Background: Health information exchange technologies are currently being implemented in many practice settings with the promise to improve quality, efficiency, and costs of care. The benefits are likely highest in settings where entry into the healthcare system is gained; however, in no setting is the need for timely, accurate, and pertinent information more critical than in the emergency department (ED). This study evaluated the use of a payer-based electronic health record (EHR) in an ED on quality, efficiency, and costs of care among a commercially insured population.Methods: Data came from a large health plan and the ED of a large urban ED. Visits with the use of a payer-based EHR were identified from claims between 9/1/05 and 2/17/06. A historical comparison sample of visits was identified from 11/1/04 to 3/31/05. Outcomes included return visits, ED duration, use of laboratory and diagnostic imaging, total costs during and in the four weeks after, and prescription drug utilization.Results: A total of 2,288 ED visits were analyzed (779 EHR visits and 1,509 comparison visits). Discharged visits were associated with an 18 minute shorter duration (95% CI: 5-33); whereas, the EHR among admitted visits was associated with a 77 minute reduction (95% CI: 28-126). The EHR was also associated with $1,560 (95% CI: $43-$2,910) savings in total plan paid for the visit among admitted visits. No significant differences were observed on return visits, laboratory or diagnostic imaging services and total costs over the four week follow-up. Exploratory analyses suggested that the EHR may be associated with a reduction in the number of prescription drugs used among chronic medication users.Conclusion: The EHR studied was associated with a significant reduction in ED duration. Technologies that can reduce ED lengths of stay can have a substantial impact on the care provided to patients and their satisfaction. The data suggests that the EHR may be associated with lower health plan paid amounts among admitted visits and a reduction in the number of pharmacy claims after the visit among chronic users of prescription drugs. Additional research should be conducted to confirm these findings.

Class of 2017 Abstract / Objectives: To assess the change in efficiency and accuracy of the medication reconciliation process at the Pima County Adult Detention Center (PCADC) after implementation of a Health Information Exchange (HIE) and also to identify the percentage of patients whose medication data is available in the HIE Methods: This program evaluation was a retrospective comparison of the traditional self-reported method of medication reconciliation to the HIE method. It compared the number and types of medication discovered for each patient using the traditional medication reconciliation collection data (the self-reported method) and the new database query method (HIE method) Results: 200 samples were randomly selected (100 random detainees and 100 with known medical record in the HIE database) to participate in the study. A total of 150 patients (61%) were retrieved from the HIE database, of which 100 were from the control group and 50 from the random group. The total numbers of medications that these 150 patients contributed was 284. Mean completeness of self-reported medications was 54% while HIE yielded an average of 99% (χ2; p<0.0001). 9 patients (4%) had both self-reported medications and medications within the HIE database in which 17 medications (62%) compared to the self-reporting method with 14 medications (52%) sharing the same name. There were no medication dose matches between self-reported medications and HIE queried medications. Conclusions: The addition of an HIE database to the existing self-reporting process of collecting a detainee’s medication reconciliation provides a more comprehensive and accurate medical record

