OBJECTIVES: Trafficked persons experience adverse health consequences and seek help, but many go unrecognized by health-care professionals. This study explored professionals' perspectives on current approaches toward identifying and supporting trafficked persons in health-care settings, highlighting current technology roles, gaps, and future directions. MATERIALS AND METHODS: We developed an interview guide to investigate current human trafficking (HT) approaches, safety procedures, and HT education. Semistructured interviews were conducted via Zoom, iteratively coded in Dedoose, and analyzed using a thematic analysis approach. RESULTS: We interviewed 19 health-care and community group professionals and identified 3 themes: (1) participants described a responsibility to build trust with patients through compassionate communication, rapport, and trauma-informed approaches across different stages of care. (2) Technology played a dual role, as professionals navigated both benefits and challenges of tools such as Zoom, virtual interpreters, and cameras in trust building. (3) Safety and privacy concerns guided how participants documented patient encounters and shared community resources, ensuring confidentiality while supporting patient and community well-being. DISCUSSION: Technology can both support and hinder trust in health care, directly affecting trafficked patients and their safety. Informatics can improve care for trafficked persons, but further research is needed on technology-based interventions. We provide recommendations to strengthen trust, enhance safety, support trauma-informed care, and promote safe documentation practices. CONCLUSION: Effective sociotechnical approaches rely on trust, safety, and mindful documentation to support trafficked patients. Future research directions include refining the role of informatics in trauma-informed care to strengthen trust and mitigate unintended consequences.

OBJECTIVES: We report on findings from a meeting convened by the American College of Medical Informatics (ACMI) to characterize aspects of the patient experience that could be improved using informatics. MATERIALS AND METHODS: The American College of Medical Informatics fellows were invited to share their experiences as patients and suggest informatics approaches that may improve the patient experience. RESULTS: We identified 4 themes: (1) getting the right care, (2) data sharing and data interoperability, (3) guiding low-cost evaluations, and (4) predictive analytics. DISCUSSION: Despite widespread adoption of health IT, patient experiences remain far from optimal. CONCLUSION: The American College of Medical Informatics fellows identified informatics approaches, applications, and research areas that have the potential to improve patient experiences with health care systems.

Qualitative research, the analysis of nonquantitative and nonquantifiable data through methods such as interviews and observation, is integral to the field of biomedical and health informatics. To demonstrate the integrity and quality of their qualitative research, authors should report important elements of their work. This perspective article offers guidance about reporting components of the research, including theory, the research question, sampling, data collection methods, data analysis, results, and discussion. Addressing these points in the paper assists peer reviewers and readers in assessing the rigor of the work and its contribution to the literature. Clearer and more detailed reporting will ensure that qualitative research will continue to be published in informatics, helping researchers disseminate their understanding of people, organizations, context, and sociotechnical relationships as they relate to biomedical and health data.

OBJECTIVE: Successful technological implementations frequently involve individuals who serve as mediators between end users, management, and technology developers. The goal for this project was to evaluate the structure and activities of such mediators in a large-scale electronic health record implementation. MATERIALS AND METHODS: Field notes from observations taken during implementation beginning in November 2017 were analyzed qualitatively using a thematic analysis framework to examine the relationship between specific types of mediators and the type and level of support to end users. RESULTS: We found that support personnel possessing both contextual knowledge of the institution's workflow and training in the new technology were the most successful in mediation of adoption and use. Those that lacked context of either technology or institutional workflow often displayed barriers in communication, trust, and active problem solving. CONCLUSIONS: These findings suggest that institutional investment in technology training and explicit programs to foster skills in mediation, including roles for professionals with career development opportunities, prior to implementation can be beneficial in easing the pain of system transition.

