One group’s workflow that would be important to consider while designing and implementing a health information exchange would be physicians. Since many of the users of HIE systems that are being developed are clinicians, their workflow and processes would be very important when designing and implementing health information exchanges. With the introduction of new technology, architects need to understand how the technology changes workflow for the users. One example of this is a study that was conducted to understand how HIE implementation changed workflow for multiple practice sites and emergency departments. In this study, they examined both the nurse workflows and the provider workflows. According to the article, “Nurses’ exchange use was highly focused on recent hospital visits and they rarely browsed medical history” while “Nurse practitioners and physicians accessed the exchange for a wider range of reasons than nurses” (Unertl, Johnson, & Lorenzi, 2011). They found that because nurses preferred summaries over raw data, “nurse access to the exchange was often frustrated by summary data unavailability” (Unertl et al., 2011). This is different from physicians, where they “accessed a broader scope of information and browsed more of a patient’s medical history” (Unertl et al., 2011). Knowing the uses of the HIE, the engineers behind the systems would be able to adjust the user experience and offer features that would help users complete their tasks efficiently. In this example, offering summary services to nurses would improve the HIE.

When considering implementing solutions, looking at previous uses is important because it allows for recognition of the failures of these systems and where improvement needs to be made. In another study that evaluated the use of HIE in emergency departments, where researchers found that “the most frequent health information exchange use was for diagnostics, discharge summaries, histories, and physicals” but this usage varied as not all providers used it frequently (Thorn, Carter, & Bailey, 2014). In the article, it is noted that the “core barrier to higher usage is difficulty accessing health information exchange” (Thorn et al., 2014). The providers “ wanted consistent data so that they knew what information was available, reports would be easy to find, and needed information was available” (Thorn et al., 2014).  In this case, designers of the HIE would have to evaluate the user’s responses to find ways to increase usability and improve workflow. For new implementations of HIE, architects need to be sure that they consider the use cases and workflows of the providers so that during implementation the users find the tools helpful. Additionally, during implementation there should be consistent improvement in the HIE to adjust the system to complement the workflow of the providers. This is in line with some of the AHRQ Health IT tools for workflow. When considering the AHRQ Health IT tools for workflow, one of the tools is to assess and adjust workflows. This can be done during the implementation phase and it allows for improvement to the system to ensure that usage rises by making sure the intervention is more beneficial than a burden.

Human factors is “the discipline that tries to optimize the relationship between technology and the human” (Meyer, 2010). To be more precise, human factors “ applies knowledge about human strengths and limitations to the design of interactive systems of people, equipment, and their environment to ensure their effectiveness, safety, and ease of use” (Henricksen et al).  In order to optimize this relationship, usability of the technology is extremely important. This can be done through a user-centered design process, which is “a set of methods to address user needs throughout the product life cycle” (Meyer, 2010). Using human factors and user-centered design will improve the usability and usefulness of technology.

In one area that physicians and nurses get frustrated with health technology is burnout and “click fatigue.” The issues of “click fatigue” comes in when providers spend more time interacting with technology and screens than they do patients. As providers spend less time completing tasks on screens and use less clicks to get the information they need, the more time they have to tackle patient centered tasks. This is important because “70% of doctors using EHRs attribute the bulk of their administrative burden to the software” (Collier, 2018). When the software is optimized for the workflows of the practice, time is saved. This is a human factors issue because the designers of the software must consider the workflows of the users to increase usability and efficiency. Another important factor to note is that researchers have found that “the quality of documentation by medical residents decreased as the number of dialog boxes they had to open to record information increased” (Collier, 2018). Optimizing the software to fit with the workflow of the users without making it overly complicated is important to ensure efficiency and quality.

In terms of health information exchange, this is important because designers of the systems must be able to identify multiple use cases and then tailor the experience to those users. For example, the use of the health information exchange in the emergency department would differ from the use of a pharmacist trying to reconcile a patient’s medication. While the HIE system would be the same, the interface for each user would have to be different depending on their needs. This is where human factors comes in, where architects need to consider the human element, or how the user’s workflow functions, during the design and implementation process.

