Health information exchange in small-to-medium sized family medicine practices: Motivators, barriers, and potential facilitators of adoption

doi:10.1016/j.ijmedinf.2009.12.001

International Journal of Medical Informatics

Volume 79, Issue 2, February 2010, Pages 123-129

https://doi.org/10.1016/j.ijmedinf.2009.12.001 Get rights and content

Abstract

Purpose

For small-to-medium sized primary care practices (those with 20 or fewer clinicians), determine desired functions of health information exchange (HIE) and potential motivators, barriers, and facilitators of adoption.

Methods

Case study approach with mixed quantitative and qualitative methods. Nine practices in Colorado were purposively selected. Five used paper records and four were already participating in health information exchange.

Results

Practices particularly desired HIE functions to allow anywhere/anytime lookup of test results and to consolidate delivery of test results. HIE-generated quality reporting was the least desired function. Practices were motivated to adopt HIE to improve the quality and efficiency of care, although they did not anticipate financial gains from adoption. The greatest facilitator of HIE adoption would be technical assistance and support during and after implementation. Financial incentives were also valued. Trust in HIE partners was a major issue, and practices with rich professional and social networks appeared to be especially favorable settings for HIE adoption.

Conclusions

These findings may assist policymakers in promoting adoption of HIE among small-to-medium sized primary care practices, a major component of the US healthcare system.

Introduction

Interoperability will be essential to reap the full value of national investments in health information technology [1]. The estimated annual net value of a fully interoperable health information infrastructure in the US may be as high as $78 billion and may provide positive net value even during the implementation period [2]. In contrast, the estimated value of an incompletely interoperable infrastructure drops to $24 billion with negative value during implementation. States and federal agencies such as the Agency for Healthcare Research and Quality [3] have accordingly made substantial investments in health information exchange (HIE).

However, while the majority of patients receive their primary care in smaller ambulatory practices, involvement of these practices in HIE projects has lagged that of hospitals and large ambulatory care settings [4]. To increase engagement of smaller ambulatory practices in HIE, they must be presented with a clear value proposition for adoption, which may differ from the value proposition for larger organizations [5], [6], [7], [8], [9]. We therefore sought to elucidate the perspectives of clinical and administrative leaders in smaller ambulatory practices regarding desired HIE functions, key motivators for adopting HIE, barriers to adoption, and potential incentives for adoption.

Section snippets

Methods

We used a case study approach, which allowed us to gain a more comprehensive understanding of the issues given the lack of prior research in this area [10]. Through a mixture of telephone and on-site guided discussions we collected and analyzed mixed quantitative and qualitative data to explore motivators, barriers, and potential incentives in depth. Iterative cycles of data collection and analysis were conducted between November 2008 and April 2009. All methods were approved by the Colorado

Description of practices

The nine practices are listed in Table 1. All practices are family medicine practices.

Ultimately, two models of COMMUNITY-HIE were represented. Practices 7–9 were members of “Quality Health Network” (QHN), a traditional regional health information organization (RHIO) in Mesa County, Colorado. QHN provides limited EMR functionality including storage and retrieval of test results and dictated notes, electronic prescribing, and shared medication and allergy lists. QHN does not provide functions to

Discussion

The smaller primary care practices studied varied in their information technology resources and their experiences with HIE but had similar perspectives on the value HIE would provide and the functionality they desired. These practices were motivated to join HIE to improve the quality, coordination, and efficiency of the care they offer. Technical and workflow issues presented the greatest barriers to adoption, and financial issues were also important for some practices. The most valuable

Authors’ contributions

Dr. Ross took primary responsibility for developing the study protocol, which was further refined in consultation with the remaining authors (Dr. Schilling, Mr. Fernald, Dr. Davidson, and Dr. West). Data was collected by Mr. Fernald, generally in conjunction with Dr. Ross and Dr. Schilling. Primary analysis of the data was conducted as a team with Dr. Ross, Dr. Schilling, Mr. Fernald, and Dr. West. During the data collection and analysis phases, Dr. Davidson reviewed interim reports and

Acknowledgements

This study was funded by the Agency for Healthcare Research and Quality (AHRQ) under Primary Care Practice-Based Research Networks Contract # HHSA290200710008. The authors wish to thank Rebecca Roper MS MPH, the Task Order Leader on the contract, for her assistance and advice throughout the study and her thoughtful review of the manuscript.

References (20)

J.M. Marchibroda
Health information exchange policy and evaluation
J. Biomed. Inform.
(2007)
J. Halamka et al.
Health care IT collaboration in Massachusetts: the experience of creating regional connectivity
J. Am. Med. Inform. Assoc.
(2005)
S.L. Penfield et al.
Toward Health Information Liquidity: Realization of Better, More Efficient Care from the Free Flow of Health Information
(2009)
J. Walker et al.
The value of health care information exchange and interoperability
Health Aff. (Millwood)
(2005)
Agency for Healthcare Research and Quality National Resource Center, Available from http://healthit.ahrq.hgov (Accessed...
eHealth Initiative
J.M. Grossman et al.
Creating sustainable local health information exchanges: can barriers to stakeholder participation be overcome?
Res. Briefs
(2008)
R.H. Miller et al.
The Santa Barbara County Care Data Exchange: what happened?
Health Aff. (Millwood)
(2007)
J. Adler-Milstein et al.
The state of regional health information organizations: current activities and financing
Health Aff. (Millwood)
(2008)
S.R. Simon et al.
Correlates of electronic health record adoption in office practices: a statewide survey

There are more references available in the full text version of this article.