Background Health information exchange (HIE) may help healthcare professionals and policymakers make informed decisions to improve patient and population health outcomes. There is, however, limited uptake of HIE in many low- and middle-income countries (LMICs). While resource constraints are an obvious barrier to implementation of HIE, it is important to explore what other political, structural, technical, environmental, legal and cultural factors may be involved. In particular, it is necessary to understand associated barriers in relation to context-specific HIE processes and deployment strategies in LMICs with a view to discovering how these can be overcome. My home country Pakistan is currently struggling to implement HIE at scale and so I undertook a detailed investigation of these issues in the context of Pakistan to generate insights on how best to promote uptake of HIE in Pakistan and in LMICs more generally. Aims The concept of HIE is evolving both over time and by context. To gain a clearer understanding of this terrain, I began by identifying different definitions of HIE in the literature to understand how these had evolved and the underlying conceptual basis for these changes. Second, I sought to understand the barriers and facilitators to the implementation and adoption of HIE in LMICs. Building on this foundational work, I then sought to explore and understand in-depth stakeholders perspectives on the context of and deployment strategies for HIE in Pakistan with a view to also identifying potentially transferable lessons for LMICs. Methods I undertook a phased programme of work. Phase 1 was a scoping review of definitions, which involved systematically searching the published literature in five academic databases and grey literature using Google to identify published definitions of HIE and related terms. The searches covered the period from January 1900 to February 2014. The included definitions were thematically analysed. In Phase 2, to identify barriers and facilitators to HIE in LMICs, I conducted a systematic review and searched for published and on-going (conference papers and abstracts) qualitative, quantitative and mixed-method studies in 11 academic databases and looked for unpublished work through Google interface from January 1990 to July 2014. Eligible studies were critically appraised and then thematically analysed. Finally, in Phase 3 I conducted a case study of HIE in Pakistan. Data collection comprised of interviews of different healthcare stakeholders across Pakistan to explore attitudes to HIE, and barriers and facilitators to its deployment. I also collected evidence through observational field notes and by analysing key international, national and regional policy documents. I used a combination of deductive thematic analysis informed by the theory of Diffusion of Innovations in Health Service Organisations that highlighted attributes of the innovation, the behaviour of adopters, and the organisational and environmental influences necessary for the success of implementation; and a more inductive iterative thematic analysis approach that allowed new themes to evolve from the data. The findings from these three phases of work were then integrated to identify potentially transferable lessons for Pakistan and other LMICs. Results In Phase 1, a total of 268 unique definitions of HIE were identified and extracted: 103 from scientific databases and 165 from Google. Eleven attributes emerged from the analysis that characterised HIE into two over-riding concepts. One was the ‘process’ of electronic information transfer among various healthcare stakeholders and the other was the HIE ‘organisation’ responsible to oversee the legal and business issues of information transfer. The results of Phase 1 informed the eligibility criteria to conduct Phase 2, in which a total of 63 studies met the inclusion criteria. Low importance given to data informed decision making, corruption and insecurity, lack of training, lack of equipment and supplies, and lack of feedback were considered to be major challenges to implementing HIE in LMICs, but strong leadership and clear policy direction coupled with the financial support to acquire essential technology, provide training for staff, assessing the needs of individuals and data standardisation all promoted implementation. The results of Phases 1 and 2 informed the design and content of Phase 3, the Pakistan case study. The complete dataset comprised of 39 interviews from 43 participants (including two group interviews), field observations, and a range of local and national documents. Findings showed that HIE existed mainly in/among some hospitals in Pakistan, but in a patchy and fragmented form. The district health information system was responsible for electronically transferring statistical data of public health facilities from districts to national offices via provincial intermediaries. Many issues were attributed to the absence of effective HIE, from ‘delays in retrieving records’ to ‘the increase in antibiotic resistance’. Barriers and facilitators to HIE were similar to the findings in Phase 2, but new findings included problems perceived to be the result of devolution of health matters from the federal to provincial governments, the politicised behaviour of international organisations, healthcare providers’ resistance to recording consultations to avoid liability and poor documentation skills. Public pressure to adopt mobile technology frameworks was found to be a novel facilitator whereas sharing regional health information with international organisations was perceived by some participants as disadvantageous as there were concerns that it may have enhanced espionage activities in the region. Conclusions HIE needs to be considered in both organisational and process terms. Effective HIE is essential to the provision of high quality care and the efficient running of health systems. Structural, political and financial considerations are important barriers to promoting HIE in LMICs, however, strong leadership, vision and policy direction along with financial support can help to promote the implementation of HIE in LMICs. Similarly, the federal and provincial governments could play an important role in implementing HIE in Pakistan along with the support of international organisations by facilitating HIE processes at federal and provincial levels across Pakistan. This however seems unlikely for the foreseeable future. At a meso- and micro-level, HIE in Pakistan and other LMICs could be achieved through using leapfrog mobile technologies to facilitate care processes for local organisations and patients. Specifically, the study on Pakistan has highlighted that LMICs may achieve modest successes in HIE through use of patient held records and use of now ubiquitous mobile phone technology with some patient and organisational benefits, but scaling these benefits is dependent on the creation of national structures and strategies which are more difficult to achieve in the low advanced informatics skill and resource settings that characterise many LMICs.

