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标题：Understanding the Decisions and Values of Stakeholders in Health Information Exchanges: Experiences From Massachusetts
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作者：Robert S. Rudin ; Steven R. Simon ; Lynn A. Volk 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2009
卷号：99
期号：5
页码：950-955
DOI：10.2105/AJPH.2008.144873
语种：English
出版社：American Public Health Association
摘要：Objectives. We studied how health information exchange systems are established by examining the decisions (and thus, indirectly, the values) of key stakeholders (health care providers) participating in a health information exchange pilot project in 3 Massachusetts communities. Our aim was to understand how these kinds of information exchanges can be made viable. Methods. We used semistructured interviews to assess health care providers' decision-making processes in selecting technical architectures and vendors for the pilot projects to uncover their needs, expectations, and motivations. Results. Our interviews indicated that, after extensive evaluations, health care providers in all 3 communities eventually selected a hybrid architecture that included a central data repository. However, the reasons for selecting this architecture varied considerably among the 3 communities, reflecting their particular values. Plans to create a community patient portal also differed across communities. Conclusions. Our findings suggest that, to become established, health information exchange efforts must foster trust, appeal to strategic interests of the medical community as a whole, and meet stakeholder expectations of benefits from quality measurements and population health interventions. If health information exchange organizations cannot address these factors, sustainability will remain precarious. Health information exchange (HIE)—mobilizing health care information electronically across organizations within a given region or community—has been heralded by health care experts and government leaders as an essential component of programs intended to improve the quality and cost-effectiveness of health care delivery and facilitate health improvements at the population level.^{1 , 2} Exchanges of clinical data will be especially important for improving public health and obtaining information that will enable early detection of disease outbreaks and make biosurveillance a reality.³ Despite considerable promise, few examples of well-functioning and sustainable HIEs exist to serve as models. A 2007 survey revealed that of more than 100 regional health information organizations, 25% were defunct and only 15 were of at least modest size and exchanging data across a range of populations.⁴ At most, 12 regional health information organizations were presumed to be self-sustaining and no longer relying on grants to support their operations. In this environment, according to one leader in the realm of HIE, “We desperately need, efficiently and expeditiously, to learn what works and what doesn't.”^{5 (pw596)} Learning “what works and what doesn't” in relation to HIE is challenging not only because of the dearth of successful models but also because knowledge of the needs, expectations, and motivations of stakeholders (physicians, their practices, and hospitals) regarding HIE is lacking.⁶ One way to better understand these stakeholder characteristics is to investigate qualitatively the factors that members of the medical community setting up an HIE consider in selecting the organization and technical architecture of their system. When stakeholders make these decisions, their individual and collective values emerge both implicitly and explicitly. Decisions about technical architecture can therefore be viewed, in economists' terms, as “revealed preferences.” The final decisions and the reasons behind them provide a helpful window into stakeholders' perspectives, bringing the complex dynamics of creating an HIE into sharper focus and allowing one to infer the factors that contribute to achieving sustainability. This knowledge may also inform the policy debate over the potential for success of the current market-oriented approach to HIE, a paradigm that assumes that the market incentives of health stakeholders will be sufficient to motivate them to engage in HIE. To explore these issues, we conducted a case study of HIE development efforts in 3 Massachusetts communities participating in the Massachusetts eHealth Collaborative ( http://www.maehc.org ) pilot, each of which had representatives of their health care providers choose their respective HIE technical architectures. The Massachusetts eHealth Collaborative, formed in 2004, was funded by a grant from Blue Cross Blue Shield of Massachusetts to promote statewide adoption of electronic health records and HIEs.⁷ As a demonstration project, the collaborative employed a request-for-proposals process to select the 3 Massachusetts communities that would take part in the project. The plan was to supply every physician with an electronic health record system and each medical community with HIE capabilities so that patient health data could be electronically transferred among independent practices and aggregated for public health reporting and population health management. The communities selected were Northern Berkshire (in northwestern Massachusetts), Greater Newburyport (60 miles north of Boston), and Greater Brockton (25 miles south of Boston). The collaborative has covered all financial costs of the electronic health records and HIE for several years. The HIE products are currently being installed in the communities and customized by the vendor companies chosen to implement each community's HIE architecture, representing the culmination of an arduous process of selecting vendors and technical architectures that occurred mostly in the summer of 2006. During that time, collaborative staff and medical community steering committees worked together to select the architecture and vendor that best met the requirements of each medical community. We investigated how the following 8 factors influenced decision-making regarding the structure and technical architecture of the HIEs: security, cost, complexity of implementation, performance, ability to measure quality of care, strategic goals, level of trust in the medical community, and stakeholders' desire for independence.