Barriers and facilitators to exchanging health information: a systematic review

doi:10.1016/j.ijmedinf.2016.01.004

International Journal of Medical Informatics

Volume 88, April 2016, Pages 44-51

https://doi.org/10.1016/j.ijmedinf.2016.01.004 Get rights and content

Highlights

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HIE that did not meet provider needs or had poor workflow hindered use.
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Incomplete patient data was consistently a barrier in US studies.
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Highest HIE use was in sites with proxy users supporting clinicians.
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Thoughtful workflows and inclusion of users early in HIE design facilitated use.

Abstract

Objectives

We conducted a systematic review of studies assessing facilitators and barriers to use of health information exchange (HIE).

Methods

We searched MEDLINE, PsycINFO, CINAHL, and the Cochrane Library databases between January 1990 and February 2015 using terms related to HIE. English-language studies that identified barriers and facilitators of actual HIE were included. Data on study design, risk of bias, setting, geographic location, characteristics of the HIE, perceived barriers and facilitators to use were extracted and confirmed.

Results

Ten cross-sectional, seven multiple-site case studies, and two before-after studies that included data from several sources (surveys, interviews, focus groups, and observations of users) evaluated perceived barriers and facilitators to HIE use. The most commonly cited barriers to HIE use were incomplete information, inefficient workflow, and reports that the exchanged information that did not meet the needs of users. The review identified several facilitators to use.

Discussion

Incomplete patient information was consistently mentioned in the studies conducted in the US but not mentioned in the few studies conducted outside of the US that take a collective approach toward healthcare. Individual patients and practices in the US may exercise the right to participate (or not) in HIE which effects the completeness of patient information available to be exchanged. Workflow structure and user roles are key but understudied.

Conclusions

We identified several facilitators in the studies that showed promise in promoting electronic health data exchange: obtaining more complete patient information; thoughtful workflow that folds in HIE; and inclusion of users early in implementation.

Introduction

Patients in the US often receive care from multiple providers who practice in unaffiliated organizations. The result is that the patient’s clinical record can be fragmented and incomplete in any one given location. Health information exchange (HIE) is the process of electronically exchanging clinical information across organizational boundaries and seeks to remedy this fragmentation [1]. This exchange occurs among health care providers, across the boundaries of health care institutions, health data repositories, states and countries, typically not within a single organization or among affiliated providers, while protecting the integrity, privacy, and security of the information. Some projections have estimated that HIE effectiveness may manifest in billions of dollars of savings per year all the while improving quality of care [2]. Outside of the US, HIE is also important in other countries with advanced health care systems [3], [4].

The US government as well as other national governments are making substantial investments to further the growth of HIE. Many local governments and individual health organizations are also following suit. As part of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, substantial funding for the creation of HIE was made available and there has been marked growth in HIEs in the US [5].

Since 2009, the number of hospitals and providers exchanging data has sharply increased but perceived barriers to use has not been well described [6]. While organizational involvement and capacity for HIE are increasing, the data about actual use of accessible HIE have been limited and suggest that HIE is still not integrated into usual care [6]. Health professionals are the primary users of HIE systems but little is known about their perceptions of such systems and the barriers they face [6]. A system that the users find slow, confusing and awkward is likely to see little adoption by front-line providers. This article expands on the work conducted as part of a larger systematic review conducted under the auspices of the Agency for Healthcare Research and Quality (AHRQ) and registered as PROSPERO Registry No. CRD42014013285 [6]. The purpose of this article is to describe the current evidence on perceived barriers/facilitators to HIE use. Prior reviews focused on barriers to HIE adoption and implementation, primarily in the US [7], [8], [9].

Section snippets

Materials and methods

HIE was defined as the electronic sharing of clinical information among users to facilitate care coordination and transitions across settings. This excludes exchange of predominantly paper-based information [6]. A standard protocol for the review was developed that incorporated input from key informants and a technical expert panel [10]. Detailed methods and search strategies for the larger review can be found in the technical report [6]. We used the bibliographies of prior reviews [7], [8], [9]

Results

We identified nine multiple site case studies [11], [12], [13], [14], [15], [16], [17], [18], [19], 11 cross-sectional studies [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], and two before-after studies [31], [32]. Fig. 1 depicts the search selection process for the full report [6] and the lower levels of the figure focus on the subset of studies that addressed facilitators and barriers to use (n = 22). All but five [21], [25], [26], [27], [32] of the studies described

Discussion

As part of a systematic review we included 19 studies evaluating perceived barriers and facilitators to HIE use. We found three main themes that hindered or facilitated HIE use: completeness of information, organization and workflow, technology and user needs. Incomplete patient data was consistently mentioned in the studies conducted in the US but not mentioned in the few studies conducted outside of the US. Culturally, individualism and privacy is more highly emphasized in the US than in

Conclusions

Barriers and facilitators fell under three broad themes: completeness of information, organization and workflow, technology and user needs. Sites with proxy users (e.g., nurses, registrars) in the workflow reported the highest HIE use. The evidence was inadequate to compare barriers to HIE use by type of function (query-based or pull vs. directed or pushed exchange) or by type of architecture (centralized or not). Understanding optimal functionality of HIE is challenged by the lack of

Conflicts of interest

None.

Funding

AHRQ funded the review but had no role in study selection, quality assessment, or synthesis. The investigators are solely responsible for the content.

Primary funding support

This project was funded under Contract No. 290-2012-00014-I, Task Order 11, from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. SK’s was also supported by the National Library of Medicine of the National Institutes of Health

Authors’ contributions

All authors made contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version that was submitted.

Summary points

What was already known on the topic

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The number of hospitals and providers exchanging healthcare data has increased significantly since 2009.
•
Prior systematic reviews of HIE focused on

Acknowledgments

The authors gratefully acknowledge the following individuals for their contributions to this project: Andrew Hamilton, M.L.S., M.S., for conducting literature searches and Spencer Dandy, B.S., for assistance with preparing this manuscript (all are located at the Oregon Health & Science University); and Jon White, M.D., Task Order Officer (TOO) at the Agency for Healthcare Research and Quality (AHRQ).

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Review articleBarriers and facilitators to exchanging health information: a systematic review

Highlights

Abstract

Objectives

Methods

Results

Discussion

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Conflicts of interest

Funding

Primary funding support

Authors’ contributions

Acknowledgments

Patient Educ. Couns.

Int. J. Med. Inform.

Ann. Emerg. Med.

Int. J. Med. Inform.

Interact. Comput.

National-scale clinical information exchange in the United Kingdom: lessons for the United States

J. Am. Med. Inform. Assoc.

Widespread adoption of information technology in primary care physician offices in Denmark: a case study

Issue Brief (Commonw Fund)

Usage and effect of health information exchange: a systematic review

Ann. Intern. Med.

Systematic review of health information exchange in primary care practices

J. Am. Board Fam. Med.

The Department of Veterans Affairs, Department of Defense, and Kaiser Permanente Nationwide Health Information Network exchange in San Diego: patient selection, consent, and identity matching

AMIA Annu. Symp. Proc.

The MidSouth eHealth Alliance: use and impact in the first year

AMIA Annu. Symp. Proc.

Health information exchange usage in emergency departments and clinics: the who, what, and why

J. Am. Med. Inform. Assoc.

How could health information exchange better meet the needs of care practitioners?

Appl. Clin. Inform.

Perceptions regarding the ease of use and usefulness of health information exchange systems among medical providers, case managers and non-clinical staff members working in HIV care and community settings

Int. J. Med. Inform.

Review article
Barriers and facilitators to exchanging health information: a systematic review