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A snapshot of health information exchange across five nations: an investigation of frontline clinician experiences in emergency care

A snapshot of health information exchange across five nations: an investigation of frontline... Abstract Objective Ensuring the ability to exchange patient information among disparate electronic health records systems is a top priority and a domain of substantial public investment across countries. However, we know little about the extent to which current capabilities meet the needs of frontline clinicians. Materials and Methods We conducted in-person, semistructured interviews with emergency care physicians and nurses in select hospitals in Canada, Denmark, Finland, Germany, and the USA. We characterized the state of health information exchange (HIE) by country and used thematic analysis to identify the perceived benefits of access to complete past medical history (PMH), the conditions under which PMH is sought, and the challenges to accessing and using HIE capabilities. Results HIE approaches, and the information electronically accessible to clinicians, differed by country. Benefits of access to PMH included safer care, reduced patient length of stay, and fewer lab and imaging orders. Conditions under which PMH was sought included moderate-acuity patients, patients with chronic conditions, and instances where accessing PMH was convenient. Challenges to HIE access and use included difficulty knowing where information is located, delay in receiving information, and difficulty finding information within documents. Discussion Even with different HIE approaches across countries, all clinicians reported shortcomings in their country’s approach. Notably, challenges were similar and shaped the conditions under which PMH was sought. Conclusion As countries continue to pursue broad-based HIE, they appear to be facing similar challenges in realizing HIE value and therefore have an opportunity to learn from one another. health information exchange, electronic health records, international, user-computer interface BACKGROUND AND SIGNIFICANCE As countries have invested in health care system digitization, many face the challenge of ensuring that information can electronically follow patients across care-delivery settings.1,2 There is widespread agreement that electronic health information exchange (HIE) is critical to realize quality and efficiency gains from electronic health records (EHRs).3 When clinical information is missing, it not only is a source of frustration and delay for clinicians, but can lead to medical errors and suboptimal patient care.4 As a result, a key component of country-level eHealth strategies is enabling HIE across disparate EHRs and approaches to the underlying technical architecture, standards, governance, and incentives.5–7 Prior work describes the HIE component of eHealth strategies and associated technology, governance, and incentives across countries. There has also been work to benchmark levels of HIE across countries, including a recent large-scale effort by the Organization for Economic Cooperation and Development that found that the majority of countries had at least 50% of hospitals able to electronically access imaging data from outside sources.8 However, there is little evidence that speaks to the experience of frontline clinicians with HIE and the extent to which their information needs are being met.9,10 Additionally, existing descriptions of eHealth strategies do not capture intracountry variations in HIE capabilities, which is needed to understand whether all clinicians are able to engage in HIE with one another, or only a subset. If only a subset, it is critical to understand what defines which clinicians can engage in HIE and which must use manual (ie, fax/phone) communication methods. Such assessment speaks to whether the approach to HIE in each country enables the exchange of all relevant clinical information or only a subset. Variations in HIE capabilities could also influence the perceived value of past medical history (PMH) and the conditions under which frontline clinicians seek it out. Finally, examining consistency among frontline clinician perspectives on the barriers to effective use of HIE capabilities across countries offers a novel assessment of whether there is an opportunity for collaboration that may not be currently pursued because of the perception that country HIE approaches are too varied.10,11 OBJECTIVE In this study, we interviewed frontline clinicians (doctors and nurses) in 5 countries (Canada, Denmark, Finland, Germany, and the United States) with mature eHealth policies and HIE strategies. We focused on clinicians in the emergency department (ED) setting, because information needs in this setting are acute and similar across countries. We conducted semistructured interviews that assessed clinician perspectives on 3 topics: perceived value of PMH, factors driving clinicians to seek PMH in the context of HIE, and barriers to accessing and using PMH in the context of HIE. We then conducted thematic analysis to identify similarities and differences across countries. We also sought to map current HIE capabilities in each country by defining, for 7 distinct types of clinical information, what bounds whether the information is part of the clinician’s local EHR or needs to be accessed from an outside system, as well as whether that access occurs via HIE. This study makes a novel contribution by capturing and comparing frontline clinician experiences with HIE in a diverse set of countries. New insights into clinician experiences with HIE serve to assess the current state of HIE, determine whether HIE has been implemented in ways that meet frontline clinician needs, and identify challenges that could benefit from cross-country learning. Our results specifically serve in facilitating cross-country learning that informs eHealth strategies and helping to ensure that the substantial investments in health IT to date translate into better care. MATERIALS AND METHODS Country and interviewee selection We purposefully selected 5 countries that have varied health system structures and eHealth strategies.12 Within each country, an expert on the HIE component of the country’s eHealth strategy was identified. We asked the expert to identify a geographic area that included at least 3 hospitals that would be reasonably representative of HIE in that country. The selected countries and expert-identified regions were the United States (Midwest), Canada (Alberta), Finland (Uusimaa and Pohjois-Savo), Denmark (northern and southern), and Germany (Lower Saxony, Bavaria, and Hamburg). For the target hospitals in each geographic region, we worked with each country expert to contact ED physicians and/or nurses at each site to schedule in-person interviews. While our results within a given country only capture the experiences of the targeted hospitals, we use country names in place of hospital names or regions in which we collected our data. Interview protocol and data collection A semistructured interview guide (Supplementary Appendix A) was developed that asked open-ended questions with specific prompts to elicit detailed descriptions of the clinician’s experience with obtaining information from outside of his or her hospital. In the first section, respondents were asked to provide an overview of patient care in their specific ED. In the next section, respondents were asked to engage in a retrospective think-out-loud exercise, in which they described when they sought PMH as well as their workflows and associated challenges when accessing patient information that originated from outside their organization.13,14 The retrospective think-out-loud protocol enabled us to capture the HIE capabilities that are in place, how these vary based on the source and type of patient information, and the usability of the various approaches. In the third section, respondents were asked to describe the benefits of access to a full patient history. In the final section, we asked clinicians to describe the effectiveness, ease, timeliness, and reliability of information gained from outside their institution. Twenty-six in-person interviews with 30 total respondents were conducted between May and September 2016. Occasionally, 2 subjects were interviewed together (based on clinician scheduling constraints), and in some interviews a translator was present. All interviews were recorded and transcribed. Analysis Transcript content was coded and analyzed using NVivo, a qualitative data analysis tool. We developed a codebook based on topics included in the interview guide. Two investigators independently coded 4 interview transcripts, then jointly reviewed and reconciled to ensure consistent application of the codes, which resulted in some minor code modifications. After the codebook was finalized, it was used to code the remaining interviews using the same process of independent coding and joint reconciliation by the same 2 investigators. To identify key themes in 3 focal topic areas – the perceived value of PMH, factors driving clinicians to seek PMH, and barriers to receiving and using PMH – we identified relevant codes and then extracted the associated transcript quotes associated with those codes. These were then organized by country. We reviewed the quotes and then summarized their content in an analytic matrix, which was then used to identify key themes. Selected quotes organized by theme are included in manuscript tables; tables with all quotes are included in Supplementary Appendix B. To map the boundaries of information access in each country, we abstracted objective descriptions for each country that specified how each of 7 types of clinical information (inpatient: physician notes, medications, lab results, image interpretations, images; outpatient: physician notes, medications) was accessed when it was stored in the respondent’s local EHR vs outside of it, recognizing that the latter could occur in multiple different ways depending on the outside source. The resulting summary specified the boundaries that defined a local EHR (eg, single hospital, multihospital system) as well as the boundaries that defined when information could be accessed via HIE (eg, if same EHR vendor, if same geographic region). In instances where there were differences between hospitals in a single country, both boundaries were included. Following the initial analysis, country experts clarified ambiguities and filled in missing information. RESULTS Perceived value of PMH The value of PMH was almost universally agreed upon by both doctors and nurses in all 5 countries. Respondents perceived the value of PMH in 2 domains: more appropriate and safer care, and avoidance of wasteful utilization (ie, reduced patient time spent in the ED and imaging and lab tests ordered) (Table 1). Table 1. Perceived value of past medical history Factors Selected quotes Appropriate and Safer Care MD, Canada: (asked how care would change without past medical history on patients) I’m not in business, but I can’t imagine a business world where you couldn’t access the information that you needed in real time to make decisions that are going to impact sales, or marketing, or something like that. And I don’t know why we accept it in medicine, where we don’t have a standard of care or something that is going to improve patient outcomes. I don’t know why patients accept that. MD, Denmark: The more you know about the patient’s history, the better the clinical assessment will be, and … [PMH] is important, it is really important because it helps you to have a focus on the most important thing. … As an ED physician, you have to act emergent, so the system is helping me to make my decision as quick as possible, as reasonable as possible, in every safe way. MD, USA: With more [past medical] information we can focus on what is necessary to do today, what is the emergency we need to address, versus the less information we have, the broader we have to be in our scope because we don’t have that info available, but we are expected to not miss anything life threatening, accurately diagnose things as much as possible, while also moving quickly. Reduced Utilization: Patient Time in the Emergency Department MD, Denmark: [By having the past medical history] you get an overview very quick then you can make your decisions much earlier. … In a way, you have reduced actually your [time] on an average, I will say for my own experience, 15 to 20 minutes per patient. MD, Finland: If I don’t have anything, the patient will stay [in the ED] for a longer time. I have to ask more questions. I have to take a longer history. And I probably will take more exams for those kind of patients than for one that has exactly the same condition, but has all the patient. MD, USA: [Without a past medical history] it is a guessing game. The slate is completely clean, we have to look at every avenue, every system, every everything, and it delays their time. Reduced Utilization: Labs and Images MD, Denmark: (asked about having little/no past medical history) You don’t know, so you have to treat them acutely, so you might overtreat them, more treatment, more CTs, etc. MD, Finland: Because if we don’t have enough patient [data], because if we don’t know patient’s previous medical history, and we have some kind of [abnormal] findings – patient’s ECG [for example]. We don’t know are they new or are they old. We have to take more lab samples. … We have to take a new ECG. It might take 5 to 6 hours more. MD, Germany: If I have an x-ray from before, I [will not order] another x-ray. Factors Selected quotes Appropriate and Safer Care MD, Canada: (asked how care would change without past medical history on patients) I’m not in business, but I can’t imagine a business world where you couldn’t access the information that you needed in real time to make decisions that are going to impact sales, or marketing, or something like that. And I don’t know why we accept it in medicine, where we don’t have a standard of care or something that is going to improve patient outcomes. I don’t know why patients accept that. MD, Denmark: The more you know about the patient’s history, the better the clinical assessment will be, and … [PMH] is important, it is really important because it helps you to have a focus on the most important thing. … As an ED physician, you have to act emergent, so the system is helping me to make my decision as quick as possible, as reasonable as possible, in every safe way. MD, USA: With more [past medical] information we can focus on what is necessary to do today, what is the emergency we need to address, versus the less information we have, the broader we have to be in our scope because we don’t have that info available, but we are expected to not miss anything life threatening, accurately diagnose things as much as possible, while also moving quickly. Reduced Utilization: Patient Time in the Emergency Department MD, Denmark: [By having the past medical history] you get an overview very quick then you can make your decisions much earlier. … In a way, you have reduced actually your [time] on an average, I will say for my own experience, 15 to 20 minutes per