Diana Forsythe, PhD, was a scholar of biomedical informatics, medical anthropology, artificial intelligence (AI), and feminism. With her upbringing by 2 renowned computer scientists, Drs. Alexandra Illmer Forsythe and George Forsythe, she was aware of the hard problems in computer science during her early years. Although she pursued a graduate degree in cultural anthropology and social demography, she went on to introduce methods, frameworks, and insights from the social sciences and the study of science and technology to the nascent fields of AI and biomedical informatics in the 1980s and1990s. The scope of her work was foundational in establishing people and organizational studies as a subdiscipline within biomedical informatics and as a working group with the American Medical Informatics Association (AMIA). Indeed, the current JAMIA editor-in-chief—a colleague of Diana’s at University of California, San Francisco—asked her to attend and reflect upon a 1997 AMIA workshop that brought together nursing vocabulary developers and other key stakeholders to address the topic of implementing nursing vocabularies in computer-based systems. Her reflections, published in JAMIA,1 pointed out the importance of culture and embedded practice in concept naming and questioned the need for a single nursing vocabulary. During her relatively brief career, Diana challenged researchers to understand that technology is never neutral and that attitudes and perspectives of researchers and technology developers profoundly influence fundamental aspects of technology design. Her work consistently challenged the field to pay attention to how people intended to use the technology, the social context within which the technology was implemented, and the potential broader and unintended impacts of technology. Through the rigorous application of qualitative methods through the lens of anthropology, her work identified how these factors influenced the intended users of technology in ways that could be detrimental. Throughout her publications and in the landmark posthumously published collection of essays, Studying Those Who Study Us: An Anthropologist in the World of Artificial Intelligence,2 Diana questioned inherent assumptions about the design and implementation of technology in medicine. In particular, her work reflected and advocated for the rigorous application of social science theory and methods in biomedical informatics research and practice. She also introduced feminist perspectives into analyses of social and technical contexts, emphasizing how the lived experiences of women intersected with technology development, use, and implementation. Toward this end, recent efforts such as the Women in AMIA Initiative and the AMIA First Look Program have sought to raise the visibility of the contributions of women and individuals from groups typically underrepresented in AMIA. As a fierce advocate for feminism and ethnography (ie, a subdiscipline of anthropology), Diana’s interactions with biomedical informatics, at the time a field largely dominated by men with computer science and information technology (IT) perspectives, were not always smooth and seamless. Her work, both as a researcher and an anthropologist, was deeply rooted in a sense of social justice and shed light on the needs and rights of disempowered communities. Additionally, Diana and her colleagues engaged in robust debates regarding rigor, reliability, and validity in qualitative research, including the importance of truly understanding and engaging with social sciences. Since her untimely death in 1997, Diana’s continued influence on the field lives on. As a foundational leader in establishing the important research space that sits at the intersection of social sciences and biomedical informatics, her work sheds light on the relevance of social sciences methods and theories, notably the importance of subjective experience and context, in informatics and computer science fields, which have a dominant perspective of objective reality. Those of us who work in people and organizational spaces in the biomedical informatics field have been profoundly influenced by Diana’s work and have also sought to build on the foundations that she established. The sustained impact of her body of research on the field can be witnessed through discussions at panels at the AMIA Symposium3 and through awards that bear her name including the annual AMIA Diana Forsythe Award honoring an outstanding publication at the intersection of the social sciences and biomedical informatics, the annual American Anthropological Association (AAA) Diana Forsythe Prize, and the Forsythe Dissertation Award for Social Studies of Science, Technology, and Health at the University of California, San Francisco or Stanford University. The definition of biomedical informatics has rapidly evolved over the last 25 years and is recognized today as a truly interdisciplinary field.4,5 This broader definition of the field recognizes the social sciences, human factors engineering, cognitive sciences, and multiple other disciplines as core contributors to continued progress in the field. However, too often, a gap still exists in the published biomedical informatics literature in capturing and representing these perspectives critical to the current healthcare context as new advancements and technologies (eg, mobile health, social media, health information exchange) emerge and as we strive to increase diversity of perspectives in the field. Over the last thirty years, researchers have continued to expand the rigorous application of qualitative methods in informatics and to include representation of patient voices and other stakeholder perspectives in technology design efforts. Thus, the time is ideal for a special