M6-Assignment essay paper
M6-Assignment
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Main Assignment
Assignment Description:
Data-Based Changes
Write a 1500 word essay addressing each of the following points/questions.
Be sure to completely answer all the questions for each number item.
There should be three sections, one for each item number below, as well the introduction (heading is the title of the essay) and conclusion paragraphs.
Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper.
Support your ideas with at least three (4) scholarly citations using APA citations in your essay.
Make sure to reference the citations using the APA writing style for the essay.
The cover page and reference page do not count towards the minimum word amount.
Identify one aspect of big data and data mining that is interesting to you. Explain the concept and how it might bring value to healthcare.
- Describe the concept of continuity planning. If you were the director or manager for your current workplace, describe the preparedness program you would recommend.
- Locate an article discussing the use of informatics in healthcare education of the general public or of nursing students. Discuss the benefits and drawbacks to using technology in this situation and recommendations from the author. Do you feel this use of technology is a viable method of educating (the public or nursing students)? Why or why not?
Start by reading and following these instructions:
- Study the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
- Consider the discussion and the any insights you gained from it.
- Create your Assignment submission and be sure to cite your sources, use APA style as required, check your spelling.
The following specifications are required for this assignment:
- Length: 500 words per essay prompt/section (1500 total for this assignment); answers must thoroughly address the questions in a clear, concise manner.
- Structure: Include a title page and reference page in APA style. These do not count towards the minimal word amount for this assignment. All APA Papers should include an introduction and conclusion.
- References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. Include at least three (4) scholarly sources to support your claims.
Reading assignment for this assignment. – Chapter 14
APA Citation of the book :
Hebda, T. L., Czar, P., & Hunter, K. (2018). Handbook of Informatics for Nurses & Healthcare Professionals (6th Edition). Pearson Education (US). https://bookshelf.vitalsource.com/books/9780134677064
Chapter 14
Health Information Network Models
The preparations for an information network include organizing a governing body and establishing financial sustainability. Several options for operational and business models exist. The US Internal Revenue Service Code, Section 501, and its respective sub-sections, stipulate criteria for organizations to qualify as tax-exempt. Tax-exempt organizations include not-for-profit 501c(3) charitable organizations, 501c(4) social-welfare organizations, and 501c(6) mutual-benefit organizations, as well as virtual businesses linked contractually, but with no separate new entity form; quasi-governmental entities; state agencies; a partnership or limited-liability corporation (LLC) pass-through entity; a special joint-powers authority; or a cooperative (Internal Revenue Service, 2016). The tax-free status for a 501 organization applies to entities that reinvest in the development of services, but these models are not always sustainable due to the challenges of meeting evolving standards. University of Massachusetts Medical School Center for Health Policy and Research (2009) provided information on sustainable models for states to implement sustainable information networks.
Three of the conceptual public-governance models are described as sustainable models (Nolan, Campbell, Thomasian, & Sailors, 2009) and these models exist today. A government-led network with a direct government program, which provides services for the network infrastructure and oversight for the information network, has been used in ten states. In this model, the state government directly runs the health information network through an existing agency, such as the Iowa Department of Public Health with the Iowa Health Information Network (IHIN) and Illinois Health Information Exchange (ILHIE); the Nevada Department of Health and Human Services in their Office of Health Information Technology; and Medicaid Agency with the governor-appointed Alabama Health Information Exchange Advisory Commission (Milken Institute School of Public Health, 2013). These models are subject to government administrative rules and processes, which may limit and delay services associated with legislating changes M6-Assignment.
The second type of sustainable model is a public-utility information network with government oversight, where a public sector serves an oversight role and regulates the private-provided services of the information network. Information networks that are a joint effort of a previously existing state agency and a newly created organization include the Health Care Authority Washington and the OneHealthPort, and CareAccord and the Oregon Health Information Exchange, with similar networks in Florida and Arizona. With this model, the state government creates an agency of the state in the form of a nonprofit authority with comprehensive and extensive powers to operate the state health information network in a businesslike manner. This type of model is accountable to the people of the state through audits, legal oversight, and financial disclosure. These models are foundations for states or regions to provide oversight with or without a level of regulatory control by state governments to exert over the information network’s infrastructure. M6-Assignment
The third type of sustainable model is an information network led by the private sector with government collaboration, where the government acts as a stakeholder and the private sector operates the services. In this model, the state government has contracted health information exchange capabilities to an existing organization. This model exists in 11 states: California, Montana, Texas, New Mexico, Louisiana, Georgia, Indiana, Wisconsin, Rhode Island, and New Jersey. Connecticut uses the Rhode Island information network. The Rhode Island Quality Institute and an Indiana collaborative were early research projects using this model, which were funded by the Agency for Healthcare Research and Quality. These networks are nimble and adaptable to changing service needs. M6-Assignment
A fourth model, existing within 22 states, creates an organization to manage and operate the information network. One example of this model is seen within the Utah Clinical Health Information Exchange (cHIE), which was one of the early research-funded models. Another example is the Massachusetts eHealth Institute, which was developed prior to any 2009 Health Information Technology for Economic and Clinical Health (HITECH) federally funded networks. Two other structures for information networks without an organization exist. One in Nebraska, known as Nebraska Health Information Exchange (NeHIE), is a collaborative of the four largest Nebraska healthcare organizations. The Idaho Health Data Exchange, a nonprofit 501(c)(6) company with volunteers, launched its services in late 2015 to fulfill the federal agenda for all states to connect to a nationwide health information network.
Clinical Data Networks or Health Information Networks
Health information networks have been vendor, community-wide, regional, statewide, and global enterprises, such as at military operating sites (Adler-Milstein, Lin, & Jha, 2016), with a goal to exchange patient-level information. Integrated delivery networks (IDN) and health systems within multiple states are organizations that predate the proposed models for health information networks IDNs have been able to exchange standard content and identifiers adopted across all member hospitals, nursing homes, hospice, homecare, and clinics. All IDNs experienced the challenges of adopting common-information formats and learning new workflows for use cases.