patient. MD, Finland: If I don’t have anything, the patient will stay [in the ED] for a longer time. I have to ask more questions. I have to take a longer history. And I probably will take more exams for those kind of patients than for one that has exactly the same condition, but has all the patient. MD, USA: [Without a past medical history] it is a guessing game. The slate is completely clean, we have to look at every avenue, every system, every everything, and it delays their time. Reduced Utilization: Labs and Images MD, Denmark: (asked about having little/no past medical history) You don’t know, so you have to treat them acutely, so you might overtreat them, more treatment, more CTs, etc. MD, Finland: Because if we don’t have enough patient [data], because if we don’t know patient’s previous medical history, and we have some kind of [abnormal] findings – patient’s ECG [for example]. We don’t know are they new or are they old. We have to take more lab samples. … We have to take a new ECG. It might take 5 to 6 hours more. MD, Germany: If I have an x-ray from before, I [will not order] another x-ray. Table 1. Perceived value of past medical history Factors Selected quotes Appropriate and Safer Care MD, Canada: (asked how care would change without past medical history on patients) I’m not in business, but I can’t imagine a business world where you couldn’t access the information that you needed in real time to make decisions that are going to impact sales, or marketing, or something like that. And I don’t know why we accept it in medicine, where we don’t have a standard of care or something that is going to improve patient outcomes. I don’t know why patients accept that. MD, Denmark: The more you know about the patient’s history, the better the clinical assessment will be, and … [PMH] is important, it is really important because it helps you to have a focus on the most important thing. … As an ED physician, you have to act emergent, so the system is helping me to make my decision as quick as possible, as reasonable as possible, in every safe way. MD, USA: With more [past medical] information we can focus on what is necessary to do today, what is the emergency we need to address, versus the less information we have, the broader we have to be in our scope because we don’t have that info available, but we are expected to not miss anything life threatening, accurately diagnose things as much as possible, while also moving quickly. Reduced Utilization: Patient Time in the Emergency Department MD, Denmark: [By having the past medical history] you get an overview very quick then you can make your decisions much earlier. … In a way, you have reduced actually your [time] on an average, I will say for my own experience, 15 to 20 minutes per patient. MD, Finland: If I don’t have anything, the patient will stay [in the ED] for a longer time. I have to ask more questions. I have to take a longer history. And I probably will take more exams for those kind of patients than for one that has exactly the same condition, but has all the patient. MD, USA: [Without a past medical history] it is a guessing game. The slate is completely clean, we have to look at every avenue, every system, every everything, and it delays their time. Reduced Utilization: Labs and Images MD, Denmark: (asked about having little/no past medical history) You don’t know, so you have to treat them acutely, so you might overtreat them, more treatment, more CTs, etc. MD, Finland: Because if we don’t have enough patient [data], because if we don’t know patient’s previous medical history, and we have some kind of [abnormal] findings – patient’s ECG [for example]. We don’t know are they new or are they old. We have to take more lab samples. … We have to take a new ECG. It might take 5 to 6 hours more. MD, Germany: If I have an x-ray from before, I [will not order] another x-ray. Factors Selected quotes Appropriate and Safer Care MD, Canada: (asked how care would change without past medical history on patients) I’m not in business, but I can’t imagine a business world where you couldn’t access the information that you needed in real time to make decisions that are going to impact sales, or marketing, or something like that. And I don’t know why we accept it in medicine, where we don’t have a standard of care or something that is going to improve patient outcomes. I don’t know why patients accept that. MD, Denmark: The more you know about the patient’s history, the better the clinical assessment will be, and … [PMH] is important, it is really important because it helps you to have a focus on the most important thing. … As an ED physician, you have to act emergent, so the system is helping me to make my decision as quick as possible, as reasonable as possible, in every safe way. MD, USA: With more [past medical] information we can focus on what is necessary to do today, what is the emergency we need to address, versus the less information we have, the broader we have to be in our scope because we don’t have that info available, but we are expected to not miss anything life threatening, accurately diagnose things as much as possible, while also moving quickly. Reduced Utilization: Patient Time in the Emergency Department MD, Denmark: [By having the past medical history] you get an overview very quick then you can make your decisions much earlier. … In a way, you have reduced actually your [time] on an average, I will say for my own experience, 15 to 20 minutes per patient. MD, Finland: If I don’t have anything, the patient will stay [in the ED] for a longer time. I have to ask more questions. I have to take a longer history. And I probably will take more exams for those kind of patients than for one that has exactly the same condition, but has all the patient. MD, USA: [Without a past medical history] it is a guessing game. The slate is completely clean, we have to look at every avenue, every system, every everything, and it delays their time. Reduced Utilization: Labs and Images MD, Denmark: (asked about having little/no past medical history) You don’t know, so you have to treat them acutely, so you might overtreat them, more treatment, more CTs, etc. MD, Finland: Because if we don’t have enough patient [data], because if we don’t know patient’s previous medical history, and we have some kind of [abnormal] findings – patient’s ECG [for example]. We don’t know are they new or are they old. We have to take more lab samples. … We have to take a new ECG. It might take 5 to 6 hours more. MD, Germany: If I have an x-ray from before, I [will not order] another x-ray. Theme 1: More appropriate and safer care. Appropriate care was discussed by the majority (67%) of respondents. A Canadian physician said that inadequate PMH might result in litigation and “wasteful, if not inappropriate treatment.” Adequate PMH allows doctors to increase the “effectiveness of the initial treatment started” (MD, Denmark), and gives physicians a “better clinical assessment” (MD, Denmark). A Finnish physician commented that “it helps you enormously to treat [patients] well from the very beginning,” and a US physician said that “with more info we can focus on what is necessary to do today.” Theme 2: Avoid wasteful utilization. Respondents also reported that access to PMH serves to reduce overall medical utilization (73% of respondents) by reducing patient time spent in the ED as well as decreasing lab and imaging orders. A Danish doctor said that, with adequate PMH, you can “make your decisions much earlier,” enabling patients to get to the appropriate ward (or be discharged) faster and thereby spend less time in the ED. More specifically, having PMH can decrease the time required for the initial differential diagnosis, partly due to not having to order and wait for new labs and imaging. Factors driving clinicians to seek PMH Despite broad agreement that PMH is valuable, respondents reported that they primarily seek it from sources outside of their local EHR based on 2 factors: the acuity of the patient and the ease of accessing information and associated impact on clinician time (Table 2). Table 2. Factors driving clinicians to seek PMH Factors Selected quotes Acuity/Complexity of Patient MD, Finland: (about whether he would call for a patient) I think I only would ask if I knew that the patient is very very ill, or has been recently examined in a certain way that would need this sort of information. That it would make a difference. MD, Germany: (about how often the physician sees a patient and wants more information) If they have another problem today, that belongs not to the previous problems hospitals, but for diseases that continue [chronic], it is necessary to look at what has happened before. MD, Finland: (about whether the physician accesses the previous medical record for all patients) Of course, almost always. Only patients that come with a simple trauma I might not visit the home medications, because it isn’t really relevant. Ease of Access and Clinician Time Constraints MD, United States: It is so tedious to get records from outside hospitals. When you are in a situation where you have multiple patients at the same time, some of them critically ill … the time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things? And sometimes the answer is no, getting the information really does matter for this particular patient, and it’s not going to be detrimental to the rest of my patient care. Other times it’s I do not have time to get this piece of info because it becomes detrimental to the rest of my patient care. Weighting the ED functionality room and your ability to provide care, not just for one patient but for every patient. And it becomes this trade, if I can do an equal job in a different way, factors into things like maybe I am wasting more health care dollars by doing this, but I am taking care of patients better by doing this, it become this weighted decision. MD, Denmark: [Contacting the PCP] takes too much time. It takes too much time and they are closed. MD, Canada: (about obtaining outside past medical records) If it is very easy to access, you are going to use that resource more often. Factors Selected quotes Acuity/Complexity of Patient MD, Finland: (about whether he would call for a patient) I think I only would ask if I knew that the patient is very very ill, or has been recently examined in a certain way that would need this sort of information. That it would make a difference. MD, Germany: (about how often the physician sees a patient and wants more information) If they have another problem today, that belongs not to the previous problems hospitals, but for diseases that continue [chronic], it is necessary to look at what has happened before. MD, Finland: (about whether the physician accesses the previous medical record for all patients) Of course, almost always. Only patients that come with a simple trauma I might not visit the home medications, because it isn’t really relevant. Ease of Access and Clinician Time Constraints MD, United States: It is so tedious to get records from outside hospitals. When you are in a situation where you have multiple patients at the same time, some of them critically ill … the time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things? And sometimes the answer is no, getting the information really does matter for this particular patient, and it’s not going to be detrimental to the rest of my patient care. Other times it’s I do not have time to get this piece of info because it becomes detrimental to the rest of my patient care. Weighting the ED functionality room and your ability to provide care, not just for one patient but for every patient. And it becomes this trade, if I can do an equal job in a different way, factors into things like maybe I am wasting more health care dollars by doing this, but I am taking care of patients better by doing this, it become this weighted decision. MD, Denmark: [Contacting the PCP] takes too much time. It takes too much time and they are closed. MD, Canada: (about obtaining outside past medical records) If it is very easy to access, you are going to use that resource more often. Table 2. Factors driving clinicians to seek PMH Factors Selected quotes Acuity/Complexity of Patient MD, Finland: (about whether he would call for a patient) I think I only would ask if I knew that the patient is very very ill, or has been recently examined in a certain way that would need this sort of information. That it would make a difference. MD, Germany: (about how often the physician sees a patient and wants more information) If they have another problem today, that belongs not to the previous problems hospitals, but for diseases that continue [chronic], it is necessary to look at what has happened before. MD, Finland: (about whether the physician accesses the previous medical record for all patients) Of course, almost always. Only patients that come with a simple trauma I might not visit the home medications, because it isn’t really relevant. Ease of Access and Clinician Time Constraints MD, United States: It is so tedious to get records from outside hospitals. When you are in a situation where you have multiple patients at the same time, some of them critically ill … the time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things? And sometimes the answer is no, getting the information really does matter for this particular patient, and it’s not going to be detrimental to the rest of my patient care. Other times it’s I do not have time to get this piece of info because it becomes detrimental to the rest of my patient care. Weighting the ED functionality room and your ability to provide care, not just for one patient but for every patient. And it becomes this trade, if I can do an equal job in a different way, factors into things like maybe I am wasting more health care dollars by doing this, but I am taking care of patients better by doing this, it become this weighted decision. MD, Denmark: [Contacting the PCP] takes too much time. It takes too much time and they are closed. MD, Canada: (about obtaining outside past medical records) If it is very easy to access, you are going to use that resource more often. Factors Selected quotes Acuity/Complexity of Patient MD, Finland: (about whether he would call for a patient) I think I only would ask if I knew that the patient is very very ill, or has been recently examined in a certain way that would need this sort of information. That it would make a difference. MD, Germany: (about how often the physician sees a patient and wants more information) If they have another problem today, that belongs not to the previous problems hospitals, but for diseases that continue [chronic], it is necessary to look at what has happened before. MD, Finland: (about whether the physician accesses the previous medical record for all patients) Of course, almost always. Only patients that come with a simple trauma I might not visit the home medications, because it isn’t really relevant. Ease of Access and Clinician Time Constraints MD, United States: It is so tedious to get records from outside hospitals. When you are in a situation where you have multiple patients at the same time, some of them critically ill … the