The healthcare system in the US faces substantial challenges related to cost, access and quality. Health Information Exchange (HIE) has been widely viewed as a viable solution for dealing with those challenges. Despite the potential contributions to the healthcare system that HIE promises, adoption and use of HIE have always been difficult, and the past two decades have witnessed significant HIE implementation failures. The limited understanding of HIE is a major obstacle for HIE success. Only recently in-depth research about HIE starts to appear in top IS journals. In addition, the uniqueness of healthcare industry adds to the complexity to HIE. Our study attempts to address this research gap by systematically examining multiple factors that influence HIE adoption and use. Using social exchange theory (SET) and diffusion of innovations theory, a research model was developed to empirically test major factors that impact healthcare providers’ relative advantages and risks perceptions for adopting and using HIE. It is further proposed that relative advantages and risks in turn impact organizations’ intentions for adopting and continuously using HIE. As such, we posit that organizations’ assessments of relative advantages and risks associated with HIE mediate the impacts of organizational and technological factors on organizations’ adoption and use intentions. This study uses questionnaire surveys for data collection. Out of a total of 163 responses, 117 surveys were completed and were analyzed using Partial Least Square software SmartPLS 3. Data analysis finds that most of the relationships were in the hypothesized directions with some of the relationships being significant. Specifically, top management support, absorptive capacity, trust, and HIE innovation characteristics positively affect relative advantages and negatively affect risk. Furthermore, relative advantages positively affect adoption/continuance intentions, whereas risk negatively affects adoption/continuance intentions. This study contributes to the literature and offers important practical implications. It is one of the early empirical attempts to understand the key factors that affect HIE’s adoptions and use. The research can also serve as a starting point for more in-depth studies in the future. Moreover, practitioners can use the several newly-developed scales to empirically examine healthcare providers’ adoption and use intentions.

BACKGROUND Integrated healthcare systems are believed to be enabled by the electronic exchange of clinical information. Canada and other national health systems are making substantial investments in information technology, in order to liberate and share clinical information between providers, improve the quality and safety of care, and reduce costs, yet we currently have no way of measuring these information flows, nor of understanding whether they contribute to the integration of care delivery. METHODS A literature review and consensus development process (nominal group) were used to provide guidance on system integration measures which are enabled by electronic information exchange. In order to conceptualize the components of electronic information exchange, establish a reference vocabulary for terminology, and guide the development of a questionnaire to gather field data, a formal ontology was developed. Validation of a sub-group of the survey data quality was achieved using the ontology and an unrelated database, demonstrating how ontologies may be used to adapt performance measurement methodologies to systems where constraints such as time-compression, lack of resources or access to needed information are prevalent. RESULTS The survey tool gathered cross-sectoral data from a regional health system which populated a summary measure of inter-provider electronic health information exchange (the eHIE), and measured perceptions of system integration from a single health region. The eHIE indicated that 7 -12% of clinical information that could be shared, was being shared electronically in the health region. ANOVA confirmed a significant correlation between the amount of information being exchanged electronically in this system and respondent perceptions of system integration suggesting that the eHIE may be used as a leading indicator for healthcare system integration. CONCLUSIONS It is possible to conceptualize and quantify inter-provider electronic health information exchange. As complex adaptive systems, healthcare systems are dynamic and open to correction; the use of a leading or proximal indicator such as the eHIE may inform effective policy-making and resource allocation in our pursuit of the goal of seamlessly integrated care.

BACKGROUND Integrated healthcare systems are believed to be enabled by the electronic exchange of clinical information. Canada and other national health systems are making substantial investments in information technology, in order to liberate and share clinical information between providers, improve the quality and safety of care, and reduce costs, yet we currently have no way of measuring these information flows, nor of understanding whether they contribute to the integration of care delivery. METHODS A literature review and consensus development process (nominal group) were used to provide guidance on system integration measures which are enabled by electronic information exchange. In order to conceptualize the components of electronic information exchange, establish a reference vocabulary for terminology, and guide the development of a questionnaire to gather field data, a formal ontology was developed. Validation of a sub-group of the survey data quality was achieved using the ontology and an unrelated database, demonstrating how ontologies may be used to adapt performance measurement methodologies to systems where constraints such as time-compression, lack of resources or access to needed information are prevalent. RESULTS The survey tool gathered cross-sectoral data from a regional health system which populated a summary measure of inter-provider electronic health information exchange (the eHIE), and measured perceptions of system integration from a single health region. The eHIE indicated that 7 -12% of clinical information that could be shared, was being shared electronically in the health region. ANOVA confirmed a significant correlation between the amount of information being exchanged electronically in this system and respondent perceptions of system integration suggesting that the eHIE may be used as a leading indicator for healthcare system integration. CONCLUSIONS It is possible to conceptualize and quantify inter-provider electronic health information exchange. As complex adaptive systems, healthcare systems are dynamic and open to correction; the use of a leading or proximal indicator such as the eHIE may inform effective policy-making and resource allocation in our pursuit of the goal of seamlessly integrated care.