issue focused on the continuing legacy of Diana Forsythe in biomedical informatics, identifying the current status of qualitative methods and ethnography in biomedical informatics, and charting a path toward the future. The purpose of our Special Issue was two-fold: to highlight the continued presence of people and organizational focused work in biomedical and health informatics; and to explore future directions for this critically important subdiscipline moving forward. In honoring and continuing Diana’s legacy, this special issue focuses on innovative and interdisciplinary scholarship at the intersection of biomedical informatics and the social sciences. In particular, it highlights the advances in knowledge about: (a) the methods and theories used to understand problems at the intersection of social sciences and informatics; (b) the impact of women and feminism in shaping the field of informatics; and (c) the role of human meaning in developing and implementing health IT and computational tools. Fourteen articles were accepted to this Special Issue from a total of 27 submissions. With the exception of a scoping review,6 all articles reported on original research studies at the intersection of informatics and the social sciences (Table 1). The majority of research studies were conducted in the United States,7–16 with the exception of 3 studies conducted in the United Kingdom,17 Netherlands,18 and Saudi Arabia.19 More than half of the studies were multisite investigations,7,13–18 while 5 studies were single-site8–12 and 1 study used an online context, LinkedIn.19 Most studies received some form of intramural or extramural funding,7,8,10,11,13–15,17 acknowledging the relevance and value of applying methods from social sciences to not only understand but also address research questions and clinical problems within biomedical informatics. In addition to the studies targeted at examining practices of patients and clinicians,8–12,14–17,19 there has been a recent shift toward broadening the scope of the stakeholder population under inquiry—for example, studies included healthcare researchers,13 women managers in the biomedical informatics field,19 and scribes.7 All but 1 study14 used multiple methods for collecting data. Six studies utilized qualitative methods to understand current workflows and gather user needs and design guidelines for health IT,7,8,12,14,16,17 while the remaining studies adopted mixed-methods approaches supported by observations, interviews, and to design and of health Most studies used a by research questions a of were used to the of the at the collection or the interdisciplinary of biomedical informatics, the reported in these studies were from other fields such as human computer computer supported work and social sciences. of studies that qualitative of JAMIA and were in publication over studies were conducted while studies were conducted Studies used interviews, observations, and have typically been the of but there has been an of on healthcare there has been a of qualitative in scope has been with the of qualitative methods used in other fields, such as and science and technology included for and of a broader of qualitative methods by and as as an of in to that to and 27 25 27 during a perspective of that some to included at the of the healthcare and with a or to work sought with the Most were to to the of to patient information of and of to work is in role for have human than in the of be new the role of needs to to be there could be an role for or as as of a new of healthcare and 3 patients and patient of patient The 3 of patient were identified in the patient the patient and and were were with in the shift on the factors can be identified that influence patient and and and future research by the include and in for and methods of critically the culture and of and and to such as and and Women managers in the field of biomedical informatics experiences and experiences meaning of biomedical informatics, meaning of health IT future and and meaning of Saudi in and in understanding the field of informatics not that was an feminist theory have The to be a women not to by attention to the understanding that women not how it to systems. Social have an impact on how women experience and on regarding of health IT and the biomedical informatics field. Studies at and the lived experiences of women in science and technology to the understanding of how these experiences knowledge of these fields in the context of healthcare advancements and work to patient to of cognitive to patient and through practices and patients to could patient to information and a to and individuals into patient and to information and on the of and and interviews, information and and for and and 5 key that health and also identified 3 practice of with health and in and to is and approaches to on context including health, social and the use, and be that the patient and the is not a for or to that the needs of the of health, the of and the and social in which to and to about of and of experience to and include technology to or new of and such information to on and systems. and in perspectives on and collecting on and methods, typically in This the need for and with mixed-methods from to for for future and but not was to working on and health and were critical within to technology included in in information and while included for and to the design of IT that can the needs of population health researchers in such as use of social media, information and tools. be by practice and of that can and human for practices in and for use during and interviews, over collection of of key to identifying and engaging user groups as users of the technology, or the as a as an and and human and in to on the social of with the that in technology the technology to a but of the technology in it to embedded in the the toward also a shift from with technology users to with patients as users and with healthcare as 2 design and of and and of the technology be to and patient and as as understand were multiple of design in informatics example, design researchers to insights and design that not have from or groups and the design a space individuals who could a included or and to individuals and included to medical and with could be to a meaning individuals have over experiences in the can technology through design. 