time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things? And sometimes the answer is no, getting the information really does matter for this particular patient, and it’s not going to be detrimental to the rest of my patient care. Other times it’s I do not have time to get this piece of info because it becomes detrimental to the rest of my patient care. Weighting the ED functionality room and your ability to provide care, not just for one patient but for every patient. And it becomes this trade, if I can do an equal job in a different way, factors into things like maybe I am wasting more health care dollars by doing this, but I am taking care of patients better by doing this, it become this weighted decision. MD, Denmark: [Contacting the PCP] takes too much time. It takes too much time and they are closed. MD, Canada: (about obtaining outside past medical records) If it is very easy to access, you are going to use that resource more often. Theme 1: Patient acuity. One factor that determines whether clinicians look outside of their local EHR is the acuity of the patient (43% of respondents). Respondents mentioned that if a young, uncomplicated patient presented with a simple acute injury (usually trauma was mentioned), they may not choose to look for additional PMH. In addition, if the patient is in critical condition, they do not have time to look for PMH. A Finnish doctor said, “If the patient is critically injured, all this info isn’t so important because I have to keep him alive.” The older and more chronically ill the patient, the more likely the doctor will look for PMH from external sources. Another Finnish doctor said, “If I knew that the patient is very very ill, or has been recently examined in a certain way that would [require] this sort of information, [then] it would make a difference.” Theme 2: Ease of PMH access and associated clinician time constraints. Thirty percent of respondents also pointed to ease of PMH access and associated implications for clinician time required to seek information as a factor in whether they attempt PMH access from outside sources. However, this factor was described somewhat differently across countries. US and German doctors mentioned available clinician time as the deciding factor. If they have enough time, they will start seeking it, but if not, then they do without. They perceived that they rarely had electronic access to outside PMH, and as a result, getting the needed information requires a phone call, which takes time. One US doctor said, “The time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things?” In Canada and Denmark, clinicians described the same dynamic, but in the context of geography as a driving factor to look for PMH. This is because if a patient comes from within their province, they have electronic access to PMH in the province, but out of province requires a phone call, requiring more time. A Canadian doctor said, “If it is very easy to access, you are going to use that resource more often.” Ability to access PMH through HIE We found varied HIE capabilities across and within countries due to heterogeneity in EHR boundaries, as well as HIE capabilities that provide access to outside sources of PMH (Table 3). In addition, we found that outpatient PMH was, in general, less likely to be accessible via HIE. Table 3. Availability of past medical history in local EHR and via HIE from an outside source Information types: inpatient, including emergency department Information types: outpatient Source of Past Medical History Country Physician notes Medications Lab results Image reports Images Physician notes Medications Accessible from internal electronic record/resource Canada: Alberta Varied: emergency department or hospital system Varied: hospital or hospital system or region (city) Nonea Denmark: northern and southern Region None Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionb Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg Hospital None USA: Midwest Hospital system Electronically accessible from external records/resources Canada: Alberta Region Denmark: northern and southern National Region None None National Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionc Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg None Varied: none or region None USA: Midwest Varied: none or EHR vendor (for select vendors) Information types: inpatient, including emergency department Information types: outpatient Source of Past Medical History Country Physician notes Medications Lab results Image reports Images Physician notes Medications Accessible from internal electronic record/resource Canada: Alberta Varied: emergency department or hospital system Varied: hospital or hospital system or region (city) Nonea Denmark: northern and southern Region None Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionb Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg Hospital None USA: Midwest Hospital system Electronically accessible from external records/resources Canada: Alberta Region Denmark: northern and southern National Region None None National Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionc Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg None Varied: none or region None USA: Midwest Varied: none or EHR vendor (for select vendors) Key: Hospital: A hospital includes all inpatient, observation, and ED beds. Hospital system: A hospital system is a set of hospitals, including their EDs, that have the same ownership or other formal affiliation. Region: A region includes all public hospitals systems, individual hospitals, and EDs in a geographic area: Canada: 14 provinces; Denmark: 5 total regions; Finland: 19 regions; Germany: 16 federal states. Region (city): A region (city) includes all public hospital systems, individual hospitals, and EDs in a given city and surrounding area. EHR vendor: EHR vendor indicates all hospital systems, individual hospitals, and EDs that utilize the same EHR vendor. Notes: aLimited number of clinics currently available. bIn regard to physician notes and medications, community hospital clinicians have access to local hospital data; tertiary university center physicians have login access to city hospital EMRs. cRegional hospitals utilize the university system lab and picture archiving and communication systems; therefore, university hospital clinicians have access to imaging and lab data for the entire region. Table 3. Availability of past medical history in local EHR and via HIE from an outside source Information types: inpatient, including emergency department Information types: outpatient Source of Past Medical History Country Physician notes Medications Lab results Image reports Images Physician notes Medications Accessible from internal electronic record/resource Canada: Alberta Varied: emergency department or hospital system Varied: hospital or hospital system or region (city) Nonea Denmark: northern and southern Region None Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionb Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg Hospital None USA: Midwest Hospital system Electronically accessible from external records/resources Canada: Alberta Region Denmark: northern and southern National Region None None National Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionc Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg None Varied: none or region None USA: Midwest Varied: none or EHR vendor (for select vendors) Information types: inpatient, including emergency department Information types: outpatient Source of Past Medical History Country Physician notes Medications Lab results Image reports Images Physician notes Medications Accessible from internal electronic record/resource Canada: Alberta Varied: emergency department or hospital system Varied: hospital or hospital system or region (city) Nonea Denmark: northern and southern Region None Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionb Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg Hospital None USA: Midwest Hospital system Electronically accessible from external records/resources Canada: Alberta Region Denmark: northern and southern National Region None None National Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionc Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg None Varied: none or region None USA: Midwest Varied: none or EHR vendor (for select vendors) Key: Hospital: A hospital includes all inpatient, observation, and ED beds. Hospital system: A hospital system is a set of hospitals, including their EDs, that have the same ownership or other formal affiliation. Region: A region includes all public hospitals systems, individual hospitals, and EDs in a geographic area: Canada: 14 provinces; Denmark: 5 total regions; Finland: 19 regions; Germany: 16 federal states. Region (city): A region (city) includes all public hospital systems, individual hospitals, and EDs in a given city and surrounding area. EHR vendor: EHR vendor indicates all hospital systems, individual hospitals, and EDs that utilize the same EHR vendor. Notes: aLimited number of clinics currently available. bIn regard to physician notes and medications, community hospital clinicians have access to local hospital data; tertiary university center physicians have login access to city hospital EMRs. cRegional hospitals utilize the university system lab and picture archiving and communication systems; therefore, university hospital clinicians have access to imaging and lab data for the entire region. Theme 1: Inconsistent access to PMH. Access to PMH was shaped both by the boundaries around clinicians’ local EHRs and by the extent to which outside sources of PMH are accessible via HIE. Both dimensions varied across countries and, in some cases, within countries. For example, in terms of EHR boundaries within Canada, one ED EHR included only ED patient data, while another ED EHR included lab and imaging data from all public hospitals in the city. In Finland, one hospital could access radiology images from a subset of hospitals, but could not access physician notes from those same hospitals. In most cases, this was due to hospitals using different systems for various information types instead of one integrated system. For example, a hospital would use an EHR for physician notes that only had information for the hospital, but a picture archiving and communication system for images that would be shared by all hospitals in a geographic region. Theme 2: HIE based on geography vs. EMR vendor. In Canada, Denmark, and Finland, the ability to access information from outside of a local EHR was primarily defined by geographic boundaries. In Canada, for example, the province of Alberta implemented Netcare, a standardized information warehouse that aggregates data from local EHRs and pharmacies. As a result, physicians and nurses felt they could access all forms of health information for patients from within the province. Unique to the United States, physicians felt they could access patient information based on the EHR vendor, regardless of geographic boundaries. In some instances, they said they could more easily get information from another health system across the country that used their vendor as opposed to a local hospital that used a different vendor. Barriers to receiving and using past medical history There was broad agreement among clinicians on the barriers to receiving and using PMH: difficulty finding and accessing sources of external PMH, time delay in receiving information, and finding relevant information in documents received (Table 4). Table 4. Barriers to receiving and using past medical history Barriers Selected Quotes Difficulty Finding and Accessing External Sources of Information RN, Finland: There are at least, I think, 10 ways to find or investigate, so it takes time. … That’s why it is great problem nowadays. RN, Finland: (asked where he could obtain information) We do have possibility to use, for example, Navitas [Finnish HIE] on the network, but it is very complicated because the passwords, and they are valid for short times, so you can’t use them. MD, Canada: (asked how ease of access affected attempts at obtaining information) One example I have is there is one radiology system that sometimes you can only see the dictations, and not the actual image. And so they sent us a piece of mail saying you can log into this website, and here is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information when I can access Netcare and get all of the information. ... It is just remembering all the steps and login. Delay in Receiving Information MD, Canada: (asked about ease and timing of EMR information access) Sometimes it can be hours before you’ll get any information back. Sometimes rarely the patient will have a name and network for the physician, and so if I can find a physician number, then I’ll just call the physician directly, or have them paged through that hospital system, if it’s, if I know that they’re working through, you know, general, you know, something like that, but most of the time, the patients come in after hours and so finding somebody that knows them is very difficult. ... To be honest, not very often are we then able to access those records in a timely fashion that would change our decision-making in the emergency department. Most often where it becomes relevant is if we know the patient is going to end up being admitted and then we get working on those records so that the admitting doctor then has access to those. MD, Germany: (asked how time impacts usability of past medical records) We have a problem now, and I need to solve the problem. And it takes too much time, and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital. MD, United States: (asked about the effect of a delay in information received) It is multifactorial, ranging from a lot of different things. In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting, you need to do it now, because there is an imminent issue that needs to be addressed. Difficulty Finding Relevant Information in Documents Received RN, Finland: (asked if he/she could use the EMR to find the right information) Because Pegasos [Finnish national EMR] is very “dull” system, because you can only scroll through it chronologically. You cannot go anywhere; you have to check chronologically. Interviewer: Can you search? RN: No! We have to scroll chronological and find the year/date. OK, you don’t have chest pain, you have had chest failure then. … I mean sometimes, the longest time that it takes me to check the patient from Pegasos take 46 minutes. It is a very long time. MD, United States: Inevitably, when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for. MD, Finland: (regarding using the Finnish HIE to find the right information) Yes, you can, but those are saved as links, and those links refer to one time of laboratory tests, so if I want to see the patient’s last week lab tests taken on Friday, and the results, let’s say, this week’s Wednesday, I can see them one page. But if I want to have some kind of reference to their blood sugar levels before that, for example blood sugar, last Friday, I would either have to open 10 or hundreds of links through Navitas. Barriers Selected Quotes Difficulty Finding and Accessing