OBJECTIVE: To assess the practice- and market-level factors associated with the amount of provider health information exchange (HIE) use. MATERIALS AND METHODS: Provider and practice-level data was drawn from the Meaningful Use Stage 2 Public Use Files from the Centers for Medicare and Medicaid Services, the Physician Compare National Downloadable File, and the Compendium of US Health Systems, among other sources. We analyzed the relationship between provider HIE use and practice and market factors using multivariable linear regression and compared primary care providers (PCPs) to non-PCPs. Provider volume of HIE use is measured as the percentage of referrals sent with electronic summaries of care (eSCR) reported by eligible providers attesting to the Meaningful Use electronic health record (EHR) incentive program in 2016. RESULTS: Providers used HIE in 49% of referrals; PCPs used HIE in fewer referrals (43%) than non-PCPs (57%). Provider use of products from EHR vendors was negatively related to HIE use, while use of Athenahealth and Greenway Health products were positively related to HIE use. Providers treating, on average, older patients and greater proportions of patients with diabetes used HIE for more referrals. Health system membership, market concentration, and state HIE consent policy were unrelated to provider HIE use. DISCUSSION: HIE use during referrals is low among office-based providers with the capability for exchange, especially PCPs. Practice-level factors were more commonly associated with greater levels of HIE use than market-level factors. CONCLUSION: This furthers the understanding that market forces, like competition, may be related to HIE adoption decisions but are less important for use once adoption has occurred.

Journal of the American Medical Informatics Association, doi: 10.1093/jamia/ocab024 The author name “Julia Adler-Milstein” was incorrectly given as “Julia Adler-Milstien”. This has been corrected online.

Prior research on health information exchange (HIE) typically measured provider usage through surveys or they summarized the availability of HIE services in a healthcare organization. Few studies utilized user log files. Using HIE access log files, we measured HIE use in real-world clinical settings over a 7-year period (2011-2017). Use of HIE increased in inpatient, outpatient, and emergency department (ED) settings. Further, while extant literature has generally viewed the ED as the most relevant setting for HIE, the greatest change in HIE use was observed in the inpatient setting, followed by the ED setting and then the outpatient setting. Our findings suggest that in addition to federal incentives, the implementation of features that address barriers to access (eg, Single Sign On), as well as value-added services (eg, interoperability with external data sources), may be related to the growth in user-initiated HIE.

OBJECTIVE: Many policymakers and advocates assume that directed and query-based health information exchange (HIE) work together to meet organizations' interoperability needs, but this is not grounded in a substantial evidence base. This study sought to clarify the relationship between the usage of these 2 approaches to HIE. MATERIALS AND METHODS: System user log files from a regional HIE organization and electronic health record system were combined to model the usage of HIE associated with a patient visit at 3 federally qualified health centers in New York. Regression models tested the hypothesis that directed HIE usage was associated with query-based usage and adjusted for factors reflective of the FITT (Fit between Individuals, Task & Technology) framework. Follow-up interviews with 8 key informants helped interpret findings. RESULTS: Usage of query-based HIE occurred in 3.1% of encounters and directed HIE in 23.5%. Query-based usage was 0.6 percentage points higher when directed HIE provided imaging information, and 4.8 percentage points higher when directed HIE provided clinical documents. The probability of query-based HIE was lower for specialist visits, higher for postdischarge visits, and higher for encounters with nurse practitioners. Informants used query-based HIE after directed HIE to obtain additional information, support transitions of care, or in cases of abnormal results. DISCUSSION: The complementary nature of directed and query-based HIE indicates that both HIE functionalities should be incorporated into EHR Certification Criteria. CONCLUSIONS: Quantitative and qualitative findings suggest that directed and query-based HIE exist in a complementary manner in ambulatory care settings.