Information network organizations are led by multiple representatives from professional groups and healthcare entities responsible for treatment, payment, and operations. Delaware was the first statewide-initiated health information network, while many before this were regional health information organizations. The Department of Defense and the Veterans Administration healthcare settings have exchanged information between settings, and have collaborated to achieve the same externally with a private healthcare organization (Office of the National Coordinator for Health Information Technology, 2016a). These information networks are centered on patient-care services, and have personal-health records (PHRs) tethered to the hospital or physician office with web-based portals to allow the patient or parent to document symptoms or statuses as in a health-record bank. The two parties upload and download information to help the patient continue care. M6-Assignment
In contrast, clinical-data networks were developed to support research on patient outcomes rather than the care delivered. The National Patient-Centered Clinical Research Network hosts a coordination of clinical-data-research networks (CDRNs) comprised of different types of health systems partnered to conduct research as a network (Timble et al., 2015). These data-research networks involve two or more healthcare systems, and include integrated delivery systems, academic medical centers, and safety-net clinics. Each CDRN will develop capacity to conduct randomized trials and observational comparative-effectiveness studies, using data from specific practices and their patient populations (Timble et al., 2015). Some examples of clinical-data research networks include: the Oregon Community Health Information Network (OCHIN), Greater Plans Collaborative (GPC), PEDSnet, Patient-Centered Network of Learning Health Systems (LHSNet), and Scalable Collaborative Infrastructure for a Learning Healthcare System (SCILHS).
Interoperability
Interoperability is the ability of two or more health information systems to exchange electronic clinical information with, and use electronic clinical information from, other systems (Office of the National Coordinator for Health Information Technology, 2016b). This ability is possible because health information systems are designed using common standards. When provided access to longitudinal information that follows consistent and shared ways of representing the meaning of clinical concepts and terms, healthcare providers quickly identify what the information is and understand the meaning (Office of the National Coordinator for Health Information Technology, 2016b). In 2016, only meaningful-use EHR users designated under the CMS Medicare and Medicaid EHR Incentive Programs and their exchange partners (i.e., behavioral health, long-term care, and post-acute care providers) were required to meet the need for interoperability exchange and use. The short-term goal for 2017 focuses on electronically sending, receiving, and finding queried and requested information; integrating the received information into a patient’s medical record; and the subsequent use of that information (Office of the National Coordinator for Health Information Technology, 2016b). Public health, emergency-medical services, schools, social services, and research consortiums will be engaged after 2017 to exchange interoperable information.
The Medicare Access and CHIP Reauthorization Act of 2015 mandated, among other requirements, that Medicare providers report on how they are using EHRS technology, with an emphasis on interoperability and exchanging information. The Office of the National Coordinator for Health Information Technology (ONCHIT) published the required measures in 2016 and will be implemented by the end of 2018. If identified barriers exist to achieving this interoperability by December 2019, the federal government is asked to recommend actions to achieve interoperability. Nurses and nurse informaticians have a significant role in ensuring that interoperability is achieved. Nurses and other caregivers in all settings (e.g., clinics, homes, schools, community-based resident facilities, and work settings) where healthcare is managed long term need interoperable data to understand the electronic health information received from settings where the patient may have been. The near-term goals are availability of information (i.e., sending, receiving, finding, and using electronic health information) from outside sources (e.g., retail pharmacies, homecare services, long-term resident facilities, schools, and individuals), and use of information from outside sources in decision making and managing care (Office of National Coordinator for Health Information Technology, 2016b). The MACRA 106(b) mandate is for physicians and hospitals to use the outside sources of electronic health information. This goal for interoperability is necessary to augment safety and evidence-based care, as well as decrease inappropriate utilization and increase efficiency.
In 2015, the ONCHIT described three classifications for interoperable data: emerging, pilot, and national. Emerging technical standards and implementation specifications require additional specification by the standards-development community, have not been broadly tested, have no or low adoption, and/or have only been implemented within a local or controlled setting. Pilot technical standards and implementation specifications have reached a level of maturity, specification clarity, and adoption, where some entities use them to exchange health information either in a testing or production environment. National technical standards and implementation specifications have reached a high-level of maturity and adoption by different entities such that most entities are using them, or are readily able to adopt them for use, to exchange health information (Office of the National Coordinator of Health Information Technology, 2016c).
In 2016, the ONCHIT first published interoperability standards describing both standards and implementation specifications. Yearly updates to the interoperability standards are expected following healthcare-provider adoption and use in multiple settings among multiple systems. In Table 14-1, some international standards that impact the documentation of nurses, nurse practitioners, and other healthcare professionals are shared.