External Sources of Information RN, Finland: There are at least, I think, 10 ways to find or investigate, so it takes time. … That’s why it is great problem nowadays. RN, Finland: (asked where he could obtain information) We do have possibility to use, for example, Navitas [Finnish HIE] on the network, but it is very complicated because the passwords, and they are valid for short times, so you can’t use them. MD, Canada: (asked how ease of access affected attempts at obtaining information) One example I have is there is one radiology system that sometimes you can only see the dictations, and not the actual image. And so they sent us a piece of mail saying you can log into this website, and here is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information when I can access Netcare and get all of the information. ... It is just remembering all the steps and login. Delay in Receiving Information MD, Canada: (asked about ease and timing of EMR information access) Sometimes it can be hours before you’ll get any information back. Sometimes rarely the patient will have a name and network for the physician, and so if I can find a physician number, then I’ll just call the physician directly, or have them paged through that hospital system, if it’s, if I know that they’re working through, you know, general, you know, something like that, but most of the time, the patients come in after hours and so finding somebody that knows them is very difficult. ... To be honest, not very often are we then able to access those records in a timely fashion that would change our decision-making in the emergency department. Most often where it becomes relevant is if we know the patient is going to end up being admitted and then we get working on those records so that the admitting doctor then has access to those. MD, Germany: (asked how time impacts usability of past medical records) We have a problem now, and I need to solve the problem. And it takes too much time, and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital. MD, United States: (asked about the effect of a delay in information received) It is multifactorial, ranging from a lot of different things. In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting, you need to do it now, because there is an imminent issue that needs to be addressed. Difficulty Finding Relevant Information in Documents Received RN, Finland: (asked if he/she could use the EMR to find the right information) Because Pegasos [Finnish national EMR] is very “dull” system, because you can only scroll through it chronologically. You cannot go anywhere; you have to check chronologically. Interviewer: Can you search? RN: No! We have to scroll chronological and find the year/date. OK, you don’t have chest pain, you have had chest failure then. … I mean sometimes, the longest time that it takes me to check the patient from Pegasos take 46 minutes. It is a very long time. MD, United States: Inevitably, when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for. MD, Finland: (regarding using the Finnish HIE to find the right information) Yes, you can, but those are saved as links, and those links refer to one time of laboratory tests, so if I want to see the patient’s last week lab tests taken on Friday, and the results, let’s say, this week’s Wednesday, I can see them one page. But if I want to have some kind of reference to their blood sugar levels before that, for example blood sugar, last Friday, I would either have to open 10 or hundreds of links through Navitas. Table 4. Barriers to receiving and using past medical history Barriers Selected Quotes Difficulty Finding and Accessing External Sources of Information RN, Finland: There are at least, I think, 10 ways to find or investigate, so it takes time. … That’s why it is great problem nowadays. RN, Finland: (asked where he could obtain information) We do have possibility to use, for example, Navitas [Finnish HIE] on the network, but it is very complicated because the passwords, and they are valid for short times, so you can’t use them. MD, Canada: (asked how ease of access affected attempts at obtaining information) One example I have is there is one radiology system that sometimes you can only see the dictations, and not the actual image. And so they sent us a piece of mail saying you can log into this website, and here is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information when I can access Netcare and get all of the information. ... It is just remembering all the steps and login. Delay in Receiving Information MD, Canada: (asked about ease and timing of EMR information access) Sometimes it can be hours before you’ll get any information back. Sometimes rarely the patient will have a name and network for the physician, and so if I can find a physician number, then I’ll just call the physician directly, or have them paged through that hospital system, if it’s, if I know that they’re working through, you know, general, you know, something like that, but most of the time, the patients come in after hours and so finding somebody that knows them is very difficult. ... To be honest, not very often are we then able to access those records in a timely fashion that would change our decision-making in the emergency department. Most often where it becomes relevant is if we know the patient is going to end up being admitted and then we get working on those records so that the admitting doctor then has access to those. MD, Germany: (asked how time impacts usability of past medical records) We have a problem now, and I need to solve the problem. And it takes too much time, and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital. MD, United States: (asked about the effect of a delay in information received) It is multifactorial, ranging from a lot of different things. In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting, you need to do it now, because there is an imminent issue that needs to be addressed. Difficulty Finding Relevant Information in Documents Received RN, Finland: (asked if he/she could use the EMR to find the right information) Because Pegasos [Finnish national EMR] is very “dull” system, because you can only scroll through it chronologically. You cannot go anywhere; you have to check chronologically. Interviewer: Can you search? RN: No! We have to scroll chronological and find the year/date. OK, you don’t have chest pain, you have had chest failure then. … I mean sometimes, the longest time that it takes me to check the patient from Pegasos take 46 minutes. It is a very long time. MD, United States: Inevitably, when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for. MD, Finland: (regarding using the Finnish HIE to find the right information) Yes, you can, but those are saved as links, and those links refer to one time of laboratory tests, so if I want to see the patient’s last week lab tests taken on Friday, and the results, let’s say, this week’s Wednesday, I can see them one page. But if I want to have some kind of reference to their blood sugar levels before that, for example blood sugar, last Friday, I would either have to open 10 or hundreds of links through Navitas. Barriers Selected Quotes Difficulty Finding and Accessing External Sources of Information RN, Finland: There are at least, I think, 10 ways to find or investigate, so it takes time. … That’s why it is great problem nowadays. RN, Finland: (asked where he could obtain information) We do have possibility to use, for example, Navitas [Finnish HIE] on the network, but it is very complicated because the passwords, and they are valid for short times, so you can’t use them. MD, Canada: (asked how ease of access affected attempts at obtaining information) One example I have is there is one radiology system that sometimes you can only see the dictations, and not the actual image. And so they sent us a piece of mail saying you can log into this website, and here is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information when I can access Netcare and get all of the information. ... It is just remembering all the steps and login. Delay in Receiving Information MD, Canada: (asked about ease and timing of EMR information access) Sometimes it can be hours before you’ll get any information back. Sometimes rarely the patient will have a name and network for the physician, and so if I can find a physician number, then I’ll just call the physician directly, or have them paged through that hospital system, if it’s, if I know that they’re working through, you know, general, you know, something like that, but most of the time, the patients come in after hours and so finding somebody that knows them is very difficult. ... To be honest, not very often are we then able to access those records in a timely fashion that would change our decision-making in the emergency department. Most often where it becomes relevant is if we know the patient is going to end up being admitted and then we get working on those records so that the admitting doctor then has access to those. MD, Germany: (asked how time impacts usability of past medical records) We have a problem now, and I need to solve the problem. And it takes too much time, and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital. MD, United States: (asked about the effect of a delay in information received) It is multifactorial, ranging from a lot of different things. In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting, you need to do it now, because there is an imminent issue that needs to be addressed. Difficulty Finding Relevant Information in Documents Received RN, Finland: (asked if he/she could use the EMR to find the right information) Because Pegasos [Finnish national EMR] is very “dull” system, because you can only scroll through it chronologically. You cannot go anywhere; you have to check chronologically. Interviewer: Can you search? RN: No! We have to scroll chronological and find the year/date. OK, you don’t have chest pain, you have had chest failure then. … I mean sometimes, the longest time that it takes me to check the patient from Pegasos take 46 minutes. It is a very long time. MD, United States: Inevitably, when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for. MD, Finland: (regarding using the Finnish HIE to find the right information) Yes, you can, but those are saved as links, and those links refer to one time of laboratory tests, so if I want to see the patient’s last week lab tests taken on Friday, and the results, let’s say, this week’s Wednesday, I can see them one page. But if I want to have some kind of reference to their blood sugar levels before that, for example blood sugar, last Friday, I would either have to open 10 or hundreds of links through Navitas. Theme 1: Difficulty in finding and accessing external sources of PMH. The majority of respondents (54%) reported difficulty knowing where the external PMH was located. First, they had to determine if the information was available through HIE or if they needed to pursue manual fax/phone. If it was electronic, some clinicians needed to search through multiple HIE systems, while others reported difficulty remembering multiple unique username and password combinations. They reported that there were too many electronic and/or paper resources that could contain the relevant information, such that they do not know where to look. A Canadian physician stated, “Here [in a different HIE] is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information.” Clinicians who worked with HIE systems that utilized single sign-on, the ability to access independent software systems with a single username and password, reported easier access. Theme 2: Delay in receiving information. Sixty percent of respondents commented that even when they could access or receive usable information, the length of time it took to receive the information limited its use. A German doctor stated, “We have a problem now, and I need to solve the problem. And it takes too much time and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other [information]. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital.” A US doctor noted, “In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting; you need to do it now because there is an imminent issue that needs to be addressed.” Theme 3: Difficulty finding relevant information in documents received. Once they received outside information, 37% of respondents reported difficulty finding the relevant information within the electronic database or document. A US physician reported, “Inevitably when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for.” In terms of electronic data, some clinicians reported difficulty scrolling through many pages. A Finnish nurse reported, “Scrolling. I mean sometimes, the longest time that it takes me to check the information from Pegasos takes 46 minutes. It is a very long time.” Others reported the need to click on dozens of links to search for information. DISCUSSION As electronic health information exchange capabilities mature worldwide, it is valuable to assess the extent to which they are meeting the needs of frontline clinicians. We interviewed emergency room physicians and nurses in the United States, Canada, Denmark, Germany, and Finland in order to characterize the state of HIE in each country and to identify (1) the perceived benefits of access to complete PMH, (2) the conditions under which PMH is sought in the context of HIE, and (3) the challenges to accessing and using HIE capabilities. Each country had a different approach to HIE that dictated what information clinicians could access electronically. Despite these differences in HIE approaches, we found overlap in clinician views on HIE. Clinicians agreed that the benefits of access to PMH included appropriate and safer care, reduced patient time in EDs, and reduced labs and imaging orders. Conditions under which PMH was sought included moderate-acuity patients, patients with chronic medical conditions, and instances where accessing PMH was easy/convenient. Challenges to access and use included difficulty knowing where external information is located and how to access it, lack of single sign-on, delay in receiving information, and difficulty finding information. That we found broad agreement on the value of HIE to access PMH is not surprising. More surprising is that, even with different HIE approaches, challenges were similar and they shaped the conditions under which PMH was sought. This suggests a potential to engage in cross-country learning to increase frontline clinician use of HIE. It is particularly interesting that frontline clinicians in all 5 countries found common ground in identifying 2 key barriers to accessing past medical records from outside institutions: not knowing where to find the information and not being able to use the information that is available to them. These barriers cut across various boundaries of what information was accessible in the local EHR versus via HIE. The barriers also cut across the 2 predominant HIE structural approaches: centralized and decentralized. In a centralized system, a third-party information aggregator, separate from the local EHR, accepts information from local sources such as other hospital