In the United States, the health care sector is 20 years behind in the use of information technology to improve the process of health care delivery as compared to other sectors. Patients have to deliver their data over and over again to every health professional they see. Most health care facilities act as data repositories with limited capabilities of data analysis or data exchange. A remaining challenge is, how do we encourage the use of IT in the health care sector that will improve care coordination, save lives, make patients more involved in decision-making, and save money for the American people? According to Healthy People 2020, several challenges such as making health IT more usable, helping users to adapt to the new uses of health IT, and monitoring the impact of health IT on health care quality, safety, and efficiency, will require multidisciplinary models, new data systems, and abundant research. In this dissertation, I developed and used systems engineering methods to understand the role of new health IT in improving the coordination, safety, and efficiency of health care delivery. It is well known that care coordination issues may result in preventable hospital readmissions. In this dissertation, I identified the status of the care coordination and hospital readmission issues in the United States, and the potential areas where systems engineering would make significant contributions (see Appendix B). This literature review introduced me to a second study (see Appendix C), in which I identified specific patient cohorts, within chronically ill patients, that are at a higher risk of being readmitted within 30 days. Important to note is that the largest volume of preventable hospital readmissions occurs among chronically ill patients. This study was a retrospective data analysis of a representative patient cohort from Tampa, Florida, based on multivariate logistic regression and Cox proportional hazards models. After finishing these two studies, I directed my research efforts to understand and generate evidence on the role of new health IT (i.e., health information exchange, HIE) in improving care coordination, and thereby reducing the chances of a patient to be unnecessarily readmitted to the hospital. HIE is the electronic exchange of patient data among different stakeholders in the health care industry. The exchange of patient data is achieved, for example, by connecting electronic medical records systems between unaffiliated health care providers. It is expected that HIE will allow physicians, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically, and thereby improving the speed, quality, safety and cost of patient care. The federal government, through the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, is actively stimulating health care providers to engage in HIE, so that they can freely exchange patient information. Although these networks of information exchange are the promise of a less fragmented and more efficient health care system, there are only a few functional and financially sustainable HIEs across the United States. Current evidence suggests four barriers for HIE: •Usability and interface issues of HIE systems •Privacy and security concerns of patient data •Lack of sustainable business models for HIE organizations •Loss of strategic advantage of "owning" patient information by joining HIE to freely share data To contribute in reducing usability and interface issues of HIE systems, I performed a user needs assessment for the internal medicine department of Tampa General Hospital in Tampa, Florida. I used qualitative research tools (see Appendix D) and machine learning techniques (see Appendix E) to answer the following fundamental questions: How do clinicians integrate patient information allocated in outside health care facilities? What are the types of information needed the most for efficient and effective medical decision-making? Additionally, I built a strategic gaming model (see Appendix F) to analyze the strategic role of "owning" patient information that health care providers lose by joining an HIE. Using bilevel mathematical programs, I mimic the hospital decision of joining HIE and the patient decision of switching from one hospital to another one. The fundamental questions I tried to answer were: What is the role of competition in the decision of whether or not hospitals will engage in HIE? Our mathematical framework can also be used by policy makers to answer the following question: What are the optimal levels of monetary incentives that will spur HIE engagement in a specific region? Answering these fundamental questions will support both the development of user-friendly HIE systems and the creation of more effective health IT policy to promote and generate HIE engagement. Through the development of these five studies, I demonstrated how systems engineering tools can be used by policy makers and health care providers to make health IT more useful, and to monitor and support the impact of health IT on health care quality, safety, and efficiency.