Table 14-1 Best Available Interoperability Standards and Implementation Specifications
Type of Need
Standard/Implementation Specifications
Adoption Level
Federally Required
Allergic reactions
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SNOMED CT
Medium-High
No
Allergens: medications
Rx NORM
Medium-High
Yes
Allergens: medications
NDF-RT (value−substance reactant for tolerance)
Unknown
No
Allergens: food substances
SNOMED CT
Unknown
No
Allergens: environmental substances
SNOMED CT
Unknown
No
Care team member
National Provider Identifier (NPI) (not required for non-billable healthcare providers)
Low
No
Patient medical encounter diagnosis
SNOMED CT
Medium-High
Yes
Patient medical encounter diagnosis
ICD-10-CM
Medium-High
Yes
Patient dental encounter diagnosis
SNOMED CT
Medium-High
Yes
Patient race and ethnicity
OMB Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, Oct. 30, 1997
Medium-High
Yes
Patient family health history
SNOMED CT
Medium
No
Functional status/disability
Support varied and not included (ICF or SNOMED CT considered)
Gender identity
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SNOMED CT
Unknown
Yes
Sex at birth
For Male and Female, HL7 Version 3 Value Set for Administrative Gender; For Unknown, HL7 Version 3 Null Flavor
Medium-High
Yes
Patient-identified sexual orientation
SNOMED CT
Unknown
Yes
Immunizations historical
HL7 Standard Code Set CVX—Clinical Vaccines Administered
High-Widespread
Yes
Immunizations historical
HL7 Standard Code Set MVX—Manufacturing Vaccine Formulation
Medium-High
No
Immunizations administered
HL7 Standard Code Set CVX—Clinical Vaccines Administered
High-Widespread
No
Immunizations administered
National Drug Code
High-Widespread
Yes
Patient industry and occupation
Varied support for National Institute for Occupational Safety and Health (NIOSH) list, which includes an Industry and Occupation Computerized Coding System (NIOCCS), US Department of Labor, Bureau of Labor Statistics, Standard Occupational Classification, and National Uniform Claim Committee Health Care Taxonomy (NUCC) codes standards
Numerical laboratory test results
LOINC
Medium
Yes
Medications
RxNorm
High-Widespread
Yes
Medications
National Drug Code (NDC)
Medium
No
Medications
National Drug File—Reference Terminology (NDF-RT)
Medium
No
Units of measure (numerical references and values)
The Unified Code for Units of Measure
Low-Medium
Yes
Patient clinical problems and conditions
SNOMED CT
High-Widespread
Yes
Patient preferred language
RFC 5646
Unknown
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Yes
Dental procedures performed
Code on Dental Procedures and Nomenclature CDT
Medium-High
Yes
Dental procedures performed
SNOMED CT
High-Widespread
Yes
Medical procedures performed
SNOMED CT
High-Widespread
Yes
Medical procedures performed
CPT-4/HCPCS
High-Widespread
Yes
Medical procedures performed
IDC-10-PCS
Medium-High
Yes
Imaging (diagnostic, interventions, procedures)
LOINC
Low-Medium
No
Tobacco use
SNOMED CT
High-Widespread
Yes
Unique implantable device identifiers
Unique device identifier as defined by the Food and Drug Administration at 21 CFR 830.3
Low
Yes
Patient vital signs
LOINC
High-Widespread
Yes
Notification of patients’ admission, discharge, and transfer status to other providers
HL7 2.5.1
High-Widespread
No
Patient care plans—standard
HL7 Clinical Document Architecture (CDA), Release 2.0, Final Edition
High-Widespread
Yes
Patient care plans—implementation specifications
HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes (US Realm), Draft Standard for Trial Use, Release 2.1
Unknown
Yes
Shareable clinical decision support
HL7 Implementation Guide: Clinical Decision Support Knowledge Artifact Implementation Guide, Release 1.3, Draft Standard for Trial Use.
Unknown
No
Electronic prescribing—implementation specification
NCPDP SCRIPT Standard, Implementation Guide, Version 10.6
High-Widespread
Yes
Prescription refill request—implementation specification
NCPDP SCRIPT Standard, Implementation Guide, Version 10.6
Medium-High
Yes
Cancel a prescription—implementation specification
NCPDP SCRIPT Standard, Implementation Guide, Version 10.6
Unknown
Yes
Medical imaging formats for data exchange and distribution
Digitalized Imaging and Communications in Medicine (DICOM)
High-Widespread
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No
Format for medical imaging reports for exchange and distribution—standards
DICOM
High-Widespread
No
Format for medical imaging reports for exchange and distribution—implementation
PS3.20 DICOM Standard-Part 20: Imaging Reports using HL7 Clinical Document Architecture
Low
No
Receive electronic laboratory reports—standard
HL7 2.5.1
High-Widespread
No
Receive electronic lab reports— implementation specifications
HL7 Version 2.5.1 Implementation Guide: S&I Framework Lab Results Interface, Release 1—US Realm [HL7 Version 2.5.1: ORU_R01] Draft Standard for Trial Use, July 2012
Medium-High
Yes
Ordering labs for a patient—standard
HL7 2.5.1
High-Widespread
No
Ordering labs—implementation specifications
HL7 Version 2.5.1 Implementation Guide: S&I Framework Laboratory Orders from EHR, Release 1 DSTU Release 2—US Realm
Low
No
Patient education materials—standard
HL7 3 standard: Context aware knowledge retrieval application (Infobutton). Knowledge Request Release 2
Medium-High
Yes
Patient education materials— implementation specifications
HL7 Implementation Guide: Service-Oriented Architecture Implementations of the Context-aware Knowledge Retrieval (Infobutton) Domain, Release 1.
Medium
Yes
Patient education materials— implementation specifications
HL7 Version 3 Implementation Guide: Context-Aware Knowledge Retrieval (Infobutton), Release 4.
Medium
Yes
Reporting antimicrobial and resistance information to public health agencies
HL7 Clinical Document Architecture (CDA), Release 2.0, Final Edition
High-Widespread
No
Reporting antimicrobial and resistance information to public health agencies
HL7 Implementation Guide for CDA Release 2—Level 3: Healthcare Associated Infection Reports, Release 1, US Realm.
Low
Yes
Reporting cancer cases to public health agencies
HL7 Clinical Document Architecture (CDA), Release 2.0, Final Edition
High-Widespread
Yes
Transition of care or referral to another healthcare provider—standard
HLT Clinical Document Architecture, (CDA), Release 2.0, Final Edition
High-Widespread
No
Transition of care or referral to another healthcare provider—implementation specifications
Consolidated CDA Release 1.1 (HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, DSTU Release 1.1—US Realm)
High-Widespread
Yes
Nursing assessments (observations)
LOINC or SNOMED CT
Unknown
No
Outcomes of nursing
LOINC
Unknown
No
Nursing diagnoses (problems, risks, needs)
SNOMED CT
Unknown
No
Nursing interventions (procedures)
SNOMED CT
Unknown
No
Reference: 2016 Interoperability Standards Advisory from Office of National Coordinator for Health IT.
International Standards
The harmonization of concepts and data normalization are both necessary to achieve a level of interoperability, allowing reuse of information for multiple purposes. This interoperability requires international standards, as noted in Table 14-1, to share patient health and care information, initially, for healthcare professionals to provide care and, subsequently, for public-health use and for researchers to generate new evidence. For example, the physicians’ and nurses’ documentation of patients’ clinical problems and conditions uses SNOMED CT, an international standard terminology, in the problem list. The international standards work to communicate the patients’ conditions among healthcare professionals, as well as for patients and families. Patients, family members, and even new healthcare professionals who do not understand what these problems and conditions represent can use knowledge databases to search, not only the definition of the condition, but also the knowledge context associated with the condition. Medical-knowledge databases and medical journals are frequently linked to electronic patient-record systems to support searching medical conditions. Drug databases may be purchased and linked to the electronic patient-record and pharmacy systems for searching. Nursing-knowledge databases and nursing journals for nursing diagnoses, nursing problems, problem risks, and needs for health enhancement and interventions may be linked as well; these sources are not linked as often as medical sources. Publishers have translated the knowledge databases into multiple languages to inform healthcare professionals, patients, and the general public. International standards are necessary to communicate information worldwide and, when linked to appropriate translated knowledge resources, provide meaning for intelligent or learned use of the information and knowledge when making decisions. Consequently, users not only need the terms, but also the knowledge context to support accurate meaning for decision making in managing care. Not all health information technology (HIT) meets the demands of a broad scope of healthcare professionals and patient users.
