Toward Adopting a Nationwide Health Information Network (NHIN): Promises and Challenges

The future of the U.S. health care system has been the subject of heated debates prior to almost every recent U.S. presidential election. The United States is the only industrialized country that does not provide nationwide health coverage to all its citizens. In addition, the U.S. health care system has to face other challenges. In a 1999 study, it was estimated that between 44,000 and 98,000 American die each year from medical error and inappropriate treatment. Adoption of Electronic Health Records (EHR) systems can extend the efficiencies and effectiveness of health care services in health professionals’ offices and improve the health care quality for patients. An important issue in using EHRs in different health care organizations is the exchange of information and data sharing among different EHR systems. The major problem facing the U.S. health care system is the integration of health information to construct a large-scale ‘network of networks’. Health care organizations throughout the nation have recognized the importance of a transition from the current highly fragmented and disconnected health care information system to a secure and reliable nationwide health care information network for sharing critical health information at the point the clinical decision has to be made. The main goal of Nationwide Healthcare Information Network (NHIN) is to develop a secure, reliable, and interoperable infrastructure that all patients, healthcare providers, and other health care related organizations -like health insurance companies, public health centers, and health care research institutes- will be able to create, update and access the health information they need, at the time, and in the form that is useful regardless of the origin of data

National Health Information Network: Lessons Learned From the USA and the UK

National Health Information Network (NHIN) is a network in which all health care organizations, government agencies and other health-related organizations are connected to each other to exchange information about health. Due to the necessity of a framework for NHIN development, in this paper, according to the literature review, a definition for NHIN framework was provided, and then the NHIN related projects were reviewed in the United States of America (USA) and the United Kingdom (UK), NHIN and National Programme for Information Technology in the NHS (NPfIT), respectively. The Review of NHIN framework in the countries studied show some similarities and differences in each dimension that are discussed in this framework. NHIN guiding principles in the NHS NPfIT were not regarded or were considered incomplete, compared to the US. NHIN architecture in the US is decentralized while it is centralized in the UK. Based on the review of NHIN framework, these two countries represent important points that can be used in many other countries. However, it can be said that the development of NHIN does not only mean the implementation of national system or systems, or the binding of local health information systems, but It also needs to build on a framework in which many of the issues related to the formation of NHIN would be considered; including the cooperation between government, private sector and stakeholders with regard to local, national and international needs

A national clinical decision support infrastructure to enable the widespread and consistent practice of genomic and personalized medicine

<p>Abstract</p> <p>Background</p> <p>In recent years, the completion of the Human Genome Project and other rapid advances in genomics have led to increasing anticipation of an era of genomic and personalized medicine, in which an individual's health is optimized through the use of all available patient data, including data on the individual's genome and its downstream products. Genomic and personalized medicine could transform healthcare systems and catalyze significant reductions in morbidity, mortality, and overall healthcare costs.</p> <p>Discussion</p> <p>Critical to the achievement of more efficient and effective healthcare enabled by genomics is the establishment of a robust, nationwide clinical decision support infrastructure that assists clinicians in their use of genomic assays to guide disease prevention, diagnosis, and therapy. Requisite components of this infrastructure include the standardized representation of genomic and non-genomic patient data across health information systems; centrally managed repositories of computer-processable medical knowledge; and standardized approaches for applying these knowledge resources against patient data to generate and deliver patient-specific care recommendations. Here, we provide recommendations for establishing a national decision support infrastructure for genomic and personalized medicine that fulfills these needs, leverages existing resources, and is aligned with the <it>Roadmap for National Action on Clinical Decision Support </it>commissioned by the U.S. Office of the National Coordinator for Health Information Technology. Critical to the establishment of this infrastructure will be strong leadership and substantial funding from the federal government.</p> <p>Summary</p> <p>A national clinical decision support infrastructure will be required for reaping the full benefits of genomic and personalized medicine. Essential components of this infrastructure include standards for data representation; centrally managed knowledge repositories; and standardized approaches for leveraging these knowledge repositories to generate patient-specific care recommendations at the point of care.</p

Health Information Technology in the United States, 2008

Provides updated survey data on health information technology (HIT) and electronic health records adoption, with a focus on providers serving vulnerable populations. Examines assessments of HIT's effect on the cost and quality of care and emerging issues

