A common feature for all HIE models is that information exchange is enabled through the electronic transmissionof data represented by 2 exchange methods—“push” and “pull”.17,23 Push takes place when clinical data are electronically deposited into a recipient’s system after a sender initiates transfer. Pull is initiated when a user proactively uses a HIE system to retrieve aggregated patient health data stemming from multiple sources across a community.
Existing studies have evaluated the use of pull-based HIE systems,24-27 and 1 quantitative study examined RHIO-managed HIEs with both push and pull capabilities,17 however, little qualitative research exists that examines the experience of healthcare professionals using multiple HIE models and push/pull methods at their place of work.
With the myriad options organizations have for HIE, our goal was to understand the dimensions of the information retrieval pathways used by healthcare professionals to engage in HIE. We sought to assess how healthcare professionals met their information needs in the context of laboratory test results, radiological images and reports, and medication histories. Access to these types of data has the greatest potential for impact on patient health, and holds the greatest promise for cost savings,28 improved diagnosing and monitoring of health and diseases,29 detection of diseases at an early stage,30 and reduced frequency of repeat diagnostic testing.31
Study Design and Setting
We undertook a qualitative multicase study approach in New York state. The state provides a relevant setting to evaluate HIE; it has invested more than $440 million in health information technology and HIE adoption over the last 7 years.32 We consulted with the New York eHealth Collaborative, a private-public nonprofit organization charged with facilitating statewide HIE by coordinating the creation of a network to connect healthcare providers, to identify 3 RHIOs serving distinctly diverse communities; this selection process would maximize variation and allow for comparison.5 The RHIOs that matched our criteria for selection agreed to participate in the study and cooperated in identifying care organizations for our study sites. The communities varied in terms of population size and consented patients, and in the number of users (clinicians and staff) with access to their local RHIO’s HIE (Table 1). Each RHIO implemented a different commercial HIE platform; the exchange architectures also differed. Community A and Community C used a federated model, and Community B used a centralized model. In a federated model, an organization locally stores and retains control over the patient information, and it responds when another organization, also a member of the same RHIO HIE effort, requests information. In a centralized model, patient data is stored in a central repository maintained by the RHIO after being collected from the organizations participating in the local RHIO effort.
We provided a brief project overview and obtained verbal and written informed consent from each care organization's clinicians and staff who agreed to participate in this study. The consent form was provided by the Institutional Review Board of Weill Cornell Medical College, which approved this study.
Data was collected during 2-day site visits at each participating care organization. To increase the internal validity of our study, we used 2 sources for evidence: observation and interviews.34 All data collection began in May 2013 and ended in June 2013. RHIO staff helped identify and secure the cooperation of key informants who had experience utilizing various HIE models. We used a snowball sampling procedure in which we first interviewed a key informant; they were then asked to identify and help recruit other potential informants who were familiar with HIE and could provide additional insight about their information retrieval experiences.35 Because these other potential informants came from the key informants' social networks, we believed this would reflect the perspectives of a diverse community of healthcare professionals.36 We also observed participants and recorded the field notes of healthcare professionals engaging in HIE activities.37 Data gathering at each site ended when the point of data saturation was reached—that is, when the interviews and observations did not produce any new information.38 All interviews lasted an average of 30 minutes and were conducted using a semi-structured protocol. This allowed us to delve deeper into a topic concerning information retrieval approaches, to pose additional questions based on subject responses, and to thoroughly understand the answers that were given. All interviews were audio recorded and transcribed.
From the interviews and observations, it was possible to obtain a narrative of HIE models and exchange methods used in each community. For this analysis, we undertook an iterative, open-coding approach to the interview and observational data.39 To begin, we identified broad themes around the important concepts of information retrieval pathways for the types of information sought, based on our research objective. We completed the initial coding as close as possible to the date of data collection. During a second cycle of coding, we identified new concepts and relationships that were not adequately represented by the initial categories. This open coding was undertaken independently by authors PK and JRV, who were responsible for all phases of the coding. Collaboratively, PK and JRV reviewed and revised the coding schemes to consolidate redundant codes.
RESULTS We interviewed a total of 48 individuals across 3 emergency departments (EDs), 7 primary care practices (PCPs), and 2 local public health departments (LHDs) (Table 1). We observed healthcare practitioner activities for more than 40 hours across all 3 communities. The PCPs included a federally qualified health center, a community health center, solo practices, and large group practices. Each care organization was equipped with an EHR) and had access to their RHIO’s HIE system. The LHDs provided clinical services but did not have an EHR. LHDs were included in this study because HIE can provide them with access to previously hard-to-obtain clinical and demographic data for the purposes of disease surveillance, disaster response, and healthcare service delivery. We obtained the perspective of 3 broad types of professionals: clinicians (physicians, nurses, physician assistants, scribes, pharmacists, and medical assistants); case managers and public health disease investigation staff; and administrative staff (directors, information technology specialists, medical records personnel, quality managers, clerks, and front-desk staff). We used these larger groupings to protect confidentiality.Information Retrieval Pathways
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...”
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.
The choice of primary and secondary information sources among different sites suggests implementation priorities for those fostering exchange. Based on this study, push methods would address many of the work flow and information needs of primary care settings, particularly when considering patient information like medication and laboratory results that have discrete data elements capable of being parsed. The nature of care in the ED suggests using RHIO-pull may be the best match. Public health agencies have less advanced internal information systems, but they possess a voracious appetite for information and their work flows are based on prolonged data collection and investigation.40 HIE systems using RHIO-pull fit the public health work flow, but only if they contain a broad amount of information sources. Remote portal access to local hospitals will support public health work, but will not necessarily help efficiency if users have to repeatedly search multiple systems institution by institution.
In addition, of interest to the leadership of health organizations, these findings indicate that both clinical and nonclinical staff would benefit from organizational support. First, the sheer number of available information sources does not, in and of itself, create increases in productivity.41 Multiple systems with different log-ins, use cases, and designs can place strains on the organization and on individuals.42
As more demands are being placed on the workforce for technology skills and competencies,43 managers need to ensure that staff members have sufficient computer skills to navigate multiple systems and avenues when challenges arise. One possibility to address the complex data-gathering situation for clinicians would be to introduce medical scribes. By assuming most of the data-gathering and documentation responsibilities, scribes tend to increase physician productivity.44 Second, the multiple information retrieval pathways indicates that professionals have complex mental models of determining where the data are available and under what circumstances they expect to find it. With the increased availability of externally created information, healthcare organizations are going to need to develop formalized methods for retaining and using this knowledge. These strategies can include creating directories, developing formal learning collaboratives, sharing best practices, holding discussion groups, or specific trainings.45-47
The primary limitation of this study is that it is confined to experiences in New York state; the differences in infrastructure, policies, and maturity of HIE systems may limit the generalizability of our findings. Additionally, while our sample included both urban and rural settings and organizations of different types and sizes, we cannot speak to the experiences of specialty care providers or use of HIE systems for inpatient care.
The exchange of health information is a critical strategy to improve patient safety and the quality of care. Healthcare professionals make use of a variety of technologies and methods to support their information needs. Understanding clinicians’ information retrieval pathways for HIE can assist in improving the design and functionality of HIE systems and aid their integration into organizational work flows. These findings provide insights for informatics professionals about the usage of information, indicate the need for managerial support within each organization, and suggest approaches to improve systems for organizations and agencies working to expand HIE adoption.