OBJECTIVE: This study evaluated the degree to which recommendations for demographic data standardization improve patient matching accuracy using real-world datasets. MATERIALS AND METHODS: We used 4 manually reviewed datasets, containing a random selection of matches and nonmatches. Matching datasets included health information exchange (HIE) records, public health registry records, Social Security Death Master File records, and newborn screening records. Standardized fields including last name, telephone number, social security number, date of birth, and address. Matching performance was evaluated using 4 metrics: sensitivity, specificity, positive predictive value, and accuracy. RESULTS: Standardizing address was independently associated with improved matching sensitivities for both the public health and HIE datasets of approximately 0.6% and 4.5%. Overall accuracy was unchanged for both datasets due to reduced match specificity. We observed no similar impact for address standardization in the death master file dataset. Standardizing last name yielded improved matching sensitivity of 0.6% for the HIE dataset, while overall accuracy remained the same due to a decrease in match specificity. We noted no similar impact for other datasets. Standardizing other individual fields (telephone, date of birth, or social security number) showed no matching improvements. As standardizing address and last name improved matching sensitivity, we examined the combined effect of address and last name standardization, which showed that standardization improved sensitivity from 81.3% to 91.6% for the HIE dataset. CONCLUSIONS: Data standardization can improve match rates, thus ensuring that patients and clinicians have better data on which to make decisions to enhance care quality and safety.

OBJECTIVE: Enterprise health information exchange (HIE) and a single electronic health record (EHR) vendor solution are 2 information exchange approaches to improve performance and increase the quality of care. This study sought to determine the association between adoption of enterprise HIE vs a single vendor environment and changes in unplanned readmissions. MATERIALS AND METHODS: The association between unplanned 30-day readmissions among adult patients and adoption of enterprise HIE or a single vendor environment was measured in a panel of 211 system-member hospitals from 2010 through 2014 using fixed-effects regression models. Sample hospitals were members of health systems in 7 states. Enterprise HIE was defined as self-reported ability to exchange information with other members of the same health system who used different EHR vendors. A single EHR vendor environment reported exchanging information with other health system members, but all using the same EHR vendor. RESULTS: Enterprise HIE adoption was more common among the study sample than EHR (75% vs 24%). However, adoption of a single EHR vendor environment was associated with a 0.8% reduction in the probability of a readmission within 30 days of discharge. The estimated impact of adopting an enterprise HIE strategy on readmissions was smaller and not statically significant. CONCLUSION: Reductions in the probability of an unplanned readmission after a hospital adopts a single vendor environment suggests that HIE technologies can better support the aim of higher quality care. Additionally, health systems may benefit more from a single vendor environment approach than attempting to foster exchange across multiple EHR vendors.

Introduction: A growing variety of diverse data sources is emerging to better inform health care delivery and health outcomes. We sought to evaluate the capacity for clinical, socioeconomic, and public health data sources to predict the need for various social service referrals among patients at a safety-net hospital. Materials and Methods: We integrated patient clinical data and community-level data representing patients' social determinants of health (SDH) obtained from multiple sources to build random forest decision models to predict the need for any, mental health, dietitian, social work, or other SDH service referrals. To assess the impact of SDH on improving performance, we built separate decision models using clinical and SDH determinants and clinical data only. Results: Decision models predicting the need for any, mental health, and dietitian referrals yielded sensitivity, specificity, and accuracy measures ranging between 60% and 75%. Specificity and accuracy scores for social work and other SDH services ranged between 67% and 77%, while sensitivity scores were between 50% and 63%. Area under the receiver operating characteristic curve values for the decision models ranged between 70% and 78%. Models for predicting the need for any services reported positive predictive values between 65% and 73%. Positive predictive values for predicting individual outcomes were below 40%. Discussion: The need for various social service referrals can be predicted with considerable accuracy using a wide range of readily available clinical and community data that measure socioeconomic and public health conditions. While the use of SDH did not result in significant performance improvements, our approach represents a novel and important application of risk predictive modeling.

