Keywords
International Medical Informatics Association Yearbook - Health Information Exchange
- Health Information - Interoperability - Data Sharing - Health Information Technology
- Electronic Health Records
1. Introduction
Health Information Exchange (HIE) refers to the electronic sharing of a broad range
of health-related information among different healthcare organizations and often disparate
systems [[1],[2]]. This process of information sharing, which can be facilitated by an organization
called an HIE, aims to facilitate access to and retrieval of clinical data to provide
safer, more timely, efficient, effective, and equitable patient-centered care [[1],[3]
[4]
[5]]. By enabling the seamless exchange of medical information, HIEs can help to reduce
the duplication of tests, minimize treatment delays, and enhance clinical decision-making
[[1],[3]
[4]
[5]]. Furthermore, HIEs can play a crucial role in public health by improving the ability
to track and manage diseases and conditions across populations. As healthcare continues
to evolve in the digital age, HIEs are becoming increasingly vital in ensuring that
healthcare providers have the information they need to deliver high-quality care.
Globally, nations have adopted various approaches and levels of HIE. Country-specific
legislative and regulatory policy impacts HIE implementation and governance. There
are differences in data collected, governance, scope, financing, levels of data sharing,
technical and technological infrastructure, maturity and public policy considerations
[[6]
[7]
[8]
[9]].
There are several ways to categorize HIE when discussing how HIE contributes to a
more connected and efficient health care system to enhance the quality of care, lower
the cost of care, and increase care continuity. For example, there are depictions
of “types” of exchange: 1) directed exchange, which allows the secure exchange of
health-related information between health providers [[10]], 2) query-based exchange, which allows providers to search for and retrieve health-related
information on specific people for a specific treatment [[11]], and 3) consumer-mediated exchange, which puts the patient at the center of the
access, management, and sharing of health-related information [[12]]. While various forms of these HIEs exist globally, depending on maturity, each
of these types of HIE can co-exist in the same technological environment and include
the same types of data, but they are more likely to exist in different technical environments
that have expanded the traditional definition of an HIE and include different types
of data with increased specificity, depending on the use and user. Whereas the traditional
perspective of HIE was focused around provider generated exchange (directed exchange
and query-based exchange), HIEs are grappling with how to accommodate consumer-mediated
exchange [[12]]. For example, the survey paper by Dullabh et al. illustrates two different mechanisms for consumer-mediated exchange to occur [[13]]. It is important to note that, regardless of the mechanism, consumer-mediated exchange
involves more than who can see and use what health-related data. Consumer-mediated
exchange can also include consumer-generated data, such as that from implantables
and wearables. Data from implantables, for example a pacemaker, has an element of
data control and therefore may be more trusted than data from wearables, such as a
fitness watch [[14]]. Wearables are often controlled by external applications with application programming
interfaces (APIs) allowing for information to be sent to or accessed by a third party,
and because of this third party, consumer-generated data from wearables, while important
and accurate may not share the same level of trust as that from implantables.
The 2023 articles that were reviewed showed a greater focus on the use of data from HIEs to conduct research and analysis rather than the actual use of the HIE to impact care. While the use of data from HIEs to conduct and inform research was not the focus
of the final paper selections, this shift could suggest that researchers increasingly
believe that the data from HIEs is accurate, adequate, and complete enough to draw
conclusions worthy of integration into a learning health system or knowledge health
system. We also noted more papers describing the use of HIEs from diverse countries,
suggesting that HIE use is maturing worldwide. Global efforts are underway to develop
and adopt the International Patient Summary[1], which is a set of basic patient level, clinical data for use in the case of an
unexpected or unscheduled medical situation (e.g. emergency or accident). While this
does not suggest any level of interoperability to facilitate global exchange of health-related
information, it is encouraging that the potential may exist.
2. About the paper Selection
2. About the paper Selection
In February 2024, with the assistance of a medical librarian, the co-editors conducted
a PubMed and Embase search using MeSH headings, keywords, and synonyms in titles and
abstracts with a focus on HIE. The publication year included first online and print
publications between January 1, 2023 and December 31, 2023, inclusive. The search
strategy is shown in [Table 1].
