Health Information Exchange [Entered Retrospectively]

Project Summary Title and Description

Health Information Exchange [Entered Retrospectively]
Objectives: This review sought to systematically review the available literature on health information exchange (HIE), the electronic sharing of clinical information across the boundaries of health care organizations. HIE has been promoted as an important application of technology in medicine that can improve the efficiency, cost-effectiveness, quality, and safety of health care delivery. However, HIE also requires considerable investment by sponsors, which have included governments as well as health care organizations. This review aims to synthesize the currently available research addressing HIE effectiveness, use, usability, barriers and facilitators to actual use, implementation; and sustainability, and to present this information as a foundation on which future implementation, expansion, and research can be based. Results: We included 136 studies overall, with 34 on effectiveness, 26 of which reported intermediate clinical, economic, or patient outcomes, and eight that reported on clinical perceptions of HIE. We also found 58 studies on the use of HIE, 22 on usability and other facilitators and barriers to actual use of HIE, 45 on facilitators or barriers to HIE implementation, and 17 on factors related to sustainability of HIE. No studies of HIE effectiveness reported impact on primary clinical outcomes (e.g., mortality and morbidity) or identified harms. Low-quality evidence somewhat supports the value of HIE for reducing duplicative laboratory and radiology test ordering, lowering emergency department costs, reducing hospital admissions (less so for readmissions), improving public health reporting, increasing ambulatory quality of care, and improving disability claims processing. In studies of clinician perceptions of HIE most respondents attributed positive changes to the HIE such as improvements in coordination, communication and knowledge about the patient. However in one study clinicians reported that the HIE did not save time and may not be worth the cost. Studies of HIE use found that HIE adoption has increased over time, with 76 percent of U.S. hospitals exchanging information in 2014, an 85 percent increase since 2008 and a 23 percent increase since 2013. HIE systems were used by 38 percent of office-based physicians in 2012 while use remains low, less than 1 percent, among long-term care providers. Within organizations with HIE, the number of users or the number of visits in which the HIE was used was generally very low. The degree of usability of an HIE was associated with increased rates of use, but not was not associated with effectiveness outcomes. The most commonly cited barriers to HIE use were lack of critical mass electronically exchanging data, inefficient workflow, and poorly designed interface and update features. Information was insufficient to allow us to assess usability by HIE function or architecture. Studies provided information on both external environmental and internal organizational characteristics that affect implementation and sustainability. General characteristics of the HIE organization (e.g. strong leadership) or specific characteristics of the HIE system were the most frequently cited facilitators while disincentives such as competition or lack of a business case for HIE were the most frequently identified barriers. Conclusions: The full impact of HIE on clinical outcomes and potential harms is inadequately studied, although evidence provides some support for benefit in reducing use of some specific resources and achieving improvements in quality of care measures. Use of HIE has risen over time and is highest in hospitals and lowest in long-term care settings. However, use of HIE within organizations that offer it is still low. Barriers to HIE use include lack of critical mass participating in the exchange, inefficient workflow, and poorly designed interface and update features. Studies have identified numerous facilitators and barriers to implementation and sustainability but the studies have not ranked or compared their impact. To advance our understanding of HIE, future studies need to address comprehensive questions, use more rigorous designs, use a standard for describing types of HIE, and be part of a coordinated, systematic approach to studying HIE.
Authors of Report
Methodology description
Abstracts and the selected full-text articles were reviewed by two investigators for inclusion based on predefined criteria. Discrepancies were resolved through discussion and consensus, with a third investigator making the final decision as needed. Data were abstracted from each included article by one person and verified by another. All analyses were qualitative, and they were customized according to the topic.
The published report is available at the following link: Data were entered retrospectively and data abstraction and quality assessment evidence tables can be found in Appendices D through I, which have been uploaded and attached to this project.
Funding Source
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA290201200014I).

Key Questions

1. Key Question 1. Is HIE effective in improving clinical (e.g., mortality and morbidity), economic (e.g., costs and resource use, the value proposition for HIE) and population (e.g., syndromic surveillance) outcomes? Key Question 1a. Does effectiveness vary by type of HIE? Key Question 1b. Does effectiveness vary by health care settings and systems? Key Question 1c. Does effectiveness vary by IT system characteristics? Key Question 1d. What evidence exists that the lack of HIE leads to poorer outcomes?