27 and of over the and how this to and and was for patient and nursing time and of was not always and in for patients were both a key of and patient as a lens for understanding work, that can be by informatics to the of and to patient for the field to and design for include the of clinical experiences for technology developers to to the lives of technology and users of clinical to new technologies with and on the needs of patients and in patient during 3 1 medical 1 1 IT IT 1 3 1 1 research and 3 1 and through healthcare and to a health as and the is on the and needs of health to the application in the current health of diversity to a of of the group of patients with in new and were In to the design of patient in design and implementation and need to to with stakeholders to not only understand or to design but also to ways to such into design. a design culture in which the of in is as and a the fields of and on the and health informatics research and design on the is interactions with and with and and was was the as as that but only were regarding were in in the is foundational to of is key to cognitive and to cognitive The the of users were to in during these cognitive reported that and to were key to of The from this have researchers to a on application for for user in the clinical As of and have been in the in to impact on and to clinical and interviews, observations, qualitative Six of the with with 3 by than knowledge and The used health IT to increase to and patient with by health IT and social of and social with health IT for and and of health IT to were to This study how on a social to and with social from and and health IT that to can to health The an for the design and implementation of efforts to and clinical efforts. that qualitative of JAMIA and were in publication over studies were conducted while studies were conducted Studies used interviews, observations, and have typically been the of but there has been an of on healthcare there has been a of qualitative in scope has been with the of qualitative methods used in other fields, such as and science and technology included for and of a broader of qualitative methods by and as as an of in to that to and 27 25 27 during a perspective of that some to included at the of the healthcare and with a or to work sought with the Most were to to the of to patient information of and of to work is in role for have human than in the of be new the role of needs to to be there could be an role for or as as of a new of healthcare and 3 patients and patient of patient The 3 of patient were identified in the patient the patient and and were were with in the shift on the factors can be identified that influence patient and and and future research by the include and in for and methods of critically the culture and of and and to such as and and Women managers in the field of biomedical informatics experiences and experiences meaning of biomedical informatics, meaning of health IT future and and meaning of Saudi in and in understanding the field of informatics not that was an feminist theory have The to be a women not to by attention to the understanding that women not how it to systems. Social have an impact on how women experience and on regarding of health IT and the biomedical informatics field. Studies at and the lived experiences of women in science and technology to the understanding of how these experiences knowledge of these fields in the context of healthcare advancements and work to patient to of cognitive to patient and through practices and patients to could patient to information and a to and individuals into patient and to information and on the of and and interviews, information and and for and and 5 key that health and also identified 3 practice of with health and in and to is and approaches to on context including health, social and the use, and be that the patient and the is not a for or to that the needs of the of health, the of and the and social in which to and to about of and of experience to and include technology to or new of and such information to on and systems. and in perspectives on and collecting on and methods, typically in This the need for and with mixed-methods from to for for future and but not was to working on and health and were critical within to technology included in in information and while included for and to the design of IT that can the needs of population health researchers in such as use of social media, information and tools. be by practice and of that can and human for practices in and for use during and interviews, over collection of of key to identifying and engaging user groups as users of the technology, or the as a as an and and human and in to on the social of with the that in technology the technology to a but of the technology in it to embedded in the the toward also a shift from with technology users to with patients as users and with healthcare as 2 design and of and and of the technology be to and patient and as as understand were multiple of design in informatics example, design researchers to insights and design that not have from or groups and the design a space individuals who could a included or and to individuals and included to medical and with could be to a meaning individuals have over experiences in the can technology through design. 