Cited by (77)

SOAP classifier for free-text clinical notes with domain-specific pre-trained language models
2024, Expert Systems with Applications
The increasing use of electronic health records (EHRs) in healthcare has led to a significant amount of unstructured clinical text data. This paper proposes a model for classifying free-text clinical notes in the Portuguese language in sentences following the SOAP (Subjective, Objective, Assessment, and Plan) note standard using domain-specific pre-trained language models. Among the five pre-trained BERT models tested, BioBERTptRT achieved the best results with a precision of 0.9461, accuracy of 0.9434, recall of 0.9437, and F1-score of 0.9435. BioBERTptRT, specialized in the Portuguese language, clinical terminology, and the medical group’s domain, outperformed the other models, showing a 0.28% increase in the F1-score compared to the second most specialized model. The proposed model focuses on high-level sentence classification rather than entity-level classification and aims to structure clinical notes at a broader level. The study utilizes a private database of 10,000 anonymized health records containing 234,673 clinical notes. These notes were divided into 1,183,345 unique sentences used to retrain BioBERTptRT. Additionally, 100,021 sentences were manually labeled for use in fine-tuning the models This work contributes to the structuring of clinical notes by showcasing the performance improvements obtained through domain specialization in BERT networks. Additionally, it presents an analysis of the performance gains achieved by BioBERTpt compared to mBERT, both in our study and other related works. Furthermore, this study provides a valuable comparison between the distribution of sentences and the results obtained in this research and similar studies conducted in English.
Identification of barriers affecting the use of health information exchange (HIE) in clinicians' practices: An empirical study in the United States
2022, Technology in Society
Health information exchange (HIE) programs as a policy subject in several developed countries can enable sharing of adequate and accurate information across providers and healthcare organizations to improve care coordination. However, besides the expected benefits of participating in HIE in enhancing coordination, reducing costs, and improving patient safety, previous studies report that clinicians' rate of using HIE mechanisms is still low. Insufficient participation of clinicians in data exchange networks can diminish the value of HIE. Based on utility theory, this study aims to identify and categorize barriers associated with the implementation of HIE projects in healthcare organizations and develop a comprehensive model to empirically examine the effects of HIE inhibitors on clinicians' intention to engage in HIE networks. Data was collected using an online survey from 318 clinicians working in different healthcare settings in the United States. Results show that internal inhibitors (including technological and organizational barriers) and external inhibitors (including partners, patients, vendors, and legal barriers) strongly influence clinicians' intention to engage in HIEs. Taking an integrated approach, this study can contribute to the existing literature by providing a more informed way of conceptualizing and explaining HIE adoption in healthcare organizations. The findings can help HIE decision-makers, healthcare organizations, and providers to identify key HIE inhibitors and take corrective actions to address them. Addressing both internal and external inhibitors would increase the likelihood of widespread implementation of HIEs in different healthcare settings and facilitate interoperability and connectivity in regional and community health information networks.
Institutional factors affecting the electronic health information exchange by ambulatory providers
2021, Health Policy and Technology
Electronic exchange of health information by health entities along the care continuum can vastly improve patient health outcomes as well as reduce costs. To realize the national goal of a health information highway, it is important for a large pool of ambulatory providers to engage in health information exchange (HIE) to share clinical information with affiliated and unaffiliated providers. Applying institutional theory, this research seeks to examine the key institutional factors that influence the HIE use by ambulatory practices.
Data was gathered through a web-based survey of 320 ambulatory providers in the US state of Illinois. Partial least squares approach to structural equation modeling was used to examine the influence of five institutional factors viz. government, patients, peers, affiliates and technology vendors on the use of HIE by ambulatory providers to share clinical information with (i) affiliated providers, and (ii) external, unaffiliated providers.
We found positive and significant influence of government initiatives, patients, peers and affiliates on ambulatory providers’ HIE with affiliated providers (R² = 0.347) and unaffiliated providers (R² = 0.328). Peer influence was positive and significant for HIE with unaffiliated providers only. No significant influence of technology vendors on HIE use by ambulatory practices was found.
Addressing a critical gap in our knowledge of how ambulatory providers engage in HIE, we provide compelling evidence for the influence of institutional factors on ambulatory providers’ electronic HIE with both affiliated and unaffiliated providers. Policy makers and healthcare leaders need to pay attention to the institutional factors and frame appropriate programs to augment and promote the use of HIE by ambulatory providers.
Unfulfilled promises of health information exchange: What inhibits ambulatory clinics from electronically sharing health information?
2021, International Journal of Medical Informatics
Citation Excerpt :