2. Key Question 2. What harms have resulted from HIE? (e.g., violations of privacy, errors in diagnosis or treatment from too much, too little or inaccurate information, or patient or provider concerns about HIE)? Key Question 2a. Do harms vary by type of HIE? Key Question 2b. Do harms vary by health care settings and systems? Key Question 2c. Do harms vary by the IT system characteristics?
3. Key Question 3. Is HIE effective in improving intermediate outcomes such as patient and provider experience, perceptions or behavior; health care processes; or the availability, completeness, or accuracy of information? Key Question 3a. Does effectiveness in improving intermediate outcomes vary by type of HIE? Key Question 3b. Does effectiveness in improving intermediate outcomes vary by health care settings and systems? Key Question 3c. Does effectiveness in improving intermediate outcomes vary by IT system characteristics? Key Question 3d. What evidence exists that the lack of HIE leads to poorer intermediate outcomes?
4. Key Question 4. What is the current level of use and primary uses of HIE? Key Question 4a. Do level of use and primary uses vary by type of HIE? Key Question 4b. Do level of use and primary uses vary by health care settings and systems, or provider type? Key Question 4c. Do level of use and primary uses vary by IT system characteristics? Key Question 4d. Do level of use and primary uses vary by data source?
5. Key Question 5. How does the usability of HIE impact effectiveness or harms for individuals and organizations? Key Question 5a. How usable are various types of HIE? Key Question 5b. What specific usability factors impact the effectiveness or harms from HIE? Key Question 5c. How does usability vary by health care settings or systems?
6. Key Question 6. What facilitators and barriers impact use of HIE? Key Question 6a. Do facilitators and barriers that impact use vary by type of HIE? Key Question 6b. Do facilitators and barriers that impact use vary by health care settings and systems? Key Question 6c. Do facilitators and barriers that impact use vary by IT system characteristics?
7. Key Question 7. What facilitators and barriers impact implementation of HIE? Key Question 7a. Do facilitators and barriers that impact implementation vary by type of HIE? Key Question 7b. Do facilitators and barriers that impact implementation vary by health care settings and systems? Key Question 7c. Do facilitators and barriers that impact implementation vary by IT system characteristics?
8. Key Question 8. What factors influence sustainability of HIE?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

Electronic health record adoption and health information exchange among hospitals in New York State.2012
A statewide assessment of electronic health record adoption and health information exchange among nursing homes.
Impact of health disclosure laws on health information exchanges.
U.S. Regional health information organizations: progress and challenges.
A survey of health information exchange organizations in the United States: implications for meaningful use.2011
Operational health information exchanges show substantial growth, but long-term funding remains a concern.
Health information exchange among US hospitals.2011
Characteristics associated with regional health information organization viability.
The state of regional health information organizations: current activities and financing.2008
Impact of a standardized communication system on continuity of care between family physicians and the emergency department.2007
Notifications of hospital events to outpatient clinicians using health information exchange: a post-implementation survey.2012
Real time alert system: a disease management system leveraging health information exchange.2012
Where are we on the diffusion curve? Trends and drivers of primary care physicians' use of health information technology.
Health information exchange reduces repeated diagnostic imaging for back pain.2013
Does health information exchange reduce unnecessary neuroimaging and improve quality of headache care in the emergency department?2013
The impact of EHR and HIE on reducing avoidable admissions: controlling main differential diagnoses.2013
Using electronic health record systems to optimize admission decisions: The Creatinine case study.2015
The Department of Veterans Affairs, Department of Defense, and Kaiser Permanente Nationwide Health Information Network exchange in San Diego: patient selection, consent, and identity matching.
The Department of Veterans Affairs' (VA) implementation of the Virtual Lifetime Electronic Record (VLER): findings and lessons learned from Health Information Exchange at 12 sites.2014
Use of electronic health records in residential care communities.2013
Push and pull: physician usage of and satisfaction with health information exchange.
Health information exchange system usage patterns in three communities: practice sites, users, patients, and data.2013
Patient encounters and care transitions in one community supported by automated query-based health information exchange.