Not all standards are developed in a method that fully supports nurses’ practices when coordinating nursing care across many settings, and helping patients and families continue healthcare. Extra steps are necessary for including details for treatment plans, health-enhancement plans, and risk-aversion interventions until the electronic health information systems meet the demands for decision making and managing care for all populations in all settings. Current electronic health information systems remain inadequate for vulnerable populations at home, such as infants and children with genetic disorders associated with developmental delays, congenital disorders, and unknown developmental and genetic disorders. The current standard for the plan of care constructed by the HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes lacks the nursing-process details that support this population (Lavin, Harper, Barr, 2015; Gonzalez, 2014). Therefore, nurses need to communicate the additional electronic information and not assume that the continuity of care document standards have achieved the communication intended for the next level of care, whether for homecare nursing services, school nurse, or other setting.
Using the consolidated CDA guide as an example, all healthcare professionals need to understand the intentions of interoperability and how these standards support healthcare professionals. The CDA templates of the future will incorporate and harmonize previous efforts from HL7: Integrating the Healthcare Enterprise Patient Care Coordination (IHE), the Continuity of Care Document, and the HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component.
The updates for clinical notes that could help support the CDA Release 2 for Patient Care Plan include the Home Health Plan of Care (HHPoC), Consultation Note, Continuity of Care Document (CCD), Diagnostic Imaging Reports (DIR), Discharge Summary, History, and Physical (H&P), Operative Note, Procedure Note, Progress Note, Referral Note, Transfer Summary, and Unstructured Document, and Patient Generated Document (US Realm Header).
Additionally, the Commission for Certification of Health Information Technology (CCHIT) (Heo et al., 2012) was a regulating body that certified HIT, using the American National Standards Institute (ANSI) standards and Health Information Technology Standards Committee (HITSC) standards. The technical standards for transport of health information to and from electronic destinations include industry-recognized transport types (e.g., Internet Protocol Version 6) and the recipient’s technical capability (e.g., broadband, electronic, fax, and print). The Federal Communications Commission (FCC) collaborates with the Department of Health and Human Services (DHHS) to ensure the connectivity bandwidth for download and upload speed requirements—upload speeds greater than 200 kilobytes per second (kbps)—for broadband connections to support rural settings with HIT. At this time, a number of carriers are now offering download speeds of 1.5 Mbps and 3.0 Mbps, and an estimated 3,600 out of approximately 307,000 small providers face a broadband connectivity gap below required FCC recommendations (Federal Communications Commission, 2010).
Nationwide Health Information Network
Nationwide Health Information Network (NHIN) is broadly defined as the set of standards, specifications, and policies that support the secure exchange of health information over the Internet (Public Health Data Standards Consortium, 2018). The Office of the National Coordinator for Health Information Technology is responsible for the support and promotion of the adoption of information technology and health information exchange (HealthIT.gov, 2017). Working with the Health Information Technology Standards Committee (HITSC), the Office of the National Coordinator outlined a standards and interoperability framework with principles and processes for the NHIN. The framework for the NHIN identified standards and implementation guides for the use cases (e.g., practice and services). In 2016, the ONCHIT (2016b) published the best available interoperability standards and implementation specifications. The implementation specifications included programs of tools and services to guide the implementation of standards, allowing interoperable exchange of information. The interoperability standards, highlighted in Table 14-1, allow providers, organizations, and agencies to join the national network to exchange health information when participating in state or regional networks. M6-Assignment
The NHIN is a set of standards, services, and policies that will bring together the state-level HIE and community health information organizations (HIOs) when all stakeholders are using the evolving information-exchange standards (Adler-Milstein et al., 2016). Kuperman and McGowan (2013) identified concerns with the completeness, accuracy, and timeliness in accessing and using the exchanged information during the provider’s clinical workflow, and that the information presented for the physician may not be sufficient for the care coordinator’s work, and could lead to unintended consequences when integrated into practice. This network has already connected a diverse set of federal agencies and private organizations that needed to securely share reliable electronic health-related information in the past five years (Department of Health and Human Services, 2016). The state-level HIE programs are responsible for organizing and facilitating the implementation of interoperability standards among stakeholders through state-wide operational planning. The state-wide information network ensures all stakeholders and communities are included, rather than excluded, and can legislate the standards to carry out functions through a single entity accountable to the citizens. The role of the state-level HIE program is to adapt to the state’s needs and priorities, based on the characteristics of providers taken from an evaluation of current HIT use. The agencies, such as public health and Medicaid services within the state government, are stakeholders and will be involved with HIE services. The success for the NHIN is dependent on the information networks. Implications of Interoperability
When the NHIN was first envisioned more than a decade ago, the issue for healthcare professionals was how to use the HIE; that is, how to query patient records and find providers to share and receive patient information. This is a process for bidirectional sharing of patient health-related information among primary providers (nurse practitioners, physicians, and physician assistants), consulting specialists, hospitals, ambulatory centers, nursing homes, post-acute providers, dentists, audiologists, optometrists, and occupational and school-health professionals. Each citizen contributes to the collection of health information when participating in interviews at healthcare settings, when applying for a job or position that requires physical and cognitive abilities to perform occupational tasks, or when participating in school activities.
The electronic health record (EHR) and personal health record (PHR) are tools that provide background information on individual abilities and disabilities (such as vision, hearing, and mobility). The records include common elements that support decisions, such as immunization status, allergies (foods, environment, and medications), values (preferences, and cultural and religious beliefs), social habits (alcohol or tobacco use), family history, advance directives, and insurance coverage or noncoverage. The health record is about health patterns and functioning, using information to keep persons safe and healthy, and not just for medical conditions or diseases. A visit to a primary-care practitioner or urgent clinic allows providers to access the information through a record-locator application to obtain the person’s allergies or past history. This past health information, once validated by a clinician, helps ensure appropriate selection of interventions or medications for safe care.