As a bigger partner in a relationship, a larger hospital might realize greater gains from HIE, relative to a smaller ambulatory clinic. Though financial gains and economic incentives could motivate ambulatory clinics to pursue HIE [29], lack of a clear ROI could act as a barrier. Current literature has documented HIE value for emergency departments and larger hospitals [9,68].
This study seeks to understand the key inhibitors for health information exchange (HIE) by ambulatory (outpatient) clinics. We examine the key technological, organizational and environmental factors that inhibit an ambulatory clinic from electronically exchanging health information with external clinics and hospitals.
We utilize survey data from 1285 ambulatory clinics in the US state of Minnesota. Using logistic regressions, we assess if the ambulatory clinic’s HIE with external clinics and external hospitals are associated with fourteen inhibitors from technological, organizational and environmental contexts in which ambulatory clinics operate.
Among the technological inhibitors, we find lack of adequate technological infrastructure, difficulties in integrating external data with electronic medical record systems, and security concerns to inhibit ambulatory clinics’ HIE with both clinics and hospitals. Inadequate technical support was a barrier for HIE with hospitals, whereas inadequate training of staff was an inhibitor for clinic-to-clinic HIE. Of the environmental variables, legal concerns and complexity in framing HIE agreements with partners were found to inhibit ambulatory clinics’ HIE with both external clinics and hospitals. Lack of partner readiness and ability was an inhibiting factor for clinic-to-hospital HIE whereas issues in patient consent, and problems in choosing the right vendor with a good fit were inhibiting ambulatory clinics’ HIE with other clinics. Among the organizational variables, lack of adequate senior leadership support and complexity of workflow changes inhibited clinic-to-clinic health data sharing, whereas unclear return on investment (ROI) for HIE was a deterrent for ambulatory clinics’ HIE with hospitals.
This study throws light on electronic HIE practices and its key inhibitors in ambulatory clinics, an understudied area in digital health. This paper provides unique insights into specific inhibitors that deter clinic-to-clinic health information sharing versus those that affect and clinic-to-hospital health information exchange.
Adoption factors of electronic health record systems
2019, Technology in Society
The main goal of the study is to investigate the factors that affect adoption of EHR systems. The adoption has been looked at through four lenses: users' satisfaction, impact on quality of care, infusion and diffusion of the technology. The study incorporates the results of the most important studies in the field. The findings of the research allow decision-makers to select an EHR that better suits needs of the users, to choose a strategy to avoid users’ resistance and lack of support. The study offers a comprehensive framework that can be used in different settings, i.e. small and large clinics, developing and developed countries, etc. Also it contributes to the state of knowledge, as it provides an extensive analysis of the factors, both system- and user-related, that affect user adoption and proves applicability of TAM in the healthcare settings.
Linking the health data system in the U.S.: Challenges to the benefits
2017, International Journal of Nursing Sciences
Citation Excerpt :
On the other hand, it is crucial to have certification and standardization of vendor applications that can permit clinical data exchange [34]. Technical assistance and support during and after implementation [52] are other facilitators for HIE adoption. Proper human resources should be allocated at the beginning of HIE implementation, and timely and accurate communication is necessary for successful implementation [59].
In order to improve patient care in the United States there, the government made a mandate called HIE (Health Information Exchange). This order was created from the belief that sharing digital health information between, across, and within health communities will improve one's healthcare experience across their lifespan. Patient health information, i.e. the personal health record, should be shareable between healthcare providers; such as private practice physicians, home health agencies, hospitals and nursing care facilities. Most of the U.S. hospitals now have electronic health records, however, with a lack of standards for structuring health information and unified communication protocols to share health information across providers, only a small percentage of U.S. hospitals engage in computerized HIE. In order to understand barriers and facilitators in the U.S. of HIE adoption, we reviewed the published research literature between 2010 and 2015. Our search yielded 664 articles from Medline, PsychInfo, Global health, InSpec, Scopus and Business Source Complete databases. Thirty-nine articles met our inclusion criteria. This article presents the compiled organizational and end user barriers and facilitators along with suggested methods to achieve continuity of care through HIE.

View all citing articles on Scopus

View full text

Health information exchange in small-to-medium sized family medicine practices: Motivators, barriers, and potential facilitators of adoption

Abstract

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Description of practices

Discussion

Authors’ contributions

Acknowledgements

J. Biomed. Inform.

J. Am. Med. Inform. Assoc.

Toward Health Information Liquidity: Realization of Better, More Efficient Care from the Free Flow of Health Information

The value of health care information exchange and interoperability

Health Aff. (Millwood)

Creating sustainable local health information exchanges: can barriers to stakeholder participation be overcome?

Res. Briefs

The Santa Barbara County Care Data Exchange: what happened?

Health Aff. (Millwood)

The state of regional health information organizations: current activities and financing

Health Aff. (Millwood)

Correlates of electronic health record adoption in office practices: a statewide survey