EHRs, pharmacy systems, and clinics. In a decentralized system, outside information is compiled and incorporated directly into the local EMR following an outside query.15 A centralized approach is employed in Alberta (Canada), Denmark, and Finland. A decentralized approach is employed in Germany and the United States. It therefore does not appear that any particular HIE approach has emerged as superior from the perspective of frontline clinicians and that all approaches need to address a key set of barriers to ensure that HIE capabilities are usable. As countries continue to invest in HIE, our findings suggest 2 key domains in which they should focus improvement efforts. First, clinicians across countries reported that they did not know where to go to find information, because information from different external organizations was accessible in different places. Making this problem worse, in many cases, clinicians were unaware of the organization(s) where patients had previously received treatment. This suggests that creating a single approach to accessing all external information would have substantial value. If that is not feasible, clinicians need more training on where to go to access information from various external organizations. For example, clinicians could receive context-sensitive popup instructions within the EMR on how to access various HIE approaches. In addition, simple reference cards could be available at EHR terminals that list the different HIE approaches available, when they should be used (eg, based on places where patients previously received treatment or the type of PMH the clinician is seeking), and how to access them. These strategies would be facilitated by ensuring that any HIE approach could be accessed without requiring clinicians to enter additional username and password information, either by integrating it into the local EHR or by enabling single sign-on. Second, not only do clinicians need more streamlined access to the information, but information needs to be presented in a way that is usable. Having access to hundreds of pages of text does not allow emergency room clinicians to quickly use the information they need in that fast-paced environment. Clinicians should be able to quickly search for and find the type of information they are seeking, and trend data across multiple encounters. This would be greatly facilitated by focusing on access to organized data. When presented with organized data, clinicians can sort information by data type (notes, labs, imaging, medications, etc.), trend structured data (eg, lab values), and search through multiple encounters. With unorganized data, clinicians generally needed to scroll through pages (sometimes >100) of medical record information with limited ability to search, sort, or organize. The example that came closest to enabling clinicians to go to a single place for all external information and emphasized access to structured data was Netcare in Alberta, Canada. Netcare is a third-party information aggregator that aggregates data from most hospitals, pharmacies, and clinics in Alberta. As a result, clinicians only need to access one source outside their local EHR to get information. In addition, Netcare includes single sign-on, direct access to a given patient’s Netcare information when the provider is in the patient’s record in the local EHR, and use of structured data that can be searched, trended, etc. One physician went so far as to say that Netcare was her primary source of PMH. Although other countries have sought to develop a national system similar to Netcare, they rely more heavily on unstructured data, making them less usable. For example, comparing Netcare to Navitas, Finland’s regional database, the latter combines all structured data (eg, labs, vitals) and unstructured data (eg, physician notes) from single encounters into unstructured text reports (though the reports have structured headers, such as time and specialty, that can be searched). To access information from those reports, clinicians must click on a hyperlink. This prevents searching within reports, trending data between reports, or sorting information by type. This comparison highlights the potential for cross-country learning to facilitate improvements to HIE capabilities and maximize effectiveness of HIE for frontline clinicians. LIMITATIONS This study has several key limitations. First, the sample size was limited to 3 hospitals within each country and a small sample of physicians and nurses within each hospital. While we attempted to select regions that were representative of the countries in terms of HIE capabilities, no region perfectly represents any country. However, the purpose of this project was not to do a generalizable assessment of HIE by country. Instead, we hoped to gain insight from frontline clinicians based on their experiences, and compare the similarities and differences. Second, interviews were semistructured, allowing for some flexibility based on the natural flow of the conversation. As such, some follow-up was required to complete or clarify responses to some questions. Finally, in some cases, the understanding by frontline clinicians of what could and could not be accessed via HIE was inaccurate (ie, they had the ability but were not aware of it). We chose to report findings as conveyed by our respondents, but noted where these varied from what was technically available as reported by country experts. CONCLUSION Despite significant investment in eHealth in general and HIE in particular, we lack data on frontline clinician experiences with HIE. In this study, we interviewed frontline clinicians in emergency settings in 5 countries about their HIE experiences. Overall, we found that no country has yet to achieve the full benefits of optimal health information exchange in which physicians and nurses can receive and use PMH in an efficient and effective manner regardless of where their patients have previously received care. We also found that, despite different approaches to HIE, clinician experiences and reported challenges were remarkably similar. This suggests that countries need to continue to work to improve HIE, and that doing so collaboratively would be valuable. CONFLICT OF INTEREST The authors of this manuscript have no conflicts of interest to declare. ACKNOWLEDGMENTS This work would not have been possible without the time and expertise of our international colleagues. We would like to acknowledge the contribution of Timo Lukkarinen, Tinja Lääveri, Hannele Hyppönen, Christian Nohr, Jørn Munkhof Møller, Jennifer Zelmer, Lee A. Green, Ursula Hertha Hübner, Moritz Esdar, and Laura Naumann for providing guidance, insights into local Health IT policy and use, and assistance in identifying clinicians and coordinating interviews in our selected countries. FUNDING This work was supported in part by the University of Michigan Medical School. ROLE OF THE FUNDER/SPONSOR The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; or decision to submit the manuscript for publication. SUPPLEMENTARY MATERIAL Supplementary material is available at Journal of the American Medical Informatics Association online. REFERENCES 1 Abouzahra M , Sartipi K , Armstrong D et al. , Integrating data from EHRs to enhance clinical decision making: the inflammatory bowel disease case . In. 2014 IEEE 27th International Symposium on Computer-Based Medical Systems; New York, NY, 2014, pp. 531–32. 2 Gray B , Bowden T , Johansen I et al. , Electronic health records: an international perspective on “meaningful use.” The Commonwealth Fund. 2011 ; 28 : 1 – 18 . 3 Craven M , Page CD . Big data in healthcare: opportunities and challenges . Big Data. 2015 ; 3 : 209 – 10 . Google Scholar CrossRef Search ADS PubMed 4 Brailer DJ . Interoperability: the key to the future health care system . Health Aff (Millwood). 2005 ; Jan–Jun (Suppl Web Exclusives) : W5-19 – W5-21 . 5 Protti D , Bowden T . Electronic medical record adoption in New Zealand primary care physician offices . The Commonwealth Fund. 2010 ; 96 : 1 – 14 . 6 Schoen C , Osborn R , Squires D et al. , A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas . Health Aff (Millwood). 2012 ; 31 : 2805 – 16 . Google Scholar CrossRef Search ADS PubMed 7 Jacob JA . On the road to interoperability, public and private organizations work to connect health care data . JAMA. 2015 ; 314 : 1213 – 15 . Google Scholar CrossRef Search ADS PubMed 8 Zelmer J , Ronchi E , Hyppönen H et al. , International health IT benchmarking: learning from cross-country comparisons . J Am Med Inform Assoc. 2017 ; 24 : 371 – 79 . Google Scholar PubMed 9 Burnett SJ , Deelchand V . Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care . BMC Health Serv Res. 2011 ; 11 : 114 . Google Scholar CrossRef Search ADS PubMed 10 Shapiro JS , Kannry J , Kushniruk AW et al. , Emergency physicians’ perceptions of health information exchange . J Am Med Inform Assoc. 2007 ; 14 : 700 – 05 . Google Scholar CrossRef Search ADS PubMed 11 Thorn SA , Carter MA , Bailey JE . Emergency physicians’ perspectives on their use of health information exchange . Ann Emerg Med. 2014 ; 63 : 329 – 37 . Google Scholar CrossRef Search ADS PubMed 12 Mossialos E , Wenzl M , Osborn R , Anderson C . International Profiles of Health Care Systems, 2014 . New York : The Commonwealth Fund ; January 2015 . 13 Bauer DT , Guerlain S , Brown PJ . The design and evaluation of a graphical display for laboratory data . J Am Med Inform Assoc. 2010 ; 17 : 416 – 24 . Google Scholar CrossRef Search ADS PubMed 14 Kjeldskov J , Skov MB , Stage J . A longitudinal study of usability in health care: does time heal? Int J Med Inform. 2010 ; 79 : e135 – 43 . Google Scholar CrossRef Search ADS PubMed 15 Just BH , Durkin S . Clinical data exchange models. Matching HIE goals with IT foundations . J AHIMA. 2008 ; 79 : 48 – 52 . Google Scholar PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the American Medical Informatics Association Oxford University Press

A snapshot of health information exchange across five nations: an investigation of frontline clinician experiences in emergency care

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com
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1067-5027
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1527-974X
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10.1093/jamia/ocx153
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Abstract

Abstract Objective Ensuring the ability to exchange patient information among disparate electronic health records systems is a top priority and a domain of substantial public investment across countries. However, we know little about the extent to which current capabilities meet the needs of frontline clinicians. Materials and Methods We conducted in-person, semistructured interviews with emergency care physicians and nurses in select hospitals in Canada, Denmark, Finland, Germany, and the USA. We characterized the state of health information exchange (HIE) by country and used thematic analysis to identify the perceived benefits of access to complete past medical history (PMH), the conditions under which PMH is sought, and the challenges to accessing and using HIE capabilities. Results HIE approaches, and the information electronically accessible to clinicians, differed by country. Benefits of access to PMH included safer care, reduced patient length of stay, and fewer lab and imaging orders. Conditions under which PMH was sought included moderate-acuity patients, patients with chronic conditions, and instances where accessing PMH was convenient. Challenges to HIE access and use included difficulty knowing where information is located, delay in receiving information, and difficulty finding information within documents. Discussion Even with different HIE approaches across countries, all clinicians reported shortcomings in their country’s approach. Notably, challenges were similar and shaped the conditions under which PMH was sought. Conclusion As countries continue to pursue broad-based HIE, they appear to be facing similar challenges in realizing HIE value and therefore have an opportunity to learn from one another. health information exchange, electronic health records, international, user-computer interface BACKGROUND AND SIGNIFICANCE As countries have invested in health care system digitization, many face the challenge of ensuring that information can electronically follow patients across care-delivery settings.1,2 There is widespread agreement that electronic health information exchange (HIE) is critical to realize quality and efficiency gains from electronic health records (EHRs).3 When clinical information is missing, it not only is a source of frustration and delay for clinicians, but can lead to medical errors and suboptimal patient care.4 As a result, a key component of country-level eHealth strategies is enabling HIE across disparate EHRs and approaches to the underlying technical architecture, standards, governance, and incentives.5–7 Prior work describes the HIE component of eHealth strategies and associated technology, governance, and incentives across countries. There has also been work to benchmark levels of HIE across countries, including a recent large-scale effort by the Organization for Economic Cooperation and Development that found that the majority of countries had at least 50% of hospitals able to electronically access imaging data from outside sources.8 However, there is little evidence that speaks to the experience of frontline clinicians with HIE and the extent to which their information needs are being met.9,10 Additionally, existing descriptions of eHealth strategies do not capture intracountry variations in HIE capabilities, which is needed to understand whether all clinicians are able to engage in HIE with one another, or only a subset. If only a subset, it is critical to understand what defines which clinicians can engage in HIE and which must use manual (ie, fax/phone) communication methods. Such assessment speaks to whether the approach to HIE in each country enables the exchange of all relevant clinical information or only a subset. Variations in HIE capabilities could also influence the perceived value of past medical history (PMH) and the conditions under which frontline clinicians seek it out. Finally, examining consistency among frontline clinician perspectives on the barriers to effective use of HIE capabilities across countries offers a novel assessment of whether there is an opportunity for collaboration that may not be currently pursued because of the perception that country HIE approaches are too varied.10,11 OBJECTIVE In this study, we interviewed frontline clinicians (doctors and nurses) in 5 countries (Canada, Denmark, Finland, Germany, and the United States) with mature eHealth policies and HIE strategies. We focused on clinicians in the emergency department (ED) setting, because information needs in this setting are acute and similar across countries. We conducted semistructured interviews that assessed clinician perspectives on 3 topics: perceived value of PMH, factors driving clinicians to seek PMH in the context of HIE, and barriers to accessing and using PMH in the context of HIE. We then conducted