Observational study and estimate of cost savings from use of a health information exchange in an academic emergency department.2014
Enhancing laboratory report contents to improve outpatient management of test results.2010
Infection preventionists' awareness of and engagement in health information exchange to improve public health surveillance.2013
Electronic laboratory data quality and the value of a health information exchange to support public health reporting processes.
Organizational challenges in developing one of the Nationwide Health Information Network trial implementation awardees.2012
Large scale health information exchange: implementation experiences from five states.2013
Cincinnati Beacon Community Program highlights challenges and opportunities on the path to care transformation.2014
Collaboration in electronic medical evidence development: a case study of the Social Security Administration's MEGAHIT System.2011
Emergency medical services: the frontier in health information exchange.2010
Inventory of electronic health information exchange in Wisconsin, 2006.2007
Health information exchange: participation by Minnesota primary care practices.
The financial impact of health information exchange on emergency department care.
Despite substantial progress In EHR adoption, health information exchange and patient engagement remain low in office settings.2014
Hospital electronic health information exchange grew substantially in 2008-12.2013
User perspectives on the usability of a regional health information exchange.
Adoption of health information exchange by emergency physicians at three urban academic medical centers.
Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study.
Creating sustainable local health information exchanges: can barriers to stakeholder participation be overcome?2008
Utilization of technology by long-term care providers: comparisons between for-profit and nonprofit institutions.2013
Implementation of an innovative, integrated electronic medical record (EMR) and public health information exchange for HIV/AIDS.
Assessing the relationship between health information exchanges and public health agencies.2009
Physicians' opinions of a health information exchange.2011
User experiences with different regional health information exchange systems in Finland.2014
The use of health information technology in seven nations.
The MidSouth eHealth Alliance: use and impact in the first year.2008
Health information exchange usage in emergency departments and clinics: the who, what, and why.2011
Health information exchange, Health Information Technology use, and hospital readmission rates.2011
Use and perceived value of health information exchange: one public healthcare system's experience.2013
User experiences with pharmacy benefit manager data at the point of care.2010
HEAL NY: Promoting interoperable health information technology in New York State.
Health information exchange and ambulatory quality of care.2012
Which components of health information technology will drive financial value?2012
Community-based health information technology alliances: potential predictors of early sustainability.
A regional informatics platform for coordinated antibiotic-resistant infection tracking, alerting, and prevention.2013
Does health information exchange reduce redundant imaging? Evidence from emergency departments.
Impact of an electronic link between the emergency department and family physicians: a randomized controlled trial.2006
Physicians' perceptions and use of a health information exchange: a pilot program in South Korea.
Proactive population health management in the context of a regional health information exchange using standards-based decision support.
Usefulness of a Regional Health Care Information System in primary care: a case study.2008
Evaluation of the electronic transmission of medical findings from hospitals to practitioners by triangulation.2006
Outcomes assessment of the regional health information exchange: a five-year follow-up study.2011
The utilization rate of the regional health information exchange: how it impacts on health care delivery outcomes.2012
Improved HIV-related outcomes associated with implementation of a novel public health information exchange.
Connecting hospital and community care: the acceptability of a regional data linkage scheme.2005
Electronic health information exchange in underserved settings: examining initiatives in small physician practices & community health centers.2014
Rural RHIOs: common issues in the development of two state-wide health information networks.2007
A system dynamics evaluation model: implementation of health information exchange for public health reporting.
The development of a health information exchange to enhance care and improve patient outcomes among HIV+ individuals in rural North Carolina.
Health information exchange, system size and information silos.2014
Satisfying patient-consumer principles for health information exchange: evidence from California case studies.2012
Event detection: a clinical notification service on a health information exchange platform.2012
Perceptions regarding the ease of use and usefulness of health information exchange systems among medical providers, case managers and non-clinical staff members working in HIV care and community settings.