Class of 2014 Abstract / Specific Aims: Assess the change in efficiency and accuracy of healthcare in provider access to HIE for medication profiles at the PCADC. Methods: Adults detainees admitted from October 22, 2012 to July 31, 2013 were enrolled in this study. A completed Intake Medical Screening form with self-reported/correction facility staff verified medication list will (the old method) be compared to the medication list obtained by querying the medication HIE (the new method). Descriptive statistics will describe the patients. Statistical significance will be calculated using the McNemar chi-square test for comparing the proportions of omissions (medications and strengths) on the 765PI to the HIE with an a priori alpha of 0.05. Main Results: In progress. Conclusion: HIE has the potential to be a valuable tool for healthcare providers operating at an adult detention facility.

Class of 2016 Abstract and Report / Objectives: To evaluate the successes and failures of the recent implementation of the Arizona Health-e Connection (AzHeC) health information exchange (HIE) at the Pima County Adult Detention Center (PCADC); to identify a generalized infrastructure and draft recommendations for implementing HIE at other correctional facilities. Methods: Participants pertinent to the implementation by current staff at the PCADC were identified through snowball sampling. Interviews were conducted in-person or by telephone using a semi-structured interview guide. Demographics regarding roles and responsibilities during implementation were collected during each interview. Participants were asked for input regarding key aspects and lessons learned from the implementation. Interviews were audio-recorded, transcribed verbatim, and then analyzed with Atlas.ti software for common themes. Results: A total of 12 individuals were interviewed, providing a comprehensive set of perspectives. Six common themes were identified: impact of being a novel implementer; challenges surrounding implementation; problems during implementation; what was done well; benefits of the system; and communication during implementation. Potential barriers that were successfully anticipated were establishing the value of the HIE through pilot studies to obtain early stakeholder buy-in, and addressing legal/privacy issues for the at-risk population in the corrections system. Problems that arose during implementation often involved information technology issues. Conclusions: Despite challenges faced throughout the HIE implementation, improvements in patient care, workflow, and time-savings made a tremendous impact for those involved. The lessons learned and advice given by the participants of this study can provide guidance for other correctional health systems wishing to implement a HIE at their facility.

abstract: Blockchain technology enables a distributed and decentralized environment without any central authority. Healthcare is one industry in which blockchain is expected to have significant impacts. In recent years, the Healthcare Information Exchange(HIE) has been shown to benefit the healthcare industry remarkably. It has been shown that blockchain could help to improve multiple aspects of the HIE system. When Blockchain technology meets HIE, there are only a few proposed systems and they all suffer from the following two problems. First, the existing systems are not patient-centric in terms of data governance. Patients do not own their data and have no direct control over it. Second, there is no defined protocol among different systems on how to share sensitive data. To address the issues mentioned above, this paper proposes MedFabric4Me, a blockchain-based platform for HIE. MedFabric4Me is a patient-centric system where patients own their healthcare data and share on a need-to-know basis. First, analyzed the requirements for a patient-centric system which ensures tamper-proof sharing of data among participants. Based on the analysis, a Merkle root based mechanism is created to ensure that data has not tampered. Second, a distributed Proxy re-encryption system is used for secure encryption of data during storage and sharing of records. Third, combining off-chain storage and on-chain access management for both authenticability and privacy. MedFabric4Me is a two-pronged solution platform, composed of on-chain and off-chain components. The on-chain solution is implemented on the secure network of Hyperledger Fabric(HLF) while the off-chain solution uses Interplanetary File System(IPFS) to store data securely. Ethereum based Nucypher, a proxy re-encryption network provides cryptographic access controls to actors for encrypted data sharing. To demonstrate the practicality and scalability, a prototype solution of MedFabric4Me is implemented and evaluated the performance measure of the system against an already implemented HIE. Results show that decentralization technology like blockchain could help to mitigate some issues that HIE faces today, like transparency for patients, slow emergency response, and better access control. Finally, this research concluded with the benefits and shortcomings of MedFabric4Me with some directions and work that could benefit MedFabric4Me in terms of operation and performance. / Dissertation/Thesis / Masters Thesis Computer Engineering 2020