Dear Dr Ohno-Machado, We thank Ancker and her colleagues for the insightful comments on our recent article.1 We wholeheartedly agree that the health informatics community should not conclude that social determinants of health (SDH) are not valuable. The literature in this area is growing, and we believe that SDH will continue to play an increasingly significant role in influencing population health. While the specific elements and local context of our work failed to demonstrate clear benefit, our study represented a single community with a novel outcome. As we noted in our article: a more diverse population or geography may have yielded different results; our results may not be generalizable to different outcomes; and that our SDH and public health measures were contextual. This last point is important, as individual and area level measures are different constructs entirely and an analysis, such as ours, is not subject to the ecological fallacy.2 Correlation between predictors is a significant problem; we believe that this was mitigated by our use of Random Forest, which selects random subsets of features to build an ensemble of trees.3 Consistent with the SDH perspective of social, political, and environmental settings, we endeavored to measure, and account for, patient context. We further agree that context is a frequently changing construct and that regularly updated measures are always better. We also believe that more individual level SDH measures would be an improvement. We applaud the Institute of Medicine (IOM) for recommending that SDH be captured in Electronic Health Records,4 as well as the International Classification of Disease (ICD) for enabling SDH collection by introducing additional SDH codes to ICD-10.5 We anticipate that the availability of patient-level SDH will increase as the adoption of these codes increases. Additionally, other patient-level SDH related to an individual’s family/social support may be inferred from his or her family medical history. Conflict of interest statement. None declared.

Objective: Widespread health information exchange (HIE) is a national objective motivated by the promise of improved care and a reduction in costs. Previous reviews have found little rigorous evidence that HIE positively affects these anticipated benefits. However, early studies of HIE were methodologically limited. The purpose of the current study is to review the recent literature on the impact of HIE. Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct our systematic review. PubMed and Scopus databases were used to identify empirical articles that evaluated HIE in the context of a health care outcome. Results: Our search strategy identified 24 articles that included 63 individual analyses. The majority of the studies were from the United States representing 9 states; and about 40% of the included analyses occurred in a handful of HIEs from the state of New York. Seven of the 24 studies used designs suitable for causal inference and all reported some beneficial effect from HIE; none reported adverse effects. Conclusions: The current systematic review found that studies with more rigorous designs all reported benefits from HIE. Such benefits include fewer duplicated procedures, reduced imaging, lower costs, and improved patient safety. We also found that studies evaluating community HIEs were more likely to find benefits than studies that evaluated enterprise HIEs or vendor-mediated exchanges. Overall, these finding bode well for the HIEs ability to deliver on anticipated improvements in care delivery and reduction in costs.

Introduction: U.S. policy on interoperable HIT has focused on increasing inter-system (ie, between different organizations) health information exchange. However, interoperable HIT also supports the movement of information within the same organization (ie, intra-system exchange). Methods: We examined the relationship between hospitals' intra- and inter-system information exchange capabilities among health system hospitals included in the 2010-2014 American Hospital Association's Annual Health Information Technology Survey. We described the factors associated with hospitals that adopted more intra-system than inter-system exchange capability, and explored the extent of new capability adoption among hospitals that reported neither intra- or inter-system information capabilities at baseline. Results: The prevalence of exchange increased over time, but the adoption of inter-system information exchange was slower; when hospitals adopt information exchange, adoption of intra-system exchange was more common. On average during our study period, hospitals could share 4.6 types of information by intra-system exchange, but only 2.7 types of information by inter-system exchange. Controlling for other factors, hospitals exchanged more types of information in an intra-system manner than inter-system when the number of different inpatient EHR vendors in use in health system is larger. Conclusion: Consistent with the U.S. goals for more widely accessible patient information, hospitals' ability to share information has increased over time. However, hospitals are prioritizing within-organizational information exchange over exchange between different organizations. If increasing inter-system exchanges is a desired goal, current market incentives and government policies may be insufficient to overcome hospitals' motivations for pursuing an intra-system-information-exchange-first strategy.

OBJECTIVE: Follow-up with a primary care provider after hospital discharge has been associated with a reduced likelihood of readmission. However, primary care providers are frequently unaware of their patients' hospitalizations. Event notification may be an effective tool for reducing readmissions by notifying primary care providers when their patients have been admitted to and discharged from a hospital. MATERIALS AND METHODS: We examined the effect of an event notification system on 30-day readmissions in the Bronx, New York. The Bronx has among the highest readmission rates in the country and is a particularly challenging setting to improve care due to the low socioeconomic status of the county and high rates of poor health behaviors among its residents. The study cohort included 2559 Medicare fee-for-service beneficiaries associated with 14 141 hospital admissions over the period January 2010 through June 2014. Linear regression models with beneficiary-level fixed-effects were used to estimate the impact of event notifications on readmissions by comparing the likelihood of rehospitalization for a beneficiary before and after event notifications were active. RESULTS: The unadjusted 30-day readmission rate when event notifications were not active was 29.5% compared to 26.5% when alerts were active. Regression estimates indicated that active hospitalization alert services were associated with a 2.9 percentage point reduction in the likelihood of readmission (95% confidence interval: -5.5, -0.4). CONCLUSIONS: Alerting providers through event notifications may be an effective tool for improving the quality and efficiency of care among high-risk populations.