Process and Use Cases for Health Information Exchange
A health information exchange (HIE) is defined as the electronic movement of health-related information or clinical data that follows patients across delivery settings, according to nationally recognized standards (Adler-Milstein et al., 2016). Adler-Milstein et al. (2016) found healthcare organizations were in agreement that broad-based HIE was needed to improve care and should support multiple approaches to HIE. The HIE processes have been developed to support a geographic region by a community of stakeholders or within a state health information network. A national survey identified 106 operational HIE network, community, and regional organizations providing services to over a third of all US providers in 2014 (Adler-Milstein et al., 2016). The organizations provide oversight in authorizing the infrastructure, location of health information, and the secure transfer and reuse of that health information electronically.
The HIE network sustains operations through a membership fee, where stakeholders pay to support shared services for all. The fees may be tiered toward size or volume of activity, or may be based on relative value to each type of participant. Another method to sustain operations is through a transaction fee where the regional or state-level network charges transaction fees for services or products on the basis of benefit to the participants. The fees could be for clinical results delivered, covered life per month, each hour of technical assistance, or monthly use of an HIE application. Additionally, a program and service fee is charged to stakeholders for participation in the HIE services, or for purchasing and implementing the HIE program. Some HIEs do not charge a fee to physicians and nurse practitioners for access to patient information, such as laboratory results, pathology reports, diagnostics reports, discharge summaries, and consultation reports. This is not a universal practice with all HIEs, and professional providers may be charged a fee for transactions when using the HIE. When the data are used for group-practice management, eprescribing, EHR-lite (i.e., basic components of EHR data), quality-measures monitoring, biomedical devices, and pharmaceutical manufacturers, fees are considered for use of the HIE. Only half of the 106 operational HIE networks and community-based organizations reported they were financially viable without government support in 2014 (Alder-Milstein et al., 2016). The secondary use of data for profit presents ethical concerns that consumers and participating providers will raise as HIPAA violations. The third-party payers have provided incentives for HIE participating providers by offering quicker reimbursements and payment for performance. CMS has offered meaningful-use incentives due to the HITECH Act, which encouraged adoption and implementation of electronic health records in eligible provider practices and hospitals. This practice resulted in disincentives for nonuse of EHRs and HIEs after 2014.
Key Factors
Health information exchanges are used for patient-care treatment, healthcare operations, and payment. The use of HIE to acquire lab results and patient summaries in primary care practices for individual patient care ranged from 55% in New Zealand to 14% in Canada, while the United States was around 31% with greater use seen in large integrated health systems (Schoen et al., 2012). Healthcare operations use included options for professional clinical decision making to diagnose, plan interventions and surveillance, coordinate care, and to evaluate patient outcomes through alerts, messages, or regular reports among health professionals. Healthcare payment includes managing operation and fiscal resources, monitoring processes for quality and continuous improvement, and reporting for accreditation and regulatory requirements within an agency or organization. Public-health related uses include processes for population health and safety, including disease surveillance and registries for births, deaths, immunizations, cancer, and trauma.
To accomplish exchanges for patient, professional, organizational, and public uses, a HIE infrastructure requires not only technology, but also an organizing structure for processes. The organizing structure establishes secure processes and rules of operation, technical and content standardization for interoperable exchanges among entities, and outlines the use cases and workflow to obtain meaningful information use. There are eleven key factors considered indispensable prerequisites for the HIE organizing infrastructure. These factors include:
Data storage. Data storage is necessary to enable the ability to aggregate data from disparate sources. Large health systems are often well-positioned to store and share patient-protected information within secure structures with private access. This is not the case for many small clinics, community centers, schools, and occupational-health staff for small businesses who need data storage to allow access to their health-related information for sharing when the agency closes on evenings and weekends. A central repository can temporarily hold information from small providers as it is collected for electronic medical or health record applications. This repository may also store data to serve as a core component for public-health use of data registries for birth certificates, immunizations, work-related injuries, cancer, diabetes, and trauma, or for monitoring communicable illnesses. The infrastructure for data storage may be consolidated with a centralized cooperative data repository to push and pull data. The infrastructure may be decentralized or federated with access to information through multiple health systems. A hybrid infrastructure is a combination of the consolidated and federated models. A hybrid-infrastructure model enables the access and exchange of data stored in existing provider networks as well as through a central-data repository maintained for smaller providers who would not be able to maintain 24/7 services for HIE access.
A master person index. A master person index (MPI) is a standard person-identifier code that uniquely identifies an individual and permits the correlation process to match the person’s data from a variety of different sources of health providers (e.g., clinics, hospitals, pharmacies, and nursing homes). Health systems often use enterprise-wide MPI applications and processes to maintain only one electronic health record for a person across many organizations within the system. When the MPI is not used or is unknown for a patient, an algorithm of multiple identifiers (name, birth date, address, etc.) will need to be used to make a match with multiple external records. The risk in not matching records with a level of certainty, which can lead to either using information from another person’s record or result in duplicate collection for the person whose identifier is not found.
Record-locator service. A record-locator service used to access and find health information that matches the identified individual. Some describe the record-locator services as a map or pointer to search and locate the information. The record locator can point to specific types of information (e.g., laboratory results, medications from pharmacies, allergies, or continuity of care documents).
Methods of authentication. Authentication is necessary to identify who is allowed to access health information through the HIE record-locator services. This individual will find important information for decision-making about patient care, and can download the information into the local record or simply document the original source of data used for local decisions. Valid users will include clinical professionals and public-health staff who use the healthcare data for patient populations and information-technology professionals who audit user access. Patients could potentially have access in the future.
Authorization for users. The authorization process can occur through the healthcare organizations that already manage employment or through professional appointments. These organizations are positioned to facilitate role-based security for a clinician user to gain access to the record-locator service for health information exchange. This authorization process includes steps to train individuals to locate and obtain correct patient-level information during their daily workflow of care or for public reporting.