thematic analysis to identify similarities and differences across countries. We also sought to map current HIE capabilities in each country by defining, for 7 distinct types of clinical information, what bounds whether the information is part of the clinician’s local EHR or needs to be accessed from an outside system, as well as whether that access occurs via HIE. This study makes a novel contribution by capturing and comparing frontline clinician experiences with HIE in a diverse set of countries. New insights into clinician experiences with HIE serve to assess the current state of HIE, determine whether HIE has been implemented in ways that meet frontline clinician needs, and identify challenges that could benefit from cross-country learning. Our results specifically serve in facilitating cross-country learning that informs eHealth strategies and helping to ensure that the substantial investments in health IT to date translate into better care. MATERIALS AND METHODS Country and interviewee selection We purposefully selected 5 countries that have varied health system structures and eHealth strategies.12 Within each country, an expert on the HIE component of the country’s eHealth strategy was identified. We asked the expert to identify a geographic area that included at least 3 hospitals that would be reasonably representative of HIE in that country. The selected countries and expert-identified regions were the United States (Midwest), Canada (Alberta), Finland (Uusimaa and Pohjois-Savo), Denmark (northern and southern), and Germany (Lower Saxony, Bavaria, and Hamburg). For the target hospitals in each geographic region, we worked with each country expert to contact ED physicians and/or nurses at each site to schedule in-person interviews. While our results within a given country only capture the experiences of the targeted hospitals, we use country names in place of hospital names or regions in which we collected our data. Interview protocol and data collection A semistructured interview guide (Supplementary Appendix A) was developed that asked open-ended questions with specific prompts to elicit detailed descriptions of the clinician’s experience with obtaining information from outside of his or her hospital. In the first section, respondents were asked to provide an overview of patient care in their specific ED. In the next section, respondents were asked to engage in a retrospective think-out-loud exercise, in which they described when they sought PMH as well as their workflows and associated challenges when accessing patient information that originated from outside their organization.13,14 The retrospective think-out-loud protocol enabled us to capture the HIE capabilities that are in place, how these vary based on the source and type of patient information, and the usability of the various approaches. In the third section, respondents were asked to describe the benefits of access to a full patient history. In the final section, we asked clinicians to describe the effectiveness, ease, timeliness, and reliability of information gained from outside their institution. Twenty-six in-person interviews with 30 total respondents were conducted between May and September 2016. Occasionally, 2 subjects were interviewed together (based on clinician scheduling constraints), and in some interviews a translator was present. All interviews were recorded and transcribed. Analysis Transcript content was coded and analyzed using NVivo, a qualitative data analysis tool. We developed a codebook based on topics included in the interview guide. Two investigators independently coded 4 interview transcripts, then jointly reviewed and reconciled to ensure consistent application of the codes, which resulted in some minor code modifications. After the codebook was finalized, it was used to code the remaining interviews using the same process of independent coding and joint reconciliation by the same 2 investigators. To identify key themes in 3 focal topic areas – the perceived value of PMH, factors driving clinicians to seek PMH, and barriers to receiving and using PMH – we identified relevant codes and then extracted the associated transcript quotes associated with those codes. These were then organized by country. We reviewed the quotes and then summarized their content in an analytic matrix, which was then used to identify key themes. Selected quotes organized by theme are included in manuscript tables; tables with all quotes are included in Supplementary Appendix B. To map the boundaries of information access in each country, we abstracted objective descriptions for each country that specified how each of 7 types of clinical information (inpatient: physician notes, medications, lab results, image interpretations, images; outpatient: physician notes, medications) was accessed when it was stored in the respondent’s local EHR vs outside of it, recognizing that the latter could occur in multiple different ways depending on the outside source. The resulting summary specified the boundaries that defined a local EHR (eg, single hospital, multihospital system) as well as the boundaries that defined when information could be accessed via HIE (eg, if same EHR vendor, if same geographic region). In instances where there were differences between hospitals in a single country, both boundaries were included. Following the initial analysis, country experts clarified ambiguities and filled in missing information. RESULTS Perceived value of PMH The value of PMH was almost universally agreed upon by both doctors and nurses in all 5 countries. Respondents perceived the value of PMH in 2 domains: more appropriate and safer care, and avoidance of wasteful utilization (ie, reduced patient time spent in the ED and imaging and lab tests ordered) (Table 1). Table 1. Perceived value of past medical history Factors Selected quotes Appropriate and Safer Care MD, Canada: (asked how care would change without past medical history on patients) I’m not in business, but I can’t imagine a business world where you couldn’t access the information that you needed in real time to make decisions that are going to impact sales, or marketing, or something like that. And I don’t know why we accept it in medicine, where we don’t have a standard of care or something that is going to improve patient outcomes. I don’t know why patients accept that. MD, Denmark: The more you know about the patient’s history, the better the clinical assessment will be, and … [PMH] is important, it is really important because it helps you to have a focus on the most important thing. … As an ED physician, you have to act emergent, so the system is helping me to make my decision as quick as possible, as reasonable as possible, in every safe way. MD, USA: With more [past medical] information we can focus on what is necessary to do today, what is the emergency we need to address, versus the less information we have, the broader we have to be in our scope because we don’t have that info available, but we are expected to not miss anything life threatening, accurately diagnose things as much as possible, while also moving quickly. Reduced Utilization: Patient Time in the Emergency Department MD, Denmark: [By having the past medical history] you get an overview very quick then you can make your decisions much earlier. … In a way, you have reduced actually your [time] on an average, I will say for my own experience, 15 to 20 minutes per patient. MD, Finland: If I don’t have anything, the patient will stay [in the ED] for a longer time. I have to ask more questions. I have to take a longer history. And I probably will take more exams for those kind of patients than for one that has exactly the same condition, but has all the patient. MD, USA: [Without a past medical history] it is a guessing game. The slate is completely clean, we have to look at every avenue, every system, every everything, and it delays their time. Reduced Utilization: Labs and Images MD, Denmark: (asked about having little/no past medical history) You don’t know, so you have to treat them acutely, so you might overtreat them, more treatment, more CTs, etc. MD, Finland: Because if we don’t have enough patient [data], because if we don’t know patient’s previous medical history, and we have some kind of [abnormal] findings – patient’s ECG [for example]. We don’t know are they new or are they old. We have to take more lab samples. … We have to take a new ECG. It might take 5 to 6 hours more. MD, Germany: If I have an x-ray from before, I [will not order] another x-ray. Factors Selected quotes Appropriate and Safer Care MD, Canada: (asked how care would change without past medical history on patients) I’m not in business, but I can’t imagine a business world where you couldn’t access the information that you needed in real time to make decisions that are going to impact sales, or marketing, or something like that. And I don’t know why we accept it in medicine, where we don’t have a standard of care or something that is going to improve patient outcomes. I don’t know why patients accept that. MD, Denmark: The more you know about the patient’s history, the better the clinical assessment will be, and … [PMH] is important, it is really important because it helps you to have a focus on the most important thing. … As an ED physician, you have to act emergent, so the system is helping me to make my decision as quick as possible, as reasonable as possible, in every safe way. MD, USA: With more [past medical] information we can focus on what is necessary to do today, what is the emergency we need to address, versus the less information we have, the broader we have to be in our scope because we don’t have that info available, but we are expected to not miss anything life threatening, accurately diagnose things as much as possible, while also moving quickly. Reduced Utilization: Patient Time in the Emergency Department MD, Denmark: [By having the past medical history] you get an overview very quick then you can make your decisions much earlier. … In a way, you have reduced actually your [time] on an average, I will say for my own experience, 15 to 20 minutes per patient. MD, Finland: If I don’t have anything, the patient will stay [in the ED] for a longer time. I have to ask more questions. I have to take a longer history. And I probably will take more exams for those kind of patients than for one that has exactly the same condition, but has all the patient. MD, USA: [Without a past medical history] it is a guessing game. The slate is completely clean, we have to look at every avenue, every system, every everything, and it delays their time. Reduced Utilization: Labs and Images MD, Denmark: (asked about having little/no past medical history) You don’t know, so you have to treat them acutely, so you might overtreat them, more treatment, more CTs, etc. MD, Finland: Because if we don’t have enough patient [data], because if we don’t know patient’s previous medical history, and we have some kind of [abnormal] findings – patient’s ECG [for example]. We don’t know are they new or are they old. We have to take more lab samples. … We have to take a new ECG. It might take 5 to 6 hours more. MD, Germany: If I have an x-ray from before, I [will not order] another x-ray. Table 1. Perceived value of past medical history Factors Selected quotes Appropriate and Safer Care MD, Canada: (asked how care would change without past medical history on patients) I’m not in business, but I can’t imagine a business world where you couldn’t access the information that you needed in real time to make decisions that are going to impact sales, or marketing, or something like that. And I don’t know why we accept it in medicine, where we don’t have a standard of care or something that is going to improve patient outcomes. I don’t know why patients accept that. MD, Denmark: The more you know about the patient’s history, the better the clinical assessment will be, and … [PMH] is important, it is really important because it helps you to have a focus on the most important thing. … As an ED physician, you have to act emergent, so the system is helping me to make my decision as quick as possible, as reasonable as possible, in every safe way. MD, USA: With more [past medical] information we can focus on what is necessary to do today, what is the emergency we need to address, versus the less information we have, the broader we have to be in our scope because we don’t have that info available, but we are expected to not miss anything life threatening, accurately diagnose things as much as possible, while also moving quickly. Reduced Utilization: Patient Time in the Emergency Department MD, Denmark: [By having the past medical history] you get an overview very quick then you can make your decisions much earlier. … In a way, you have reduced actually your [time] on an average, I will say for my own experience, 15 to 20 minutes per patient. MD, Finland: If I don’t have anything, the patient will stay [in the ED] for a longer time. I have to ask more questions. I have to take a longer history. And I probably will take more exams for those kind of patients than for one that has exactly the same condition, but has all the patient. MD, USA: [Without a past medical history] it is a guessing game. The slate is completely clean, we have to look at every avenue, every system, every everything, and it delays their time. Reduced Utilization: Labs and Images MD, Denmark: (asked about having little/no past medical history) You don’t know, so you have to treat them acutely, so you might overtreat them, more treatment, more CTs, etc. MD, Finland: Because if we don’t have enough patient [data], because if we don’t know patient’s previous medical history, and we have some kind of [abnormal] findings – patient’s ECG [for example]. We don’t know are they new or are they old. We have to take more lab samples. … We have to take a new ECG. It might take 5 to 6 hours more. MD, Germany: If I have an x-ray from before, I [will not order] another x-ray. Factors Selected quotes Appropriate and Safer Care MD, Canada: (asked how care would change without past medical history on patients) I’m not in business, but I can’t imagine a business world where you couldn’t access the information that you needed in real time to make decisions that are going to impact sales, or marketing, or something like that. And I don’t know why we accept it in medicine, where we don’t have a standard of care or something that is going to improve patient outcomes. I don’t know why patients accept that. MD, Denmark: The more you know about the patient’s history, the better the clinical assessment will be, and … [PMH] is important, it is really important because it helps you to have a focus on the most important thing. … As an ED physician, you have to act emergent, so the system is helping me to make my decision as quick as possible, as reasonable as possible, in every safe way. MD, USA: With more [past medical] information we can focus on what is necessary to do today, what is the emergency we need to address, versus the less information we have, the broader we have to be in our scope because we don’t have that info available, but we are expected to not miss anything life