HIE-i-health information exchange with intelligence.2014
Shared experience in 13 local Danish EPR projects: the Danish EPR Observatory.2001
Success and failure factors in the regional health information system design process--results from a constructive evaluation study.2006
Geographical distribution of patients visiting a health information exchange in New York City.2013
Communities' readiness for health information exchange: the National Landscape in 2004.2005
A comparison of the completeness and timeliness of automated electronic laboratory reporting and spontaneous reporting of notifiable conditions.2008
Revisiting sociotechnical systems in a case of unreported use of health information exchange system in three hospital emergency departments.2013
Electronic Clinical Communications Implementation (ECCI) in Scotland: a mixed-methods programme evaluation.2004
Patients' perceptions of a health information exchange: a pilot program in South Korea.2013
Physician capability to electronically exchange clinical information, 2011.2013
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.2014
Building an inter-organizational communication network and challenges for preserving interoperability.2008
Effects of health information exchange adoption on ambulatory testing rates.2013
Health information exchange in small-to-medium sized family medicine practices: motivators, barriers, and potential facilitators of adoption.2010
What Affects Clinicians' Usage of Health Information Exchange?2011
Understanding the decisions and values of stakeholders in health information exchanges: experiences from Massachusetts.2009
The Bay Area HIE. A case study in connecting stakeholders.2010
From a paper-based transmission of discharge summaries to electronic communication in health care regions.2006
A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas.2012
Health information exchange improves identification of frequent emergency department users.2013
Success in health information exchange projects: solving the implementation puzzle.2010
A shared electronic health record: lessons from the coalface.2009
Minnesota clinics' adoption, use and exchange of electronic health information.2013
The essential role of reconfiguration capabilities in the implementation of HIV-related health information exchanges.2012
Emergency physicians' perspectives on their use of health information exchange.2014
Engaging patients for health information exchange.2009
The business case for payer support of a community-based health information exchange: a humana pilot evaluating its effectiveness in cost control for plan members seeking emergency department care.2011
"Hidden" value: how indirect benefits of health information exchange further promote sustainability.2012
Health information exchange technology on the front lines of healthcare: workflow factors and patterns of use.2012
Health information exchange and healthcare utilization.2009
More than just a question of technology: factors related to hospitals' adoption and implementation of health information exchange.2010
Challenges, alternatives, and paths to sustainability for health information exchange efforts.2013
Factors associated with health information exchange system usage in a safety-net ambulatory care clinic setting.2012
Using a health information exchange system for imaging information: patterns and predictors.2013
Factors related to public health data sharing between local and state health departments.2014
How are health professionals using health information exchange systems? Measuring usage for evaluation and system improvement.2012
Use of a health information exchange system in the emergency care of children.2011
Association between use of a health information exchange system and hospital admissions.2014
The potential for community-based health information exchange systems to reduce hospital readmissions.2015
The association between health information exchange and measures of patient satisfaction.2011
Factors motivating and affecting health information exchange usage.2011
Decision support for evidence-based pharmacotherapy detects adherence problems but does not impact medication use.2013
Care everywhere, a point-to-point HIE tool: utilization and impact on patient care in the ED.2014
Factors related to health information exchange participation and use.2014
Meaningful use status and participation in health information exchange among New York State hospitals: A longitudinal assessment
Health information exchange among U.S. hospitals: Who's in, who's out, and why?2014
Evolution of State Health Information Exchange/A Study of Vision, Strategy, and Progress
Benchmarking Deployment of eHealth among General Practitioners (2013) – Final Report
Barriers to achieving the last mile in health information exchange: a survey of small hospitals and physician practices.2013
The State HIE Program Four Years Later: Key Findings on Grantees’ Experiences from a Six-State Review
Result from Survey on Health Data Exchange 2013. The Challenge to Connect.
Post HITECH: The Landscape of Health Information Exchange
Health Information Exchange Implementation: Lessons Learned and Critical Success Factors From a Case Study2014
Emphasizing Public Health Within a Health Information Exchange: An Evaluation of the District of Columbia’s Health Information Exchange Program2014
Enhancing a geriatric emergency department care coordination intervention using automated health information exchange-based clinical event notifications.2014
How could health information exchange better meet the needs of care practitioners?2014
Learning from health information exchange technical architecture and implementation in seven beacon communities.2014
Query-Based Exchange: Key Factors Influencing Success and Failure
Information technology for collaborative advantage in healthcare revisited
Health Information Exchange among U.S. Non-federal Acute Care Hospitals: 2008-2014
Bridging organizational divides in health care: an ecological view of health information exchange.2013

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