27 and of over the and how this to and and was for patient and nursing time and of was not always and in for patients were both a key of and patient as a lens for understanding work, that can be by informatics to the of and to patient for the field to and design for include the of clinical experiences for technology developers to to the lives of technology and users of clinical to new technologies with and on the needs of patients and in patient during 3 1 medical 1 1 IT IT 1 3 1 1 research and 3 1 and through healthcare and to a health as and the is on the and needs of health to the application in the current health of diversity to a of of the group of patients with in new and were In to the design of patient in design and implementation and need to to with stakeholders to not only understand or to design but also to ways to such into design. a design culture in which the of in is as and a the fields of and on the and health informatics research and design on the is interactions with and with and and was was the as as that but only were regarding were in in the is foundational to of is key to cognitive and to cognitive The the of users were to in during these cognitive reported that and to were key to of The from this have researchers to a on application for for user in the clinical As of and have been in the in to impact on and to clinical and interviews, observations, qualitative Six of the with with 3 by than knowledge and The used health IT to increase to and patient with by health IT and social of and social with health IT for and and of health IT to were to This study how on a social to and with social from and and health IT that to can to health The an for the design and implementation of efforts to and clinical efforts. medical informatics computer supported health information human computer health information for patient of studies that qualitative of JAMIA and were in publication over studies were conducted while studies were conducted Studies used interviews, observations, and have typically been the of but there has been an of on healthcare there has been a of qualitative in scope has been with the of qualitative methods used in other fields, such as and science and technology included for and of a broader of qualitative methods by and as as an of in to that to and 27 25 27 during a perspective of that some to included at the of the healthcare and with a or to work sought with the Most were to to the of to patient information of and of to work is in role for have human than in the of be new the role of needs to to be there could be an role for or as as of a new of healthcare and 3 patients and patient of patient The 3 of patient were identified in the patient the patient and and were were with in the shift on the factors can be identified that influence patient and and and future research by the include and in for and methods of critically the culture and of and and to such as and and Women managers in the field of biomedical informatics experiences and experiences meaning of biomedical informatics, meaning of health IT future and and meaning of Saudi in and in understanding the field of informatics not that was an feminist theory have The to be a women not to by attention to the understanding that women not how it to systems. Social have an impact on how women experience and on regarding of health IT and the biomedical informatics field. Studies at and the lived experiences of women in science and technology to the understanding of how these experiences knowledge of these fields in the context of healthcare advancements and work to patient to of cognitive to patient and through practices and patients to could patient to information and a to and individuals into patient and to information and on the of and and interviews, information and and for and and 5 key that health and also identified 3 practice of with health and in and to is and approaches to on context including health, social and the use, and be that the patient and the is not a for or to that the needs of the of health, the of and the and social in which to and to about of and of experience to and include technology to or new of and such information to on and systems. and in perspectives on and collecting on and methods, typically in This the need for and with mixed-methods from to for for future and but not was to working on and health and were critical within to technology included in in information and while included for and to the design of IT that can the needs of population health researchers in such as use of social media, information and tools. be by practice and of that can and human for practices in and for use during and interviews, over collection of of key to identifying and engaging user groups as users of the technology, or the as a as an and and human and in to on the social of with the that in technology the technology to a but of the technology in it to embedded in the the toward also a shift from with technology users to with patients as users and with healthcare as 2 design and of and and of the technology be to and patient and as as understand were multiple of design in informatics example, design researchers to insights and design that not have from or groups and the design a space individuals who could a included or and to individuals and included to medical and with could be to a meaning individuals have over experiences in the can technology through design. 