Hospitals’ progress toward interoperability is slow and that progress has mainly been focused on moving information between hospitals, such as sending and receiving data, and not on ensuring the usability of information in clinical decisions, according to research recently published in Health Affairs.
In the paper, Julia Adler-Milstein, Ph.D., an associate professor of medicine in the School of Medicine at the University of California, San Francisco, and her colleagues, A Jay Holmgren, a doctoral student in Health Policy at Harvard Business School and Vaishali Patel, a senior advisor of planning, evaluation and analysis at the Office of the National Coordinator for Health Information Technology (ONC), sought to track progress in hospitals’ interoperability engagement at the national level.
In the paper, titled, “Progress in Interoperability: Measuring US Hospitals’ Engagement in Sharing Patient Data,” the researchers note that achieving “widespread interoperability” by 2018 has been declared a national objective, however, as of 2014, only about one-fifth of U.S. hospitals were engaged in all four of its primary domains—electronically finding, sending, receiving and integrating information into electronic health records (EHRs).
The researchers note that research may show that hospitals are making rapid progress, as new technologies and policies make it easier for them to engage with interoperability domains. “However, it is also possible that the one-fifth of hospitals engaging in the four primary interoperability domains included a unique set of early adopters and that remaining hospitals are moving slowly because of limited health information technology (IT) capabilities or weak incentives to share patient data,” Adler-Milstein and colleagues wrote.
Tracking interoperability over time is critical to informing a wide array of existing public- and private-sector efforts to ensure that EHRs across the United States will give providers access to complete clinical patient information. In particular, new policies such as the 21st Century Cures Act of 2016 seek to encourage data sharing in a variety of ways, and tracking hospitals’ engagement with interoperability is critical to guiding the implementation of this legislation,” the researchers wrote.
The researchers used data for 2014 and 2015 from the IT Supplement of the American Hospital Association Annual Survey based on responses from 3,538 hospitals. The study look at the four domains of interoperability, finding data, sending data, receiving data and integrating data, yet the researchers noted that integrating patient information from outside sources is the “key capability that separates interoperability from health information exchange (HIE),” or the integration of information into the EHR without manual effort. The researches also examined whether providers in a hospital routinely had electronic access to clinical information from outside sources and used that information for patient are.
Looking at the study results, fewer than 30 percent of the nation's hospitals (29.7 percent) completed all four pillars of information sharing in 2015, up from 24.5 percent in 2014 (or an increase of only 5.2 percentage points). The level of hospital engagement increased in three of the four domains but remained almost unchanged in integration. “This is substantially slower than the annual rate of national hospital EHR adoption over the past five years, which suggests that existing policy efforts have stimulated interoperability engagement only modestly,” the researchers wrote.
The fact that engagement in one domain, integration, was stagnant over time is a concern because integration is critical to data usability, the researchers noted.
In 2015, 43 percent of hospitals reported that they had outside clinical information available electronically when necessary and 19 percent of hospitals reported that they used this clinical information for care delivery “often." Further, 29 percent of hospitals reported using outside clinical information “sometimes,” 18 percent reported using it “rarely” and 19 percent “never” used it. The researchers concluded that 35 percent of hospitals reported that information was available electronically and used it “often” or “sometimes” in the delivery of care.
The fact that almost half of hospitals have outside clinical information available is an encouraging development, the researchers note, yet there is still much room for progress.
Among hospitals that reported that they “rarely” or “never” used information received electronically from outside sources, the most commonly cited barrier (49 percent) was the fact that clinicians could not view the information in the EHR as part of their workflow. Other barriers included difficulty in integrating information into the EHR, not having the information available when needed, and not having it presented in a useful manner, the researchers wrote.
The findings also shed light on how different health IT capabilities may be supporting hospitals’ engagement in different interoperability domains. The researchers noted that while having a basic EHR system was associated with engagement in finding, sending, and receiving information, only having a comprehensive EHR system was associated with the integration of information without manual intervention.
The study also found that hospitals that were part of a health care system, privately owned and for profit, and specialty hospitals; and those that participated in a patient-centered medical home (but not an ACO) were all more likely to have outside information available and use it in patient care.
The study findings indicate that integration is a more difficult function and only the more advanced EHR systems support this functionality. Similarly, having a third-party HIE vendor and participating in a regional health information organization were positively associated with finding, sending and receiving, but not with integrating information. Overall, the findings reveal that existing health IT infrastructure has primarily focused on how to move information between hospitals, not on ensuring that the information can be integrated, which is critical for information usability, the researchers wrote in the study.
“A key enabler of integration appears to be using the same vendor for EHR and HIE, which avoids the complexity associated with integrating external information received from a third-party intermediary, and likely explains the growth of EHR-vendor HIE networks,” Adler-Milstein wrote.
In conclusion, the researchers contend that the study findings underscore the need to shift the policy focus from transmitting information to information usability. “A greater policy focus on integration, rather than on the sending and receiving of data, may help shift hospitals’ focus to making data available at the point of care when it is clinically relevant,” Adler-Milstein and her colleagues wrote. “Policy interventions, such as those in the recent 21st Century Cures Act, should therefore focus on ensuring that all hospitals are incentivized to pursue robust interoperability, with a particular focus on integration, to realize the cost savings and quality improvements that are expected to follow.”
The hospitals in the study were predominantly small (52 percent) or medium-size (42 percent), located in an urban setting (65 percent), and privately owned nonprofits (55 percent). Nearly a quarter participated in an accountable care organization (24 percent) or patient-centered medical home (23 percent), while 10 percent participated in both.
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