Turbow is a primary care physician and health services researcher. Ali is a family physician and vice chair of research.
Most people think their doctor has access to all their health information, no matter where they were seen. You’ve probably experienced this firsthand: a patient arrives for an appointment, only for you to lack access to a critical test result, leading to wasted time and a trip back to the lab or imaging center to repeat the same test.
Health information exchanges (HIEs) — electronic systems that share clinical and administrative data between clinics, hospitals, and other settings of care — are supposed to solve this. Not to be confused with EHRs (electronic health records, which are internal only), HIEs are often touted as a solution to the fragmented landscape of healthcare and health information in the U.S., one that can move us into an era where we are not reliant on faxing health records to each other. Their promise has been bolstered by billions of dollars of investment from the federal government, state governments, and industry. However, popular understanding of health information exchange differs markedly from the reality.
First, while most clinicians have access to an HIE, we know well that not all HIEs are connected to each other. As of 2022, 93% of U.S. hospitals reported being able to send and 87% reported being able to receive information via an HIE. While certain key structural barriers have been addressed — such as the achievement of a critical mass of hospitals and health systems participating in electronic information exchange and the incorporation of HIEs into electronic health records — significant challenges remain.
First, the hospitals and clinics that do participate in HIEs don’t all participate in the same HIE. Currently there are an estimated 89 different HIEs available. Unless two hospitals or clinics participate in the same HIE, it is unlikely that they can actually share information. Most popular articles about HIEs treat them as one large entity, when in fact they consist of dozens of smaller networks. Federal and industry efforts to consolidate HIEs, or make them interoperable as well as making them user-friendly, are critical next steps to increasing the effectiveness of health information exchange.
Second, the popular presentation of health information exchange suggests that doctors, nurses, and other clinical staff know how to use HIEs and that they use them all the time. In reality, point-of-care use of HIEs is lagging, with a 2021 study estimating that HIEs were accessed in less than 20% of clinical encounters. To improve patient care, HIEs must be available and be used by clinicians at the point of care.
However, there is no consensus on the best way to use HIEs in different clinical scenarios. We do not know which types of clinicians (primary care, emergency medicine, inpatient doctors, or specialists) gain the most benefit for their patients from using HIEs. We don’t know when in the course of care HIEs can be most impactful — during an emergency department visit to reconcile medications and past medical history? During a specialist visit to look up previous imaging reports? Both? Or neither?
Effective HIE use will likely vary by clinician specialty and practice setting, but HIEs generally do not allow the sort of customization that would allow two different clinicians to mold the information they see in the HIE to meet their specific needs. These factors, plus the age-old challenges of limited time with patients and information overload, have led to a situation where HIEs are available but underutilized. Research into these foundational questions of who should be using the HIE, how they can use it most effectively, and the ideal customization of user interfaces must be conducted in tandem with efforts to expand and improve HIE systems.
Finally, the benefits of HIEs are enumerated in the lay press as fact — for example: health information exchange “minimizes errors, provides efficiency, acts as a support tool, [and] eliminates testing and improves outcomes.” The reality is more complicated: while there are many studies that have found benefits to HIE use, there are many others that have found no benefit. Systematic reviews have not demonstrated a clear benefit of HIEs with convincing evidence across all outcomes. Outcomes such as reductions in mortality, readmissions, and costs have mixed evidence, and the majority of studies cannot convey cause and effect.
HIEs certainly have great promise to reduce waste, increase efficiency, and improve patient outcomes, but more research with stronger study designs is still needed to build the scientific evidence for the impact of HIEs on health and costs of care.
The moral of the story: HIEs have a long way to go! They are a powerful tool that has received significant investments from the government and industry and can be incredibly useful in the care of our patients. But — they are far from perfect.
Clinicians are a key part of the puzzle and must get involved in providing feedback to information technology and administrative leaders about what is or isn’t working and how the technology can be improved to provide better support at the point of care. In addition, clinicians should also continue to try and use HIEs to look up those missing test results before repeating them, as change in healthcare is slow and every bit counts to reduce the astronomical costs and waste present in U.S. healthcare.
Sara Turbow, MD, MPH, is a primary care physician and health services researcher at Emory University School of Medicine in Atlanta. Her research focuses on the causes and effects of care fragmentation in vulnerable populations, such as older adults with Alzheimer’s disease, as well as health information technology solutions to fragmented care. Mohammed K. Ali, MD, MSc, MBA, is a family physician, vice chair of research for the Department of Family and Preventive Medicine, the William H. Foege Professor, and co-director of the Emory Global Diabetes Research Center at Emory University in Atlanta.
Disclosures
Turbow has received funding from the National Institute on Aging/NIH for research related to this work. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Source : MedPageToday