27 and of over the and how this to and and was for patient and nursing time and of was not always and in for patients were both a key of and patient as a lens for understanding work, that can be by informatics to the of and to patient for the field to and design for include the of clinical experiences for technology developers to to the lives of technology and users of clinical to new technologies with and on the needs of patients and in patient during 3 1 medical 1 1 IT IT 1 3 1 1 research and 3 1 and through healthcare and to a health as and the is on the and needs of health to the application in the current health of diversity to a of of the group of patients with in new and were In to the design of patient in design and implementation and need to to with stakeholders to not only understand or to design but also to ways to such into design. a design culture in which the of in is as and a the fields of and on the and health informatics research and design on the is interactions with and with and and was was the as as that but only were regarding were in in the is foundational to of is key to cognitive and to cognitive The the of users were to in during these cognitive reported that and to were key to of The from this have researchers to a on application for for user in the clinical As of and have been in the in to impact on and to clinical and interviews, observations, qualitative Six of the with with 3 by than knowledge and The used health IT to increase to and patient with by health IT and social of and social with health IT for and and of health IT to were to This study how on a social to and with social from and and health IT that to can to health The an for the design and implementation of efforts to and clinical efforts. that qualitative of JAMIA and were in publication over studies were conducted while studies were conducted Studies used interviews, observations, and have typically been the of but there has been an of on healthcare there has been a of qualitative in scope has been with the of qualitative methods used in other fields, such as and science and technology included for and

OBJECTIVE: Human trafficking is a global problem taking many forms, including sex and labor exploitation. Trafficking victims can be any age, although most trafficking begins when victims are adolescents. Many trafficking victims have contact with health-care providers across various health-care contexts, both for emergency and routine care. MATERIALS AND METHODS: We propose 4 specific areas where medical informatics can assist with combatting trafficking: screening, clinical decision support, community-facing tools, and analytics that are both descriptive and predictive. Efforts to implement health information technology interventions focused on trafficking must be carefully integrated into existing clinical work and connected to community resources to move beyond identification to provide assistance and to support trauma-informed care. RESULTS: We lay forth a research and implementation agenda to integrate human trafficking identification and intervention into routine clinical practice, supported by health information technology. CONCLUSIONS: A sociotechnical systems approach is recommended to ensure interventions address the complex issues involved in assisting victims of human trafficking.

OBJECTIVE: Research to date focused on quantifying team collaboration has relied on identifying shared patients but does not incorporate the major role of communication patterns. The goal of this study was to describe the patterns and volume of communication among care team members involved in treating breast cancer patients. MATERIALS AND METHODS: We analyzed 4 years of communications data from the electronic health record between care team members at Vanderbilt University Medical Center (VUMC). Our cohort of patients diagnosed with breast cancer was identified using the VUMC tumor registry. We classified each care team member participating in electronic messaging by their institutional role and classified physicians by specialty. To identify collaborative patterns, we modeled the data as a social network. RESULTS: Our cohort of 1181 patients was the subject of 322 424 messages sent in 104 210 unique communication threads by 5620 employees. On average, each patient was the subject of 88.2 message threads involving 106.4 employees. Each employee, on average, sent 72.9 messages and was connected to 24.6 collaborators. Nurses and physicians were involved in 98% and 44% of all message threads, respectively. DISCUSSION AND CONCLUSION: Our results suggest that many providers in our study may experience a high volume of messaging work. By using data routinely generated through interaction with the electronic health record, we can begin to evaluate how to iteratively implement and assess initiatives to improve the efficiency of care coordination and reduce unnecessary messaging work across all care team roles.

Increasing access to biomedical informatics experiences is a significant need as the field continues to face workforce challenges. Looking beyond traditional medical school and graduate school pathways into the field is crucial for expanding the number of individuals and increasing diversity in the field. This case report provides an overview of the development and initial implementation of the American Medical Informatics Association (AMIA) High School Scholars Program. Initiated in 2014, the program's primary goal was to provide dissemination opportunities for high school students engaged in biomedical informatics research. We discuss success factors including strong cross-institutional, cross-organizational collaboration and the high quality of high school student submissions to the program. The challenges encountered, especially around working with minors and communicating program expectations clearly, are also discussed. Finally, we present the path forward for the continued evolution of the AMIA High School Scholars Program.