Defining Health Information Exchange: Scoping Review of Published Definitions

Objective The term Health Information Exchange (HIE) is often used in health informatics, yet uncertainties remain about its precise meaning. This study aimed to capture and analyse existing definitions in order to map variations in its use and the concepts associated with it. Methods Systematic literature search to identify published definitions of HIE and equivalent terms such as Clinical Information Exchange. Medline, Web of Science, Library Information Science and Technology Abstracts, EMBASE and CINAHL Plus were searched to identify relevant research, and Google to identify grey literature. Searches were not limited by language or date of publication. In order to warrant inclusion documents had to either define the concept explicitly or do so via a concrete description.  Included references were tabulated by author affiliation, source of quote, year of publication, country of origin and definitions and the definitions themselves were analysed thematically. Results Searches revealed 603 scientific articles and 5981 website links. From these, a total of 268 unique definitions of HIE were identified and extracted: 103 from scientific databases and 165 from Google. Eleven constructs emerged from the thematic analysis. Contextual factors influenced the emphasis of the definitions and the framing of HIE as a concept/process, a set of enabling technologies, or an entity/organisation. Conclusions HIE is a complex and evolving concept and uses of the term vary across settings, presenting challenges for communication.  Developing a generic term is difficult, given the importance of context, but the authors suggest one covering key attributes of HIE, which may be helpful

Converging outcomes in nationally shareable electronic health records (NEHRs): An historical institutionalist explanation of similar NEHR outcomes in Australia, England and the United States of America

The adoption of nationally shareable electronic health records (NEHRs) in Australia, England and the United States became major policy and political issues between c1998 and 2015. They continue to be so. As a policy issue, the benefits of ehealth, and subsequently NEHRs as mechanisms for institutional change, were rhetorically popular. Politically however, the development, implementation and regulation of NEHRs proved to be difficult and fraught with criticism from nearly all ehealth stakeholders. The NEHR programs each country pursued at the national level were exceptionally expensive and complex infrastructure undertakings. They involved institutional change management that produced tension amongst stakeholders, required the state to decide on trade-offs that produced winners and losers, and resulted in unintended consequences. Initially, each country approached these policy and political issues differently. Examining why they then had substantially similar outcomes is the substantive puzzle that lies at the centre of this research. This thesis adopts an historical institutionalist approach to explain why state efforts to pursue the development, implementation and regulation of NEHRs at the national level in Australia, England and the United States resulted in substantially similar outcomes despite adopting initially different approaches. The thesis first compares why each case study country pursued ehealth, embarked on organisational change in order to achieve its ehealth and NEHR goals, and adopted NEHRs, noting similarities and major differences. The thesis then compares the state's role in the development of NEHRs at the national level in each country, again noting similarities and differences. A comparative evaluation of the cases is then undertaken in order to explain why each state continued to pursue NEHRs, despite the significant barriers to institutional change they faced. Here, the theoretical concepts of path dependency, critical junctures and incremental change are used to enhance the explanation. The thesis will then explain why the outcomes, as assessed through the lens of public policy evaluation, were substantially similar in each country. Finally, the thesis details the findings of the research through the lens of historical institutionalism and states the significance and implications of the research. The research found that while each case study country approached the policy and political issues of ehealth and NEHRs differently, the outcomes were substantially the same because their goals, and the barriers they faced in trying to achieve them, were very similar. Australia started with a decentralised national health information network (NHIN) then changed to a centralised NEHR. England started with, and continued to pursue, a centralised NEHR. The United States eschewed government development and implementation of an NEHR and took the path of incentivising and regulating electronic health records (EHRs) in an effort to make them nationally shareable. Similar goals across the three countries included moving from a paper to an EHR system; giving patients more control over their health information; making EHRs interoperable; increasing EHR usability and the meaningful use of patient health information; and improving the efficiency and effectiveness of care. Similar barriers included: cost, privacy, trust, stakeholder preferences, and the state attempting to drive change too quickly producing stakeholder resistance and negative outcomes. The thesis findings also provide support for theoretical explanations of institutional stasis and change within the context of path dependency, critical junctures and incremental institutional change

Characterization and Representation of Patient Use of Virtual Health Technology in Primary Care

Purpose. Advances in virtual care technology have made healthcare more convenient and accessible. The goal of this study was to elucidate current patient portal behaviors by examining the pattern of time and service type use of patients, via data provided by access logs within electronic health records, to increase communication and care coordination through online healthcare portals. Methods. We conducted a retrospective study of patients in an academic healthcare center over a 5-year period using access log records in electronic health records (EHR). Dimensionality reduction analysis was applied to group portal functionalities into more interpretable and meaningful feature domains, followed by negative binomial regression analysis to evaluate how patient and practice characteristics affected the use of each feature domain. Results. Patient portal usage was categorized into four feature domains: messaging, health information management, billing/insurance, and resource/education. Individuals having more chronic conditions, lab tests or prescriptions generally had greater patient portal usage. However, patients who were male, elderly, in minority groups, or living in rural areas persistently had lower portal usage. Individuals on public insurance were also less likely than those on commercial insurance to use patient portals, though Medicare patients showed greater portal usage on health information management features and uninsured patients had greater usage on viewing resource/education features. Having Internet access only affected the use of messaging features, but not other feature. Conclusions. Efforts in enrolling patients in online portals does not guarantee patients using the portals to manage their health. While promoting the use of virtual health tools as part of patient-center care delivery model, primary care clinicians need to be aware of technological, socioeconomic, and cultural challenges faced by their patients

An exploration of factors affecting participation in U.S. health information exchange networks : a dual network participation theory based case study.

