Using Information Technology to Exchange Health Information among Healthcare Providers : Measuring Usage and Understanding Value

Health information exchange (HIE) the electronic exchange of health information among healthcare institutions has been projected to hold enormous promise as an antidote to the fragmented healthcare delivery system in the United States. After decades of mostly failed attempts, we still do not know how to make HIE work. This thesis is the beginning of a systematic understanding of HIE, focusing on the clinical users and the context in which the users and the technology interact. It uses a systems approach to understand HIE from the perspectives of the core stakeholders including healthcare providers, patients, health IT vendor companies, public policy, and the HIE organizations that supply data exchange services. The core contributions of the thesis are contained in four studies. Values of healthcare providers as stakeholders in HIE In a stud y of three communities, healthcare provider organizations were found to expect regional HIE organizations to bring them benefits from the ability to measure care quality. However, one relatively larger community placed greater value on the strategic interests of its individual provider institutions, whereas two smaller communities valued the interests of the communities as a whole. Factors that affect clinicians' usage of HIE. In a study of clinician-users of an operational HIE, usage factors were categorized as motivators and moderators. Motivators for individual clinicians' usage of HIE included improving care quality and time savings. Moderators were numerous and included gaps in data, workflow complexity and usability issues. Several policy options and implications are discussed including: requiring HIE organizations to report metrics of HIE contributions and accesses; certifying HIE vendor companies to provide standardized usage metrics; and creating incentives for clinicians as well as HIE organizations and regional health IT extension centers to meet HIE usage targets. Analysis of opportunities to use HIE. In one community, 51% of visits involved "care transitions" among individual providers, and 36-41% involved care transitions between medical groups. The percentage of a provider's visits which involved care transitions varied considerably by clinical specialty and even within specialties. Within primary care, individual clinicians' "transition percentages" varied from 32% to 95%. This study discusses how policies designed to foster HIE usage should take this variation into account. Analysis of mergers and provider recruitment on HIE value. In a simulation study of patient visit patterns in 10 communities, the results suggest that even after substantial consolidation of medical groups, an HIE would still have considerable value as measured by the number of opportunities for data exchange. However, in each community a small number of medical groups were key: if absent from a community HIE, these groups would reduce the value by 50%. Conversely, if they were the only groups participating, the HIE's value would only achieve 10-20% of its value with all groups participating. The results of these studies suggest that HIE will be needed even in the event of the expected large-scale consolidation of healthcare providers. However, efforts will be needed to recruit medical groups to join HIE organizations, to improve HIE technology, and to train clinicians to integrate HIE into their workflows. Thesis Supervisors: Stuart Madnick Title: John Norris Maguire Professor of Information Technologies and Professor of Engineering Systems