Security policies and procedures to ensure a person’s privacy and confidentiality. These procedures clarify when information requests and reuse require patient consent. The operating rules include establishing data agreements among organizations to retrieve and reuse patient information previously collected and managed within other healthcare organizations. Additionally, each state or regional HIE establishes procedures to allow persons either to opt-in (allow data to be shared) or to opt-out (data are not to be shared) from health information exchange. Networks and regional organizations may vary in their procedures. The Health Information Security and Privacy Collaborative (HISPC) provided a framework, toolkit, and templates for data agreements, patient consents, and requests for opt-in and opt-out; public-education materials; and interstate and intrastate policies and legislation. Regional and state organizations need to apply broad restrictions on access to specific health information to allow individual protections, while permitting exchanges for both public safety and statistics. In the future, after the development of common request standards, an individual may have the opportunity to specify access limits for specific health information (e.g., genetic code) or allow information to be shared (e.g., healthcare systems or clinical research). The HIPAA guidelines expand on meeting needs for exchange of PHI for continuous care, while requiring informed consent and tracking disclosure of other requests for information.
Audits and logs of HIE activity. This includes both intentional and unintentional connections, and disconnections to network services. These networking activities allow improved configuration and generation of alerts and notifications during connection for users. The networks and organizations monitor and report on activity and response levels to track thresholds for technical stability and for any security violation.
Criteria-based standards. Criteria-based standards are needed for data transport, messaging, transfer of care, and other use cases that specify content formats and workflows for use of health information. A referral for consultation, a discharge summary, and a continuity of care document are examples of using standardized formats for content exchange. HIT users must conform in order to exchange information within statewide networks. Requirements include data-storage configurations and processes (e.g., edge servers and web services), determining the frequency in which data is made available through the HIE, and disaster recovery. The previously mentioned standards for interoperability align with this factor.
Determination of scope of services. The scope of services is determined by functionality that enables sets of standard types of data to be exchanged through the networks. These data are exchanged through HIE using a push or pull function that may be triggered by user-initiated events. An example could include a request for a continuity of care document being pulled in anticipation of receiving a patient in transfer from one facility to another. Push examples include a push of final pathology results to update previously sent preliminary results, a push of new prescriptions or the changes in medications prescribed to a pharmacy, or a push to notify a public-health department about the occurrence of communicable illness for a disease-surveillance registry.
Knowledge of workflow between providers and other users for patient- and public-health outcomes. The Health Information Technology Standards Panel developed, harmonized, and integrated technical standards for facilitating widespread adoption and use of interoperability in healthcare. This panel was created by the ONCHIT and conducted its work from 2007 to 2010. A complete library of the panel’s work products is available at the HITSP website: www.hitsp.org/default.aspx. Recent interest and efforts in workflow and HIE have focused on understanding the standard data needs for precision medicine and global sharing of accurate genotypic and phenotypic data for novel genes or variants (Ashley, 2016). Use cases for precision medicine will require a deeper knowledge about diseases such as cancer, and targeting interventions on cardiovascular and other body systems with greater therapeutic precision (Ashley, 2016).
A portal for access. The portal for access enables authorized users to sign on to the HIE. Different portals may be necessary to support different types of information exchanges (or HIE services) required for continuous care delivery, public reporting, and quality monitoring. An example is a provider portal aligned within the EHR to query a patient record, and retrieve and download the continuity of care document and laboratory results, or make a referral to a physician or nurse specialist or therapists, with key data included. For a consumer and patient, the portal would allow going to a PHR to collect self-monitored blood-glucose levels, daily weight, responses to a pre-visit questionnaire, or logging respiratory symptoms with chronic diseases.
In summary, the constituents who set up regional or state health information exchange infrastructures need to engage consumers, providers, and public-health professionals from the community to design processes. Consumer focus groups and healthcare-professionals’ feedback sessions are important methods to stimulate dialogue with providers and consumers, in order to test ideas and develop procedures for the HIE and privacy protections. The providers will likely store data captured about the patient within a repository that is external to the active electronic health record. This storage (e.g., cache with edge server) will allow others to find and pull data from healthcare providers on an as-needed basis without disrupting the clinicians’ workflow. Statewide toolkits and communication plans help guide entities and consumers on how to work together to standardize content, as well as to find and use it with the exchange technology. The implication is to educate the population in the state to allow information to be stored and shared—and thus, be accessible. However, for the HIE processes to accomplish these goals, the adoption of EHRs must first be broadly implemented.
Driving Forces
The steps toward exchange began back in 1965, when Medicare and Medicaid programs required accurate and timely information for reimbursement procedures (Staggers, Thompson, & Snyder-Halpern, 2001), as well as with the 2003 Medicare Modernization Act, which supported the first electronic prescribing through HIE. The HITECH Act legislation in 2009 was the driving force for funding state HIE programs. Today, the level of centralization of the community or network decision making, the establishment for EHRs in all care settings, the diversity of EHR systems that need to be integrated into the exchange, and the vast number of patient records are all factors affecting the rate of adopting HIE; while meaningful-use requirements with incentive payments, and the need for information at transitions of care in order to reduce fragmentation drive HIE (Frankel, Chinitz, Salzberg, & Reichman, 2013). Since 2016, MACRA rules have initiated Medicare performance-incentive payments to eligible clinicians who electronically find, use, and share health information with external providers.
The impacts on HIE is that it reduces duplication by sharing information often and in many different settings (i.e., clinics, pharmacies, ambulatory services, nursing homes, hospitals, schools, occupational-health centers, and public-health centers). The costs of fragmentation in delivering healthcare have resulted in duplicated tests, quality gaps due to multiple records and discrepancies within those records, and increased costs to deliver. A person’s complete longitudinal health record is important because a uniform holistic picture of the person’s symptoms, conditions, and functional health patterns can impact the person’s receipt of appropriate and timely care and treatment. HIE allows reuse of patient health information.
The methods to transfer information across settings vary widely in format (e.g., letter, report, or note) and method (e.g., mail, fax, or portal to HIE record locator). When the information is not easily obtained, providers are forced to recreate the information or take action with incomplete information because the person often does not remember. The primary goals of HIE are to facilitate access to and retrieval of clinical data to provide safe, timely, efficient, effective, equitable, and patient-centered care. The associated benefits of HIE are to save money, improve outcomes, and improve provider-patient relationships.