References

Beth, M. (2016, June 16). Introduction to Human Factors and Usability in Health IT Design. Retrieved October 28, 2020, from http://www.himss.org/News/NewsDetail.aspx?ItemNumber=6088

Collier, R. (2018). Rethinking EHR interfaces to reduce click fatigue and physician burnout. Canadian Medical Association Journal, 190(33). doi:10.1503/cmaj.109-5644

Henricksen et al. Chapter 5. Understanding Adverse Events: A Human Factors Framework

Thorn, S. A., Carter, M. A., & Bailey, J. E. (2014). Emergency Physicians’ Perspectives on Their Use of Health Information Exchange. Annals of Emergency Medicine, 63(3), 329-337. doi:10.1016/j.annemergmed.2013.09.024

Unertl, K. M., Johnson, K. B., & Lorenzi, N. M. (2011). Health information exchange technology on the front lines of healthcare: Workflow factors and patterns of use. Journal of the American Medical Informatics Association, 19(3), 392-400. doi:10.1136/amiajnl-2011-000432

Health information exchange, or HIE, is an important component of health informatics because it helps with the transmission of health data between multiple points of care. HIE efforts work to bring “ information about the patient—regardless of where care or services have been delivered— to the clinician and the care team to enable well-informed, coordinated, patient-centered care” (Health Policy Brief). These systems are intended to allow clinicians to access a patient’s health history regardless of where the patient has previously received care. Additionally, these systems can be beneficial to public health organizations, with them playing “a critical role in many other strategies designed to improve the health of populations, including clinical research, assessing the effectiveness of various treatments, monitoring the safety of medical products, and detecting and responding to health threats” (Health Policy Brief). HIE can provide patient level information that may be beneficial on the population level and can allow public health professionals tools to mitigate disease through surveillance and contact tracing.

Public health is a broad discipline that is tasked with protecting the health of entire populations. This is done through implementing educational programs, recommending policies, administering services and conducting research to prevent the spread and occurrence of health problems. In order to do this, “Public health relies on data reported by healthcare partners to conduct nearly every aspect of its core functions” (Shapiro, Mostashari, Hripcsak, Soulakis, & Kuperman, 2011). Historically, reporting processes have been done manually. However, “information technology offers the opportunity to replace manual reporting processes with automated ones, and innovators are increasingly developing such approaches” (Shapiro et al., 2011). One benefit that public health agencies can receive through the use of health information exchange include the transmission of laboratory reports to public health surveillance programs. For example, health departments could use the information that has been given to them to trigger investigations and contact tracing. The HIE could be a “a gateway to relevant epidemiologic information” and assist with not only surveillance programs but also give users information that they may be interested in (Shapiro et al., 2001).

One example of a public health HIE is the Northwest Public Health Information Exchange, or the NW-PHIE. This health information exchange covers points of care across Washington and Idaho and is used by public health programs to monitor and respond to health emergencies. According to a study that examined the NW-PHIE, it was noted that the organization “has implemented HITSP Biosurveillance standards, developed a specification for sharing summary syndromic surveillance data and demonstrated how the NHIN Gateway and services can be used to support public health surveillance” (Dobbs, Trebatoski, & Revere, 2010). This was done through sending patient-level, transactional data to the public health agencies and creating a process for taking that data to create “a patient encounter record which then gets analyzed to identify incidents of importance to public health” (Dobbs et al., 2010). The data that is sent is meant to be easily imported for the creation of epidemiology curves for public health tracking.

Telehealth allows for health professionals and patients who are separated by a distance to use information and technologies to provide care. This can include the practice of medicine between health providers and patients when they are not in the same location and exchanging information between multiple health professionals (Adeogun, Tiwari, & Alcock, 2011). In one model for telehealth, health information exchange is used in multiple steps of the care process. First, alters can be set up to inform or remind patients to carry out tests or take their medications. Then, patients can send their test results to their health providers when tests have been conducted outside of the provider’s office. Additionally, health professionals can set up alerts for the patient to inform the patient of the arrival of the results or when the results are outside of a set parameter. This can lead to the next stage, where “patients and health professionals have a live dialogue either on the phone or through video conferencing to discuss results and progress of patients” (Adeogun et al., 2011). In order to facilitate the visit, providers would be able to have access to the patient’s health information and check the patient’s compliance to their health regimens. Telehealth allows for better connections to care and helps patients achieve care outside of the traditional setting. In order to make sure this is possible, providers should be able to utilize HIE to make sure both them and patients have access to all of the patients’ information.