OBJECTIVE: Event notifications are real-time, electronic, automatic alerts to providers of their patients' health care encounters at other facilities. Our objective was to examine the effects of organizational capability and related social/organizational issues upon users' perceptions of the impact of event notifications on quality, efficiency, and satisfaction. MATERIALS AND METHODS: We surveyed representatives (n = 49) of 10 organizations subscribing to the Bronx Regional Health Information Organization's event notification services about organizational capabilities, notification information quality, perceived usage, perceived impact, and organizational and respondent characteristics. The response rate was 89%. Average item scores were used to create an individual domain summary score. The association between the impact of event notifications and organizational characteristics was modeled using random-intercept logistic regression models. RESULTS: Respondents estimated that organizations followed up on the majority (83%) of event notifications. Supportive organizational policies were associated with the perception that event notifications improved quality of care (odds ratio [OR] = 2.12; 95% CI, = 1.05, 4.45), efficiency (OR = 2.06; 95% CI = 1.00, 4.21), and patient satisfaction (OR = 2.56; 95% CI = 1.13, 5.81). Higher quality of event notification information was also associated with a perceived positive impact on quality of care (OR = 2.84; 95% CI = 1.31, 6.12), efficiency (OR = 3.04; 95% CI = 1.38, 6.69), and patient satisfaction (OR = 2.96; 95% CI = 1.25, 7.03). CONCLUSIONS: Health care organizations with appropriate processes, workflows, and staff may be better positioned to use event notifications. Additionally, information quality remains critical in users' assessments and perceptions.

OBJECTIVE: We investigated ways that patient-centered medical homes (PCMHs) are currently using health information technology (IT) for care coordination and what types of health IT are needed to improve care coordination. MATERIALS AND METHODS: A multi-disciplinary team of researchers conducted semi-structured telephone interviews with 28 participants from 3 PCMHs in the United States. Participants included administrators and clinicians from PCMHs, electronic health record (EHR) and health information exchange (HIE) representatives, and policy makers. RESULTS: Participants identified multiple barriers to care coordination using current health IT tools. We identified five areas in which health IT can improve care coordination in PCMHs: 1) monitoring patient populations, 2) notifying clinicians and other staff when specific patients move across care settings, 3) collaborating around patients, 4) reporting activities, and 5) interoperability. To accomplish these tasks, many participants described using homegrown care coordination systems separate from EHRs. DISCUSSION: The participants in this study have resources, experience, and expertise with using health IT for care coordination, yet they still identified multiple areas for improvement. We hypothesize that focusing health IT development in the five areas we identified can enable more effective care coordination. Key findings from this work are that homegrown systems apart from EHRs are currently used to support care coordination and, also, that reporting tools are key components of care coordination. CONCLUSIONS: New health IT that enables monitoring, notifying, collaborating, reporting, and interoperability would enhance care coordination within PCMHs beyond what current health IT enables.

BACKGROUND: Hospital readmissions are common, costly, and offer opportunities for utilization reduction. Electronic health information exchange (HIE) systems may help prevent readmissions by improving access to clinical data by ambulatory providers after discharge from the hospital. OBJECTIVE: We sought to determine the association between HIE system usage and 30-day same-cause hospital readmissions among patients who consented and participated in an operational community-wide HIE during a 6-month period in 2009-2010. METHODS: We identified a retrospective cohort of hospital readmissions among adult patients in the Rochester, New York area. We analyzed claims files from two health plans that insure more than 60% of the area population. To be included in the dataset, patients needed to be continuously enrolled in the health plan with at least one encounter with a participating provider in the 6 months following consent to be included in the HIE system. Each patient appeared in the dataset only once and each discharge could be followed for at least 30 days. RESULTS: We found that accessing patient information in the HIE system in the 30 days after discharge was associated with a 57% lower adjusted odds of readmission (OR 0.43; 95% CI 0.27 to 0.70). The estimated annual savings in the sample from averted readmissions associated with HIE usage was $605 000. CONCLUSIONS: These findings indicate that usage of an electronic HIE system in the ambulatory setting within 30 days after hospital discharge may effectively prevent hospital readmissions, thereby supporting the need for ongoing HIE efforts.