OBJECTIVE: We compare 5 health informatics research projects that applied community-based participatory research (CBPR) approaches with the goal of extending existing CBPR principles to address issues specific to health informatics research. MATERIALS AND METHODS: We conducted a cross-case analysis of 5 diverse case studies with 1 common element: integration of CBPR approaches into health informatics research. After reviewing publications and other case-related materials, all coauthors engaged in collaborative discussions focused on CBPR. Researchers mapped each case to an existing CBPR framework, examined each case individually for success factors and barriers, and identified common patterns across cases. RESULTS: Benefits of applying CBPR approaches to health informatics research across the cases included the following: developing more relevant research with wider impact, greater engagement with diverse populations, improved internal validity, more rapid translation of research into action, and the development of people. Challenges of applying CBPR to health informatics research included requirements to develop strong, sustainable academic-community partnerships and mismatches related to cultural and temporal factors. Several technology-related challenges, including needs to define ownership of technology outputs and to build technical capacity with community partners, also emerged from our analysis. Finally, we created several principles that extended an existing CBPR framework to specifically address health informatics research requirements. CONCLUSIONS: Our cross-case analysis yielded valuable insights regarding CBPR implementation in health informatics research and identified valuable lessons useful for future CBPR-based research. The benefits of applying CBPR approaches can be significant, particularly in engaging populations that are typically underserved by health care and in designing patient-facing technology.

OBJECTIVE: To examine the financial impact health information exchange (HIE) in emergency departments (EDs). MATERIALS AND METHODS: We studied all ED encounters over a 13-month period in which HIE data were accessed in all major emergency departments Memphis, Tennessee. HIE access encounter records were matched with similar encounter records without HIE access. Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms. Our estimates employed generalized estimating equations for logistic regression models adjusted for admission type, length of stay, and Charlson co-morbidity index. Marginal probabilities were used to calculate changes in outcome variables and their financial consequences. RESULTS: HIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied. In 11 EDs directly accessing HIE data only through a secure Web browser, access was associated with a decrease in hospital admissions (adjusted odds ratio (OR)=0.27; p<0001). In a 12th ED relying more on print summaries, HIE access was associated with a decrease in hospital admissions (OR=0.48; p<0001) and statistically significant decreases in head CT use, body CT use, and laboratory test ordering. DISCUSSION: Applied only to the study population, HIE access was associated with an annual cost savings of $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions. CONCLUSION: Access to additional clinical data through HIE in emergency department settings is associated with net societal saving.

OBJECTIVE: The goal of this study was to develop an in-depth understanding of how a health information exchange (HIE) fits into clinical workflow at multiple clinical sites. MATERIALS AND METHODS: The ethnographic qualitative study was conducted over a 9-month period in six emergency departments (ED) and eight ambulatory clinics in Memphis, Tennessee, USA. Data were collected using direct observation, informal interviews during observation, and formal semi-structured interviews. The authors observed for over 180 h, during which providers used the exchange 130 times. RESULTS: HIE-related workflow was modeled for each ED site and ambulatory clinic group and substantial site-to-site workflow differences were identified. Common patterns in HIE-related workflow were also identified across all sites, leading to the development of two role-based workflow models: nurse based and physician based. The workflow elements framework was applied to the two role-based patterns. An in-depth description was developed of how providers integrated HIE into existing clinical workflow, including prompts for HIE use. DISCUSSION: Workflow differed substantially among sites, but two general role-based HIE usage models were identified. Although providers used HIE to improve continuity of patient care, patient-provider trust played a significant role. Types of information retrieved related to roles, with nurses seeking to retrieve recent hospitalization data and more open-ended usage by nurse practitioners and physicians. User and role-specific customization to accommodate differences in workflow and information needs may increase the adoption and use of HIE. CONCLUSION: Understanding end users' perspectives towards HIE technology is crucial to the long-term success of HIE. By applying qualitative methods, an in-depth understanding of HIE usage was developed.