Current Status
In 2016, all states had an operational process for information networks to exchange health information. In 2014, within the United States, 82% of office-based physicians used an electronic health record system (EHRS), and 74.1% used systems certified by the CDC (2015). Six states exceeded adoption rates: Iowa (83.4%), North Carolina (84.8%), Oregon (85.0%), Vermont (85.0%), South Dakota (86.1%), and Minnesota (88.6%). In 2013, while nine states exceeded the national average for use of EHRSs in office-based clinics, the range in use of any part of an EHR ranged from 66% to 94%. The state-initiated HIEs and regional HIEs have supported 42% of all primary-care physicians to share data (Center for Disease Control and Prevention, 2015). Of the physicians with a certified EHRS, those offices electronically sharing patient health information with external providers ranged from 17.7% in New Jersey to 58.8% in North Dakota. In exchanging health information, Adler-Milstein et al. (2016) found the patient summary was shared most often (89%), followed by sharing of discharge summaries (78%), messages alerting providers of admission/discharge/transfers from the hospital (69%), medication lists and problem lists from ambulatory settings (66%), and lab results (63%). Acute-care hospitals were providing and receiving data in operational HIE with 81% to 82% effort in the nation, followed by ambulatory physician practices with 75% effort in providing data with 88% effort in receiving information (Adler-Milstein et al., 2016). Long-term facilities were providing information effort at 40%, while receiving data at 51%; while public-health departments were at 44% effort in providing information and receiving data at 56% effort (Adler-Milstein et al., 2016). Adler-Milstein et al. found laboratories, imaging services, and other healthcare professionals and providers at, or well below, 50% effort in providing information and receiving data from HIE.
Information networks continue to evolve and seek stakeholder buy-in to adopt use cases, while improving response to operation and technology issues. Early return-on-investment models suggest that federal and state governments may indeed benefit the most from HIE and NHIN exchanges by reducing duplicated tests and consultations, and by reducing readmissions for the same medical condition; thus, controlling Medicare costs and Medicaid reimbursements to providers. With this expectation, the employers or purchasers of health-insurance plans, the insurers themselves, and even consumers should see declines in cost over time with the reductions of duplicated services when moving the patient between multiple settings. Hospitals can benefit as well, with reduction of costs, fewer test supplies required to take care of a patient, having prospective payment plans, and shorter lengths of stay from better care coordination. Understanding this expected ROI forecast would mean those collecting information electronically will see an increase in burden and costs associated with documenting aspects of care in standard formats, or they may see an eventual decline in tests or in paperwork when fully automated. In this picture, the benefit to individual physicians, nurses, and pharmacists are minimal because the burden to collect and validate more data to ensure safety and prevention of error increases.
Obstacles
Developing a sustainable HIE business model was the greatest barrier to progressing the efforts of HIE in 2014, as reported by 33% of operational HIEs (Alder-Milstein et al., 2016). Another barrier that impacts adoption of technology solutions is the integration of the HIE process into the professionals’ daily workflow. The lack of funding remains a barrier reported by those responding to the evaluation of HIE by Adler-Milstein and colleagues. Twenty-five % of HIE respondents identified the limitations of interface standards and a lack of resources to implement interface standards as barriers for practices. Providers were asked to pay for costly interfaces to share documentation with the network’s HIE in addition to the costs of EHR systems, which delayed the timely adoption of HIE processes.
Even successful state and regional information networks are struggling to engage ambulatory providers and community agencies outside the traditional healthcare system. Only 15% of office-based physicians with a certified EHRS electronically shared patient information with external providers. Among all specialist and primary-care physicians, sharing was far less with home health (11.8%), long-term care (10.6%), and behavioral-health providers (11.4%) (CDC, 2015). This lack of capability for healthcare operations and EHRSs to interface data across applications (e.g., EHR documentation systems, scheduling and staffing systems, and accounting systems) remains a barrier. This impacts the ease of extracting data for sharing health information with these external providers, and directly impacts continuous services for vulnerable populations, such as infants and children with disabilities and congenital conditions, geriatric people with disabilities and chronicity, and persons with mental and behavioral conditions who require multiple services.
For the community of providers, the challenge will be to ensure the additional adoption of new 2016 standards for EHRSs to exchange common data (see Table 14-1). The process for adoption of new standards includes the adoption of implementation specifications, new workflows, and new functions within EHRS technology. The education of end users on the use of clinical terminologies, information models, evidence-based content, and redesigned workflows must accompany the information technology to ensure the right clinical data is captured by the right persons, at the right time, in the right place, and is stored and retrievable for interpretation when needed. New skills are necessary to support these needs.
Future Directions
The need to generate greater value from sharing healthcare data may have to come through analytics, decision support, and patient engagement, to overcome the barriers of cost, which are passed onto providers, though this value is hindered without more providers using HIE services (Adler-Milstein et al., 2016). The era of accountable care models with bundled payment models could create more demand for HIE sharing of information. This is because hospital and primary-care providers need the information about their patients from other healthcare professionals who share in the care of their patients within homes, schools, workplaces, and community services, but are not part of their organization. There is room for the adoption of HIE services within primary-care practices and imaging services, but also across many of the community service professionals who serve patients. These professionals include optometrists; dentists; audiologists; chiropractors; physical and occupational therapists; dietitians; nurses in work, school, or home settings; and others providing healthcare outside of the traditional healthcare systems. M6-Assignment
Critical implications for the future of health information networks are additional adoption of EHRSs by external providers, and the far-reaching adoption of the 2016 interoperable standards at all levels of providers (Office of the National Coordinator for Health Information Technology, 2016b). This chapter shares many of the standards and implementation specifications published within the final 2016 advisory. The 2016 interoperability standards include the transition of care to another healthcare provider and public-health reporting, but likely will expand to include standards relevant for all external providers. For instance, the standards and implementation specifications for nursing documentation were not explicitly outlined for nursing-process data elements—though shared within the standards, the standards are in need of further public comment and input from the greater nursing community, which represents a lot of external providers outside the traditional healthcare system. Any future standards and implementation specifications will include future public comments and HITSC recommendations for 2017 and future years. At this time, the advisory did not include within its scope administrative healthcare operations or payment-data needs, nor were the administrative-transaction requirements for HIPAA and CMS included. The ONCHIT advisory provided reference to the best available standards and implementation specifications, and therefore, the Secretary of Health and Human Services has not formally approved these interoperability standards.