BACKGROUND: Health information technology (HIT) certification and meaningful use are interventions encouraging the adoption of electronic health records (EHRs) in the USA. However, these initiatives also constitute a significant intervention which will change the structure of the EHR market. OBJECTIVE: To describe quantitatively recent changes to both the demand and supply sides of the EHR market. MATERIALS AND METHODS: A cohort of 3447 of hospitals from the HIMSS Analytics Database (2006-10) was created. Using hospital referral regions to define the local market, we determined the percentage of hospitals using paper records, the number of vendors, and local EHR vendor competition using the Herfindahl-Hirschman Index. Changes over time were assessed using a series of regression equations and geographic information systems analyses. RESULTS: Overall, there was movement away from paper records, upward trends in the number of EHR vendors, and greater competition. However, changes differed according to hospital size and region of the country. Changes were greatest for small hospitals, whereas competition and the number of vendors did not change dramatically for large hospitals. DISCUSSION: The EHR market is changing most dramatically for those least equipped to handle broad technological transformation, which underscores the need for continued targeted support. Furthermore, wide variations across the nation indicate a continued role for states in the support of EHR utilization. CONCLUSION: The structure of the EHR market is undergoing substantial changes as desired by the proponents and architects of HIT certification and meaningful use. However, these transformations are not uniform for all hospitals or all the country.

OBJECTIVE: Health information exchange (HIE) is the process of electronically sharing patient-level information between providers. However, where implemented, reports indicate HIE system usage is low. The aim of this study was to determine the factors associated with different types of HIE usage. DESIGN: Cross-sectional analysis of clinical data from emergency room encounters included in an operational HIE effort linked to system user logs using crossed random-intercept logistic regression. MEASUREMENTS: Independent variables included factors indicative of information needs. System usage was measured as none, basic usage, or a novel pattern of usage. RESULTS: The system was accessed for 2.3% of all encounters (6142 out of 271,305). Novel usage patterns were more likely for more complex patients. The odds of HIE usage were lower in the face of time constraints. In contrast to expectations, system usage was lower when the patient was unfamiliar to the facility. LIMITATIONS: Because of differences between HIE efforts and the fact that not all types of HIE usage (ie, public health) could be included in the analysis, results are limited in terms of generalizablity. CONCLUSIONS: This study of actual HIE system usage identifies patients and circumstances in which HIE is more likely to be used and factors that are likely to discourage usage. The paper explores the implications of the findings for system redesign, information integration across exchange partners, and for meaningful usage criteria emerging from provisions of the Health Information Technology for Economic & Clinical Health Act.

Recent federal policies and actions support the adoption of health information exchange (HIE) in order to improve healthcare by addressing fragmented personal health information. However, concerted efforts at facilitating HIE have existed for over two decades in this country. The lessons of these experiences include a recurrence of barriers and challenges beyond those associated with technology. Without new strategies, the current support and methods of facilitating HIE may not address these barriers.

Under the provisions of the Health Information Technology for Economic & Clinical Health act providers need to demonstrate their 'meaningful use' of electronic health record systems' health information exchange (HIE) capability. HIE usage is not a simple construct, but the choice of its measurement must attend to the users, context, and objectives of the system being examined. This review examined how usage is reported in the existing literature and also what conceptualizations of usage might best reflect the nature and objectives of HIE. While existing literature on HIE usage included a diverse set of measures, most were theoretically weak, did not attend to the interplay of measure, level of analysis and architectural strategy, and did not reflect how HIE usage affected the actual process of care. Attention to these issues will provide greater insight into the effects of previously inaccessible information on medical decision-making and the process of care.