Table 1.
Search Strategy
|
PubMed
|
|
Embase
|
|
(“Health Information Exchange”[Majr] OR Health-Information-Exchange*[Title/Abstract]
OR Medical-Information-Exchange*[Title/Abstract] OR Clinical-information-system* OR
clinical-pharmacy-information-system*[Title/Abstract] OR health-information-network*[Title/Abstract]
OR health-information-system*[Title/Abstract] OR medical-information-service*[Title/Abstract]
OR is-h-med[Title/Abstract]) AND (“2023/01/01”[Date - Publication] : “2023/12/31”[Date
- Publication])
|
|
‘(‘medical information system'/exp/mj OR ‘health information exchange*’:ab,ti OR ‘medical
information exchange*’:ab,ti OR ‘clinical-information-system*or clinical-pharmacy-information-system*’:ab,ti
OR ‘health information network*’:ab,ti OR ‘health information system*’:ab,ti OR ‘medical
information service*’:ab,ti OR ‘is h med’:ab,ti) AND [2023-2023]/py AND (‘article’/it
OR ‘article in press’/it OR ‘review’/it)
|
All studies were imported into EndNote® for first round deduplication. The remaining studies were imported into Covidence[2] for further deduplication, screening, and analysis. Each of the two section editors
independently screened 752 studies. Inclusion differences were reconciled through
conversation and then by eventual mutual agreement between the section editors. Of
the 12 studies for consideration, five were excluded, resulting in seven studies for
final IMIA Yearbook consideration ([Figure 1]).
Figure 1. PRISMA diagram of literature search (Generated from Covidence.org)
A content summary of the best papers ([Table 2]) can be found in the appendix of this synopsis.
Table 2.
Selection of best papers for the 2024 IMIA Yearbook of Medical Informatics for the
section Health Information Exchange. The articles are listed in alphabetical order
of the first author's surname.
|
Section Health Information Exchange
|
|
Aniekwe C, Cuffe K, Audu I, Nalda N, Ibezim B, Nnakwe M, Anazodo T, Dada M, Romano
ER, Okoye M, Martin M. Assessing the effect of electronic health information exchange
on the completeness and validity of data for measuring viral load testing turnaround
time in Nigeria. International Journal of Medical Informatics. 2023 Jun 1;174:105059.
https://doi.org/10.1016/j.ijmedinf.2023.105059
Sloan-Aagard C, Glenn J, Nañez J, Crawford SB, Currey JC, Hartmann E. The impact of
community health information exchange usage on time to reutilization of hospital services.
The Annals of Family Medicine. 2023 Jan 1;21(1):19-26. https://doi.org/10.1370/afm.2903
|
3. Outlook
The seven candidate best papers for 2023 reflected an increase in international HIE
usage and more attention to the validity of the data retrieved through an HIE. The
use of HIE for public health purposes was noted as a cross-cutting domain where innovative
uses of HIE were recognized. Below, we discuss the major themes of the seven papers
from 2023 that were candidates for being selected as a “Best Paper for 2024 Yearbook
HIE Section”.
3.1 Clinical Services Utilization
Three of the seven studies examined the use of an HIE to impact clinical services
utilization. A study by Adler-Milstein et al. used secondary data sets to identify HIE participation and then looked at the impact
of HIE participation on repeat imaging and hospital admission. This study found that
HIE participation was not associated with decreased repeat imaging [[15]]]. The authors report on hospital admission in terms of admission following a treat-and-release
emergency department (ED) visit, which was associated with a lower likelihood of hospital
admission and admission following discharge, which was associated with a higher likelihood
of admission. A second study examined the availability of patient information and
the impact on repeat diagnostics, primarily in oncology patients in The Netherlands
[[16]]. This study showed that diagnostics were repeated unnecessarily in 15.8% of the
study sample. The last of these three studies, by Sloan-Aagard et al., one of the two papers selected as a best paper for the 2024 Yearbook, is one of
a few studies that looks at clinical services utilization with HIE use of community
primary care physicians [[17]]. Often referred to as the “white space” of electronic health record adoption and
subsequent HIE connectivity, community-based primary care was largely ignored in the
early days of United States (US) regulations incentivizing health data collection,
exchange and reporting. As such, there was little motivation for community physicians
to be HIE participants. The study by Soan-Aagard et al. suggested that querying the HIE had a statistically significant association with
reducing ED visits by 53% and a rehospitalization reduction by 61%. It further showed
that HIE querying was associated with an increased median time to use ED services.