Background: Failure to achieve their goals of over 200 U.S. Health Information Exchange Networks (HIENs) which formed or operated in the U.S. from 2004 to 2010, lost time, capital and opportunity at individual, organizational and societal levels, and a lack of theory driven research on HIENs underscores a need for research to better understand factors affecting development of these kinds of large, complex collaborations. Purpose: A new dual network participation theory is developed by combining three source theories. The new theory supports integrated consideration of organizational and technological factors which affect participation by individuals and their affiliated organizations in complex collaborations like HIENs. Research questions are formulated focused on advancing knowledge about: types of participation in HIENs; validity of variables used to operationalize the theory; barriers and enablers to participation in HIENs; and implications for theory and research. Method: A retrospective, theory-driven, multi-level, multi-case, mixed methods case study is done using a convenience sample of 6 HIEN sites (network level), 109 individuals (individual level) and 125 organizations (organizational level). Qualitative data is analyzed to develop valid ordinal variables and test hypotheses for each case. Valid ordinal variables are entered into SPSS. A principle component analysis is done to create combined predictor variables. An OLS regression analysis supports identification of predictor effects on intent to participate. Network level analyses identify key influences on the predictors. Findings: Network level barriers to participation include heterogeneity of participants, lack of HIEN resources, lack of qualified leadership, lack of training and education and lack of stable Network IT. Individual/organizational level barriers include lack of support from influential others, low benefit expectancy, lack of knowledge, and high cost expectancy. Recommendations are made for future research studies with enough statistical power for hypothesis testing across larger populations of sites/participants (e.g., 100-300 sites; 1,000 - 3,000 participants). Conclusions: While the use of a small, non-random sample of sites/subjects implies caution regarding generalization, the research yields new insights with implications for both practice and theory. These include preliminary recommendations for improving the success of HIENs and new opportunities for research on barriers and enablers of participation in large scale collaborations

The Impact of Individual Learning on Electronic Health Record Routinization: An Empirical Study

Since the passage of the HITECH Act, adoption of electronic health records (EHR) has increased significantly EHR refers to an electronic version of a patient’s medical history. The adoption of EHR has potential to reduce medical errors, duplication of testing, and delays in treatment. However, current literature indicates that implementation of EHR is not resulting in the automatic routinization of EHR. Routinization refers to the notion that truly successful technological innovations are no longer perceived as being new or out-of-the-ordinary. The complexity of EHRs allow individual users to use these systems at different levels of sophistication. Research shows that healthcare professionals are using non-standard ways to use or circumvent the EHR to complete their work and are limited in EHR systems use. Further, although workarounds may seem necessary to physicians and are not perceived to be problematic, they can pose a threat to patient safety and hinder the potential benefits. Hence, we argue the EHR implementations are limited in their potential due to the lack of routinization. Any new technological innovation requires the physician support and willingness to learn about the system to move to the routinization phase of implementation. Hence, we draw from the literature on organization learning, individual learning, and routines to understand factors that influence EHR routinization

The Impact of Individual Learning on Electronic Health Record Routinization: An Empirical Study

Since the passage of the HITECH Act, adoption of electronic health records (EHR) has increased significantly EHR refers to an electronic version of a patient’s medical history. The adoption of EHR has potential to reduce medical errors, duplication of testing, and delays in treatment. However, current literature indicates that implementation of EHR is not resulting in the automatic routinization of EHR. Routinization refers to the notion that truly successful technological innovations are no longer perceived as being new or out-of-the-ordinary. The complexity of EHRs allow individual users to use these systems at different levels of sophistication. Research shows that healthcare professionals are using non-standard ways to use or circumvent the EHR to complete their work and are limited in EHR systems use. Further, although workarounds may seem necessary to physicians and are not perceived to be problematic, they can pose a threat to patient safety and hinder the potential benefits. Hence, we argue the EHR implementations are limited in their potential due to the lack of routinization. Any new technological innovation requires the physician support and willingness to learn about the system to move to the routinization phase of implementation. Hence, we draw from the literature on organization learning, individual learning, and routines to understand factors that influence EHR routinization