JAMIA: Why do some providers use HIEs and others not?
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Publishing their findings in the May edition of the Journal of the American Medical Informatics Association, Kim M. Unertl, PhD, department of biomedical informatics at Vanderbilt Implementation Sciences Laboratory, and colleagues conducted an ethnographic qualitative study from January to August 2009 in six emergency departments (EDs) and eight ambulatory clinics in Memphis, Tenn.
“Over the past 20 years, various HIE systems have been developed, but many have failed for technological and organizational reasons,” the authors stated. “High-level issues must be addressed to implement an HIE successfully, including disparate health IT infrastructures and vastly different organizational cultures. Much previous HIE research focused on these high-level issues and evaluating impacts on healthcare utilization, public health tracking, return on investment and cost benefits.”
Data were collected using direct observation, informal interviews during observation and formal semi-structured interviews. During 121 hours of ED observation, the researchers observed 91 instances of exchange use and six instances of alternative HIE system use. During 66 hours of observation in the ambulatory environment, they observed 39 instances of exchange use and 12 instances of alternative HIE system use (including external EMR systems, the Tennessee web immunization service and the Tennessee controlled substance monitoring database). The total amount of observation time in individual ED ranged from seven to 38 hours and from four to 13 hours at ambulatory clinic sites.
HIE-related workflow was modeled for each ED site and ambulatory clinic group and substantial site-to-site workflow differences were identified. Unertl and colleagues found common patterns in HIE-related workflow were identified across all sites, leading to the development of two role-based workflow models: nurse-based and physician-based. “The workflow elements framework was applied to the two role-based patterns. An in-depth description was developed of how providers integrated HIE into existing clinical workflow, including prompts for HIE use.”
Workflow differed substantially among sites, but two general role-based HIE usage models were identified, they noted. “Although providers used HIE to improve continuity of patient care, patient–provider trust played a significant role,” they wrote.
Types of information retrieved related to roles, with nurses seeking to retrieve recent hospitalization data and more open-ended usage by nurse practitioners and physicians. User and role-specific customization to accommodate differences in workflow and information needs may increase the adoption and use of HIE.
“Based on observation and interviews, we identified five categories describing reasons for exchange use: other hospital visits, lack of trust in a patient's narrative, communication challenges, referrals and consultations and technology problems,” they found.
The researchers concluded thaht their research addressed a significant gap in the knowledge about the front-line impact of HIE on patient care delivery. “Our next steps include applying workflow research to other HIE projects in project design and implementation stages.”