One way to illustrate health information exchange is to consider the example of COVID-19 surveillance and reporting. Public health agencies could utilize HIE to gather up to date information from emergency rooms, primary care providers, and testing sites to track population level data and to conduct contact tracing. This is important because patients might be using multiple points of care and tracking this information will allow for better individual care and population level tracking. In one example, a patient may be screened for COVID-19 symptoms through telehealth, obtain testing at a drive through site of Health System A, and have a follow up with a provider in Health System B. For this reason, there has to be a system that allows for patient data to follow the patient so providers at these multiple sites can coordinate care and so public health officials can use this information for contact tracing and disease monitoring. One proposed method of further integrating HIE with COVID-19 surveillance is to “link medical records of COVID-19 patients to their cellular devices and obtain the histories of their movements before diagnosis and of other persons whose cellular devices indicate they came in proximity of these persons” (Lenert & McSwain, 2020). While this method could pose important questions about patient privacy, if implemented properly it could be an important tool that uses the integration of technology and contact tracing methods to improve public health outcomes during the pandemic.

(Lenert & Mcswain, 2020)

Meaningful Use was a policy that was created to promote the meaningful use of certified Electronic Health Record systems. This also included ensuring that EHRs could connect and provide for the electronic transfer of information. During the first stage of Meaningful Use, it was “optional for providers transferring a patient to the care of another provider to furnish that provider with a summary of care record 50 percent of the time, and noted that such information need not be transmitted electronically” (Health Policy Brief). This changed during stage 2, where hospitals and professionals were required to submit a summary of care electronically for “more than 10 percent of transitions of care and referrals” (Health Policy Brief). Additionally, during this stage patients would be able to download and transmit their own information. This is important because the Meaningful Use objectives support the interoperability of EHR technologies, which is essential for HIE. Health information exchange organizations that utilize EHR systems for data input benefited significantly from Meaningful Use because it made sure that these systems were able to output their information to other systems.

Just as HIE has benefited from Meaningful Use objectives, HIE is supported in the Federal Health IT Strategic Plan. One example of this is Objective 1C, which aims to advance the communications infrastructure that supports health delivery. This is also a primary use of HIE, meaning that health information exchanges seek to improve the infrastructure that health data is transmitted on and to ensure the health data can be accessible from many points of care. The next example is Object 2A, which involves enabling individuals, providers, and public health entities to securely transmit and access electronic health information. Again, this objective is directly in line with the goals of many HIE systems because a common goal is that patient data can be accessible from not only providers, but also the patients and public health agencies. Similarly Objective 2B, which is to identify and advance the technical standards to support secure and interoperable health information, helps advance HIE because health information exchanges need consistent standards for health information so different health records can be accessed and incorporated into the HIE.

References

Adeogun, O., Tiwari, A., & Alcock, J. (2011). Models of information exchange for UK telehealth systems. International Journal of Medical Informatics, 80(5), 359-370. doi:10.1016/j.ijmedinf.2011.01.013

Dobbs, D., Trebatoski, M., & Revere, D. (2010). The Northwest Public Health Information Exchange’s Accomplishments in Connecting a Health Information Exchange with Public Health. Online Journal of Public Health Informatics, 2(2). doi:10.5210/ojphi.v2i2.3210

Federal Health IT Strategic Plan

“Health Policy Brief: Interoperability,” Health Affairs, August 11, 2014

Lenert, L., & Mcswain, B. Y. (2020). Balancing health privacy, health information exchange, and research in the context of the COVID-19 pandemic. Journal of the American Medical Informatics Association, 27(6), 963-966. doi:10.1093/jamia/ocaa039

Shapiro, J. S., Mostashari, F., Hripcsak, G., Soulakis, N., & Kuperman, G. (2011). Using Health Information Exchange to Improve Public Health. American Journal of Public Health, 101(4), 616-623. doi:10.2105/ajph.2008.158980