The best-available published interoperability standards, shown in Table 14-1, have been studied and will require more research in trial sites for the Nationwide Health Information Network. The performance category of advancing care information (ACI) was recently added to the meaningful-use incentive program, with 11 meaningful-use indicators. Eligible clinicians will need to meet certain MACRA criteria for the advanced alternative payment model (APM) professionals. The administrative rules for MACRA requirements on sharing information would distribute incentive payments to eligible clinicians in 2019. CMS intends to have budget neutrality, where the negative adjustments for care delivered offset the positive adjustments to eligible clinicians. CMS expects this to drive quality improvement in care to Medicare beneficiaries and patients.
Summary
The health information exchange (HIE) infrastructure is a process for bi-directional sharing of patient health-related information among primary providers (nurse practitioners, physicians, and physician assistants), consulting specialists, hospitals, ambulatory centers, nursing homes, dentists, audiologists, optometrists, and occupational- and school-health professionals.
Shared information includes standard elements such as immunization status, allergies (foods, environment, and medications), values (preferences, cultural and religious beliefs), social habits (alcohol or tobacco use), family history, medication list, care plan, and insurance coverage or non-coverage that support decisions.
HIE requires an organizing structure, in addition to technology, for exchange at individual, professional, organization, public-health, and national levels.
Key factors for consideration in creating the HIE infrastructure include data storage, a master person index (MPI) or code that can be used to uniquely identify an individual and his or her information from different sources, a record-locator service used to access and find health information that matches the identified individual, authentication of allowed users, security policies and procedures to ensure privacy and confidentiality, audit trails of all activity, standards for transport and messaging, scope of services, knowledge of workflow, and a portal for access.
Regional or state health information-exchange infrastructures need to engage consumers, providers, and public-health professionals from the community to design processes.
The impetus for HIE began with the inception of the Medicare and Medicaid programs.
HIE has the potential to reduce duplication and provide reuse of patient health information.
Preparations for an HIE include organizing a governing body and establishing financial sustainability.
There are several models for information networks including not-for-profit, public utility, mutual benefit, for-profit, government-led initiatives, and for-research, as well as permutations of these models.
The public-authority HIE is accountable to the people of the individual state through audits and legal oversight and financial disclosure.
Integrated delivery networks (IDNs) and health systems within multiple states pre-dated the proposed models for HIE organizations.
The Department of Defense and the Veterans Administration healthcare settings have HIE within these organizations and are working to achieve HIE with external enterprises.
The challenge with information-network models is to be financially self-sustaining over time. Many were started with public funds, some charge for access to patient information, while others only charge for other services or generate revenue from the secondary use of data. Third-party incentives for HIE include quicker reimbursement payment for services.
All states have implemented HIEs with the ONC-HIT oversight.
The success of HIEs will be determined by the level of responsiveness to what stakeholders need and want for improving patient-centered healthcare and population health.
Even successful HIEs have endured a variety of obstacles with policy, organizational structure, financial sustainability, legal procedures, technical designs and equipment, and operational processes.
The NHIN is a structure that will bring together the state-level HIE and regional HIOs when the stakeholders are using the evolving information-exchange standards.
Characteristics that greatly affect the state-wide HIE initiative are stakeholders driving the effort, the capabilities and availability of skilled human resources for the effort, ability to access sufficient financial resources, and the strength of leadership.
Case Study Patient-Emergency Room
A widowed 85-year-old male is in transport to the emergency room for a fractured hip after being found dazed and semi-oriented at home by a visiting neighbor. The triage nurse receives the emergency medical service (EMS) phone call that the patient is 20-minutes out. The nurse uses the patient’s name and other identifiers to search within the state’s information-network record-locator service to access essential information. The nurse finds one unique patient, based on the EMS-reported patient name and address. After logging into the information network for HIE, the emergency-room nurse views information from the patient’s primary-care physician and cardiologist, the patient’s pharmacy, the public-health registry, the laboratory results on his last INR and chemistry, and hematology results. An old hospital record is located and used to help prepare for the patient. On his arrival, the nurse and the emergency physician find the patient unable to state allergies and some of his medications, so they use HIE information to verify past history. The nurse verifies the information with the patient and uses the provider-data repository to contact the pharmacy on recent dosing protocols for the patient’s anticoagulant. They are able to complete assessments, determine the patient’s current status, and route the patient to the radiology department for additional testing.
What is the standard healthcare information the nurse will be able to find through the health information exchange?
What types of services could the triage nurse and emergency physician use after accessing the HIE?
Case Study Transfer from the Hospital to a Skilled-Nursing/Long-Term Care Facility
An 85-year-old male had a total-hip replacement, is stable, and agrees to complete his rehabilitation and strengthening at the local nursing home, which has skilled nursing services. The staff nurse prepares the patient for discharge and transfer. The assessments are completed prior to discharge within the hospital EHRS. New electronic prescriptions are sent to the patient’s pharmacy for delivery to the nursing home. The nurse updates the patient’s problem list and adds the problem of risk for falls, and ensures that interventions (e.g., fall prevention, pain management, and exercise promotion) and the current status on patient outcomes for pain and mobility level are up-to-date on the care plan. The nurse contacts the receiving setting and provides the name and other identifying information to the receiving manager or clinical nurse leader. While on the phone, the nurse at the nursing home accesses the state’s information network through a web portal to use a record-locator service to search for the patient. The receiving nurse pulls in the advance directive, the plan of care, the problem list, new prescriptions, and continued medications. The last INR test result was posted this morning with the most recent dose for anticoagulation, which was administered in the morning. The two nurses discuss the plans for the anticoagulant protocol that was ordered by the cardiologist for the patient during the patient’s rehabilitation.
Will the long-termcare setting be able to use the record-locator service to obtain the information if they do not have a full electronic health record system?
How does the nursing home access the patient’s information before arrival?
Should the long-termcare facility wait to use the state’s health information network after they implement the EHRS? How can the facility receive training?