This study is presented in more detail in the appendices of this synopsis.
3.2 Continuity of Care
There have been a number of efforts to associate the use of HIE in contributing to
care continuity, especially in the mental health space and other chronic care conditions
where patients are often “lost” during hand offs [[18]
[19]
[20]]. As such, this study by Itzhaki et al., details the criticality of HIE awareness among all stakeholders prior to HIE-facilitated
information sharing [[21]]. While the findings from this study are not new and have been articulated by others
[[22]], this study is set in Israel where HIEs are less mature than as compared to that
in the US and further illustrates global HIE implementation and use.
3.3 Public and Population Health
Three of the seven studies considered for the IMIA Yearbook cut across HIE and public
or population health illustrating a greater use of HIE in this domain. The first study,
conducted by Feldman et al. (no relation to the co-editor), examined a partnership between Maryland's HIE, Chesapeake
Regional Information System for Our Patients (CRISP), and the Maryland Department
of Health to use CRISP as a transport vehicle for positive COVID-19 test results [[23]]. The use of CRISP as a transport vehicle facilitated more accurate patient matching
and more expeditious contact tracing efforts. While there are other studies detailing
the value of near real-time data transmission of COVID-19 test results [[24],[25]], the innovative use of CRISP to do so made a valuable contribution to the HIE literature
for public health uses and demonstrated a real-world use case that could prove beneficial
in future times of widespread communicable disease situations.
Another innovative use case of HIE for public and population health was for refugees
as they entered a military camp in the US (Indiana) from Afghanistan. What made this
study unique was the fact that 50% of the 6600 refugees were under 18 years, necessitating
an expansion in the traditional public health focus to pediatrics [[26]]. This was further complicated by a concurrent surge in COVID-19 cases in Indiana,
making this use case one of population and public health significance. A centralized refugee inbox was created to facilitate
expeditious and secure communications between providers. Additionally, the creation
of a primary care identifier that was linked to the camp address, allowed for refugees
to have a temporary, yet primary medical home for health data exchange and secure
communications, resulting in almost 2700 messages during the 20-week study period.
Of those 2700 messages, almost 73% were exchanged with the Children's Hospital. Across
all messages, 56% were ED related. It was a bit surprising that only 23% of the messages
were related to laboratory and radiology messages. This study illustrated the utility
for leveraging existing partnerships and a robust HIE to provide healthcare services
for a transient or temporary population.
The last paper to be considered for the IMIA Yearbook, was conducted in Nigeria, and
highlighted the effect of data completeness of HIE data on HIV viral load testing
turnaround times. This study suggested that data completeness increased from 47% pre-HIE
implementation to 67% 6-months post-HIE implementation [[27]]. This study was selected for inclusion in the IMIA Yearbook and is therefore presented
in more detail in the appendices.
4. Conclusion
Studies on HIE published in 2023, of which seven are summarized here, suggested increased
breadth and depth in the use of data from HIEs and the use of HIEs to impact clinical services utilization, continuity of care, and public and
population health. The HIE section editors' note that can be viewed as a follow on
to finding from the 2023 IMIA Yearbook showing HIE being used in more diverse settings
[[3]]. It is further noted that these studies set the stage for more innovation around
the use of HIEs as a transport mechanism to improve care across a variety of unconventional
settings. The survey paper also sets the stage for better integration of HIEs and
consumer-mediated HIE and represents an area ripe for more research in this area,
especially in the use of consumer-generated health information in clinical decision-making.