OBJECTIVE: Health information exchange (HIE) systems are being developed across the nation. Understanding approaches taken by existing successful exchanges can help new exchange efforts determine goals and plan implementations. The goal of this study was to explore characteristics of use and users of a successful regional HIE. DESIGN: We used a mixed-method analysis, consisting of cross-sectional audit log data, semi-structured interviews, and direct observation in a sample of emergency departments and ambulatory safety net clinics actively using HIE. For each site, we measured overall usage trends, user logon statistics, and data types accessed by users. We also assessed reasons for use and outcomes of use. RESULTS: Overall, users accessed HIE for 6.8% of all encounters, with higher rates of access for repeat visits, for patients with comorbidities, for patients known to have data in the exchange, and at sites providing HIE access to both nurses and physicians. Discharge summaries and test reports were the most frequently accessed data in the exchange. Providers consistently noted retrieving additional history, preventing repeat tests, comparing new results to retrieved results, and avoiding hospitalizations as a consequence of HIE access. CONCLUSION: HIE use in emergency departments and ambulatory clinics was focused on patients where missing information was believed to be present in the exchange and was related to factors including the roles of people with access, the setting, and other site-specific issues that impacted the overall breadth of routine system use. These data should form an important foundation as other sites embark upon HIE implementation.

The objective of this review was to describe methods used to study and model workflow. The authors included studies set in a variety of industries using qualitative, quantitative and mixed methods. Of the 6221 matching abstracts, 127 articles were included in the final corpus. The authors collected data from each article on researcher perspective, study type, methods type, specific methods, approaches to evaluating quality of results, definition of workflow and dependent variables. Ethnographic observation and interviews were the most frequently used methods. Long study durations revealed the large time commitment required for descriptive workflow research. The most frequently discussed technique for evaluating quality of study results was triangulation. The definition of the term "workflow" and choice of methods for studying workflow varied widely across research areas and researcher perspectives. The authors developed a conceptual framework of workflow-related terminology for use in future research and present this model for use by other researchers.

OBJECTIVES: The goal of the study was to develop an in-depth understanding of work practices, workflow, and information flow in chronic disease care, to facilitate development of context-appropriate informatics tools. DESIGN: The study was conducted over a 10-month period in three ambulatory clinics providing chronic disease care. The authors iteratively collected data using direct observation and semi-structured interviews. MEASUREMENTS: The authors observed all aspects of care in three different chronic disease clinics for over 150 hours, including 157 patient-provider interactions. Observation focused on interactions among people, processes, and technology. Observation data were analyzed through an open coding approach. The authors then developed models of workflow and information flow using Hierarchical Task Analysis and Soft Systems Methodology. The authors also conducted nine semi-structured interviews to confirm and refine the models. RESULTS: The study had three primary outcomes: models of workflow for each clinic, models of information flow for each clinic, and an in-depth description of work practices and the role of health information technology (HIT) in the clinics. The authors identified gaps between the existing HIT functionality and the needs of chronic disease providers. CONCLUSIONS: In response to the analysis of workflow and information flow, the authors developed ten guidelines for design of HIT to support chronic disease care, including recommendations to pursue modular approaches to design that would support disease-specific needs. The study demonstrates the importance of evaluating workflow and information flow in HIT design and implementation.

As health care organizations dramatically increase investment in information technology (IT) and the scope of their IT projects, implementation failures become critical events. Implementation failures cause stress on clinical units, increase risk to patients, and result in massive costs that are often not recoverable. At an estimated 28% success rate, the current level of investment defies management logic. This paper asserts that there are "chasms" in IT implementations that represent risky stages in the process. Contributors to the chasms are classified into four categories: design, management, organization, and assessment. The American College of Medical Informatics symposium participants recommend bold action to better understand problems and challenges in implementation and to improve the ability of organizations to bridge these implementation chasms. The bold action includes the creation of a Team Science for Implementation strategy that allows for participation from multiple institutions to address the long standing and costly implementation issues. The outcomes of this endeavor will include a new focus on interdisciplinary research and an inter-organizational knowledge base of strategies and methods to optimize implementations and subsequent achievement of organizational objectives.