threatening, accurately diagnose things as much as possible, while also moving quickly. Reduced Utilization: Patient Time in the Emergency Department MD, Denmark: [By having the past medical history] you get an overview very quick then you can make your decisions much earlier. … In a way, you have reduced actually your [time] on an average, I will say for my own experience, 15 to 20 minutes per patient. MD, Finland: If I don’t have anything, the patient will stay [in the ED] for a longer time. I have to ask more questions. I have to take a longer history. And I probably will take more exams for those kind of patients than for one that has exactly the same condition, but has all the patient. MD, USA: [Without a past medical history] it is a guessing game. The slate is completely clean, we have to look at every avenue, every system, every everything, and it delays their time. Reduced Utilization: Labs and Images MD, Denmark: (asked about having little/no past medical history) You don’t know, so you have to treat them acutely, so you might overtreat them, more treatment, more CTs, etc. MD, Finland: Because if we don’t have enough patient [data], because if we don’t know patient’s previous medical history, and we have some kind of [abnormal] findings – patient’s ECG [for example]. We don’t know are they new or are they old. We have to take more lab samples. … We have to take a new ECG. It might take 5 to 6 hours more. MD, Germany: If I have an x-ray from before, I [will not order] another x-ray. Theme 1: More appropriate and safer care. Appropriate care was discussed by the majority (67%) of respondents. A Canadian physician said that inadequate PMH might result in litigation and “wasteful, if not inappropriate treatment.” Adequate PMH allows doctors to increase the “effectiveness of the initial treatment started” (MD, Denmark), and gives physicians a “better clinical assessment” (MD, Denmark). A Finnish physician commented that “it helps you enormously to treat [patients] well from the very beginning,” and a US physician said that “with more info we can focus on what is necessary to do today.” Theme 2: Avoid wasteful utilization. Respondents also reported that access to PMH serves to reduce overall medical utilization (73% of respondents) by reducing patient time spent in the ED as well as decreasing lab and imaging orders. A Danish doctor said that, with adequate PMH, you can “make your decisions much earlier,” enabling patients to get to the appropriate ward (or be discharged) faster and thereby spend less time in the ED. More specifically, having PMH can decrease the time required for the initial differential diagnosis, partly due to not having to order and wait for new labs and imaging. Factors driving clinicians to seek PMH Despite broad agreement that PMH is valuable, respondents reported that they primarily seek it from sources outside of their local EHR based on 2 factors: the acuity of the patient and the ease of accessing information and associated impact on clinician time (Table 2). Table 2. Factors driving clinicians to seek PMH Factors Selected quotes Acuity/Complexity of Patient MD, Finland: (about whether he would call for a patient) I think I only would ask if I knew that the patient is very very ill, or has been recently examined in a certain way that would need this sort of information. That it would make a difference. MD, Germany: (about how often the physician sees a patient and wants more information) If they have another problem today, that belongs not to the previous problems hospitals, but for diseases that continue [chronic], it is necessary to look at what has happened before. MD, Finland: (about whether the physician accesses the previous medical record for all patients) Of course, almost always. Only patients that come with a simple trauma I might not visit the home medications, because it isn’t really relevant. Ease of Access and Clinician Time Constraints MD, United States: It is so tedious to get records from outside hospitals. When you are in a situation where you have multiple patients at the same time, some of them critically ill … the time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things? And sometimes the answer is no, getting the information really does matter for this particular patient, and it’s not going to be detrimental to the rest of my patient care. Other times it’s I do not have time to get this piece of info because it becomes detrimental to the rest of my patient care. Weighting the ED functionality room and your ability to provide care, not just for one patient but for every patient. And it becomes this trade, if I can do an equal job in a different way, factors into things like maybe I am wasting more health care dollars by doing this, but I am taking care of patients better by doing this, it become this weighted decision. MD, Denmark: [Contacting the PCP] takes too much time. It takes too much time and they are closed. MD, Canada: (about obtaining outside past medical records) If it is very easy to access, you are going to use that resource more often. Factors Selected quotes Acuity/Complexity of Patient MD, Finland: (about whether he would call for a patient) I think I only would ask if I knew that the patient is very very ill, or has been recently examined in a certain way that would need this sort of information. That it would make a difference. MD, Germany: (about how often the physician sees a patient and wants more information) If they have another problem today, that belongs not to the previous problems hospitals, but for diseases that continue [chronic], it is necessary to look at what has happened before. MD, Finland: (about whether the physician accesses the previous medical record for all patients) Of course, almost always. Only patients that come with a simple trauma I might not visit the home medications, because it isn’t really relevant. Ease of Access and Clinician Time Constraints MD, United States: It is so tedious to get records from outside hospitals. When you are in a situation where you have multiple patients at the same time, some of them critically ill … the time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things? And sometimes the answer is no, getting the information really does matter for this particular patient, and it’s not going to be detrimental to the rest of my patient care. Other times it’s I do not have time to get this piece of info because it becomes detrimental to the rest of my patient care. Weighting the ED functionality room and your ability to provide care, not just for one patient but for every patient. And it becomes this trade, if I can do an equal job in a different way, factors into things like maybe I am wasting more health care dollars by doing this, but I am taking care of patients better by doing this, it become this weighted decision. MD, Denmark: [Contacting the PCP] takes too much time. It takes too much time and they are closed. MD, Canada: (about obtaining outside past medical records) If it is very easy to access, you are going to use that resource more often. Table 2. Factors driving clinicians to seek PMH Factors Selected quotes Acuity/Complexity of Patient MD, Finland: (about whether he would call for a patient) I think I only would ask if I knew that the patient is very very ill, or has been recently examined in a certain way that would need this sort of information. That it would make a difference. MD, Germany: (about how often the physician sees a patient and wants more information) If they have another problem today, that belongs not to the previous problems hospitals, but for diseases that continue [chronic], it is necessary to look at what has happened before. MD, Finland: (about whether the physician accesses the previous medical record for all patients) Of course, almost always. Only patients that come with a simple trauma I might not visit the home medications, because it isn’t really relevant. Ease of Access and Clinician Time Constraints MD, United States: It is so tedious to get records from outside hospitals. When you are in a situation where you have multiple patients at the same time, some of them critically ill … the time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things? And sometimes the answer is no, getting the information really does matter for this particular patient, and it’s not going to be detrimental to the rest of my patient care. Other times it’s I do not have time to get this piece of info because it becomes detrimental to the rest of my patient care. Weighting the ED functionality room and your ability to provide care, not just for one patient but for every patient. And it becomes this trade, if I can do an equal job in a different way, factors into things like maybe I am wasting more health care dollars by doing this, but I am taking care of patients better by doing this, it become this weighted decision. MD, Denmark: [Contacting the PCP] takes too much time. It takes too much time and they are closed. MD, Canada: (about obtaining outside past medical records) If it is very easy to access, you are going to use that resource more often. Factors Selected quotes Acuity/Complexity of Patient MD, Finland: (about whether he would call for a patient) I think I only would ask if I knew that the patient is very very ill, or has been recently examined in a certain way that would need this sort of information. That it would make a difference. MD, Germany: (about how often the physician sees a patient and wants more information) If they have another problem today, that belongs not to the previous problems hospitals, but for diseases that continue [chronic], it is necessary to look at what has happened before. MD, Finland: (about whether the physician accesses the previous medical record for all patients) Of course, almost always. Only patients that come with a simple trauma I might not visit the home medications, because it isn’t really relevant. Ease of Access and Clinician Time Constraints MD, United States: It is so tedious to get records from outside hospitals. When you are in a situation where you have multiple patients at the same time, some of them critically ill … the time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things? And sometimes the answer is no, getting the information really does matter for this particular patient, and it’s not going to be detrimental to the rest of my patient care. Other times it’s I do not have time to get this piece of info because it becomes detrimental to the rest of my patient care. Weighting the ED functionality room and your ability to provide care, not just for one patient but for every patient. And it becomes this trade, if I can do an equal job in a different way, factors into things like maybe I am wasting more health care dollars by doing this, but I am taking care of patients better by doing this, it become this weighted decision. MD, Denmark: [Contacting the PCP] takes too much time. It takes too much time and they are closed. MD, Canada: (about obtaining outside past medical records) If it is very easy to access, you are going to use that resource more often. Theme 1: Patient acuity. One factor that determines whether clinicians look outside of their local EHR is the acuity of the patient (43% of respondents). Respondents mentioned that if a young, uncomplicated patient presented with a simple acute injury (usually trauma was mentioned), they may not choose to look for additional PMH. In addition, if the patient is in critical condition, they do not have time to look for PMH. A Finnish doctor said, “If the patient is critically injured, all this info isn’t so important because I have to keep him alive.” The older and more chronically ill the patient, the more likely the doctor will look for PMH from external sources. Another Finnish doctor said, “If I knew that the patient is very very ill, or has been recently examined in a certain way that would [require] this sort of information, [then] it would make a difference.” Theme 2: Ease of PMH access and associated clinician time constraints. Thirty percent of respondents also pointed to ease of PMH access and associated implications for clinician time required to seek information as a factor in whether they attempt PMH access from outside sources. However, this factor was described somewhat differently across countries. US and German doctors mentioned available clinician time as the deciding factor. If they have enough time, they will start seeking it, but if not, then they do without. They perceived that they rarely had electronic access to outside PMH, and as a result, getting the needed information requires a phone call, which takes time. One US doctor said, “The time utilization and resource utilization become critical. So I am left with the decision of, really, am I going to be able to provide better care for my entire ED by getting on the phone and getting this one piece of information? Or so should I just obtain my own version of this, which frees up my time to do more things?” In Canada and Denmark, clinicians described the same dynamic, but in the context of geography as a driving factor to look for PMH. This is because if a patient comes from within their province, they have electronic access to PMH in the province, but out of province requires a phone call, requiring more time. A Canadian doctor said, “If it is very easy to access, you are going to use that resource more often.” Ability to access PMH through HIE We found varied HIE capabilities across and within countries due to heterogeneity in EHR boundaries, as well as HIE capabilities that provide access to outside sources of PMH (Table 3). In addition, we found that outpatient PMH was, in general, less likely to be accessible via HIE. Table 3. Availability of past medical history in local EHR and via HIE from an outside source Information types: inpatient, including emergency department Information types: outpatient Source of Past Medical History Country Physician notes Medications Lab results Image reports Images Physician notes Medications Accessible from internal electronic record/resource Canada: Alberta Varied: emergency department or hospital system Varied: hospital or hospital system or region (city) Nonea Denmark: northern and southern Region None Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionb Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg Hospital None USA: Midwest Hospital system Electronically accessible from external records/resources Canada: Alberta Region Denmark: northern and southern National Region None None National Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionc Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg None Varied: none or region None USA: Midwest Varied: none or EHR vendor (for select vendors) Information types: inpatient, including emergency department Information types: outpatient Source of Past Medical History Country Physician notes Medications Lab results Image reports Images Physician notes Medications Accessible from internal electronic record/resource Canada: Alberta Varied: emergency department or hospital system Varied: hospital or hospital system or region (city) Nonea Denmark: northern and southern Region None Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionb Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg Hospital None USA: Midwest Hospital system Electronically accessible from external records/resources Canada: Alberta Region Denmark: northern and southern National Region None None National Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionc Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg None Varied: none or region None USA: Midwest Varied: none or EHR vendor (for select vendors) Key: Hospital: A hospital includes all inpatient, observation, and ED beds. Hospital system: A hospital system is a set of hospitals, including their EDs, that have the same ownership or other formal affiliation. Region: A region includes all public hospitals systems, individual hospitals, and EDs in a geographic area: Canada: 14 provinces; Denmark: 5 total regions; Finland: 19 regions; Germany: 16 federal states. Region (city): A region (city) includes all public hospital systems, individual hospitals, and EDs in a given city and surrounding area. EHR vendor: EHR vendor indicates all hospital systems, individual hospitals, and EDs that utilize the same EHR vendor. Notes: aLimited number of clinics currently available. bIn regard to physician notes and medications, community hospital clinicians have access to local hospital data; tertiary university center physicians have login access to city hospital EMRs. cRegional hospitals utilize the university system lab and picture archiving and communication systems; therefore, university hospital clinicians have access to imaging and lab data for the entire region. Table 3. Availability of past medical history in local EHR and via HIE from an outside source Information types: inpatient, including emergency department Information types: outpatient Source of Past Medical History Country Physician notes Medications Lab results Image reports Images Physician notes Medications Accessible from internal electronic record/resource Canada: Alberta Varied: emergency department or hospital system Varied: hospital or hospital system or region (city) Nonea Denmark: northern and southern Region None Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionb Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg Hospital None USA: Midwest Hospital system Electronically accessible from external records/resources Canada: Alberta Region Denmark: northern and southern National Region None None National Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionc Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg None Varied: none or region None USA: Midwest Varied: none or EHR vendor (for select vendors) Information types: inpatient, including emergency department Information types: outpatient Source of Past Medical History Country Physician notes Medications Lab results Image reports Images Physician notes Medications Accessible from internal electronic record/resource Canada: Alberta Varied: emergency department or hospital system Varied: hospital or hospital system or region (city) Nonea Denmark: northern and southern Region None Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionb Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg Hospital None USA: Midwest Hospital system Electronically accessible from external records/resources Canada: Alberta Region Denmark: northern and southern National Region None None National Finland: Uusimaa and Pohjois-Savo Varied: hospital network or region (city)b Varied: hospital or regionc Varied: none or region (city)b Germany: Lower Saxony, Bavaria, and Hamburg None Varied: none or region None USA: Midwest Varied: none or EHR vendor (for select vendors) Key: Hospital: A hospital includes all inpatient, observation, and ED beds. Hospital system: A hospital system is a set of hospitals, including their EDs, that have the same ownership or other formal affiliation. Region: A region includes all public hospitals systems, individual hospitals, and EDs in a geographic area: Canada: 14 provinces; Denmark: 5 total regions; Finland: 19 regions; Germany: 16 federal states. Region (city): A region (city) includes all public hospital systems, individual hospitals, and EDs in a given city and surrounding area. EHR vendor: EHR vendor indicates all hospital systems, individual hospitals, and EDs that utilize the same EHR vendor. Notes: aLimited number of clinics currently available. bIn regard to physician notes and medications, community hospital clinicians have access to local hospital data; tertiary university center physicians have login access to city hospital EMRs. cRegional hospitals utilize the university system lab and picture archiving and communication systems; therefore, university hospital clinicians have access to imaging and lab data for the entire region. Theme 1: Inconsistent access to PMH. Access to PMH was shaped both by the boundaries around clinicians’ local EHRs and by the extent to which outside sources of PMH are accessible via HIE. Both dimensions varied across countries and, in some cases, within countries. For example, in terms of EHR boundaries within Canada, one ED EHR included only ED patient data, while another ED EHR included lab and imaging data from all public hospitals in the city. In Finland, one hospital could access radiology images from a subset of hospitals, but could not access physician notes from those same hospitals. In most cases, this was due to hospitals using different systems for various information types instead of one integrated system. For example, a hospital would use an EHR for physician notes that only had information for the hospital, but a picture archiving and communication system for images that would be shared by all hospitals in a geographic region. Theme 2: HIE based on geography vs. EMR vendor. In Canada, Denmark, and Finland, the ability to access information from outside of a local EHR was primarily defined by geographic boundaries. In Canada, for example, the province of Alberta implemented Netcare, a standardized information warehouse that aggregates data from local EHRs and pharmacies. As a result, physicians and nurses felt they could access all forms of health information for patients from within the province. Unique to the United States, physicians felt they could access patient information based on the EHR vendor, regardless of geographic boundaries. In some instances, they said they could more easily get information from another health system across the country that used their vendor as opposed to a local hospital that used a different vendor. Barriers to receiving and using past medical history There was broad agreement among clinicians on the barriers to receiving and using PMH: difficulty finding and accessing sources of external PMH, time delay in receiving information, and finding relevant information in documents received (Table 4). Table 4. Barriers to receiving and using past medical history Barriers Selected Quotes Difficulty Finding and Accessing External Sources of Information RN, Finland: There are at least, I think, 10 ways to find or investigate, so it takes time. … That’s why it is great problem nowadays. RN, Finland: (asked where he could obtain information) We do have possibility to use, for example, Navitas [Finnish HIE] on the network, but it is very complicated because the passwords, and they are valid for short times, so you can’t use them. MD, Canada: (asked how ease of access affected attempts at obtaining information) One example I have is there is one radiology system that sometimes you can only see the dictations, and not the actual image. And so they sent us a piece of mail saying you can log into this website, and here is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information when I can access Netcare and get all of the information. ... It is just remembering all the steps and login. Delay in Receiving Information MD, Canada: (asked about ease and timing of EMR information access) Sometimes it can be hours before you’ll get any information back. Sometimes rarely the patient will have a name and network for the physician, and so if I can find a physician number, then I’ll just call the physician directly, or have them paged through that hospital system, if it’s, if I know that they’re working through, you know, general, you know, something like that, but most of the time, the patients come in after hours and so finding somebody that knows them is very difficult. ... To be honest, not very often are we then able to access those records in a timely fashion that would change our decision-making in the emergency department. Most often where it becomes relevant is if we know the patient is going to end up being admitted and then we get working on those records so that the admitting doctor then has access to those. MD, Germany: (asked how time impacts usability of past medical records) We have a problem now, and I need to solve the problem. And it takes too much time, and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital. MD, United States: (asked about the effect of a delay in information received) It is multifactorial, ranging from a lot of different things. In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting, you need to do it now, because there is an imminent issue that needs to be addressed. Difficulty Finding Relevant Information in Documents Received RN, Finland: (asked if he/she could use the EMR to find the right information) Because Pegasos [Finnish national EMR] is very “dull” system, because you can only scroll through it chronologically. You cannot go anywhere; you have to check chronologically. Interviewer: Can you search? RN: No! We have to scroll chronological and find the year/date. OK, you don’t have chest pain, you have had chest failure then. … I mean sometimes, the longest time that it takes me to check the patient from Pegasos take 46 minutes. It is a very long time. MD, United States: Inevitably, when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for. MD, Finland: (regarding using the Finnish HIE to find the right information) Yes, you can, but those are saved as links, and those links refer to one time of laboratory tests, so if I want to see the patient’s last week lab tests taken on Friday, and the results, let’s say, this week’s Wednesday, I can see them one page. But if I want to have some kind of reference to their blood sugar levels before that, for example blood sugar, last Friday, I would either have to open 10 or hundreds of links through Navitas. Barriers Selected Quotes Difficulty Finding and Accessing External Sources of Information RN, Finland: There are at least, I think, 10 ways to find or investigate, so it takes time. … That’s why it is great problem nowadays. RN, Finland: (asked where he could obtain information) We do have possibility to use, for example, Navitas [Finnish HIE] on the network, but it is very complicated because the passwords, and they are valid for short times, so you can’t use them. MD, Canada: (asked how ease of access affected attempts at obtaining information) One example I have is there is one radiology system that sometimes you can only see the dictations, and not the actual image. And so they sent us a piece of mail saying you can log into this website, and here is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information when I can access Netcare and get all of the information. ... It is just remembering all the steps and login. Delay in Receiving Information MD, Canada: (asked about ease and timing of EMR information access) Sometimes it can be hours before you’ll get any information back. Sometimes rarely the patient will have a name and network for the physician, and so if I can find a physician number, then I’ll just call the physician directly, or have them paged through that hospital system, if it’s, if I know that they’re working through, you know, general, you know, something like that, but most of the time, the patients come in after hours and so finding somebody that knows them is very difficult. ... To be honest, not very often are we then able to access those records in a timely fashion that would change our decision-making in the emergency department. Most often where it becomes relevant is if we know the patient is going to end up being admitted and then we get working on those records so that the admitting doctor then has access to those. MD, Germany: (asked how time impacts usability of past medical records) We have a problem now, and I need to solve the problem. And it takes too much time, and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital. MD, United States: (asked about the effect of a delay in information received) It is multifactorial, ranging from a lot of different things. In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting, you need to do it now, because there is an imminent issue that needs to be addressed. Difficulty Finding Relevant Information in Documents Received RN, Finland: (asked if he/she could use the EMR to find the right information) Because Pegasos [Finnish national EMR] is very “dull” system, because you can only scroll through it chronologically. You cannot go anywhere; you have to check chronologically. Interviewer: Can you search? RN: No! We have to scroll chronological and find the year/date. OK, you don’t have chest pain, you have had chest failure then. … I mean sometimes, the longest time that it takes me to check the patient from Pegasos take 46 minutes. It is a very long time. MD, United States: Inevitably, when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for. MD, Finland: (regarding using the Finnish HIE to find the right information) Yes, you can, but those are saved as links, and those links refer to one time of laboratory tests, so if I want to see the patient’s last week lab tests taken on Friday, and the results, let’s say, this week’s Wednesday, I can see them one page. But if I want to have some kind of reference to their blood sugar levels before that, for example blood sugar, last Friday, I would either have to open 10 or hundreds of links through Navitas. Table 4. Barriers to receiving and using past medical history Barriers Selected Quotes Difficulty Finding and Accessing External Sources of Information RN, Finland: There are at least, I think, 10 ways to find or investigate, so it takes time. … That’s why it is great problem nowadays. RN, Finland: (asked where he could obtain information) We do have possibility to use, for example, Navitas [Finnish HIE] on the network, but it is very complicated because the passwords, and they are valid for short times, so you can’t use them. MD, Canada: (asked how ease of access affected attempts at obtaining information) One example I have is there is one radiology system that sometimes you can only see the dictations, and not the actual image. And so they sent us a piece of mail saying you can log into this website, and here is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information when I can access Netcare and get all of the information. ... It is just remembering all the steps and login. Delay in Receiving Information MD, Canada: (asked about ease and timing of EMR information access) Sometimes it can be hours before you’ll get any information back. Sometimes rarely the patient will have a name and network for the physician, and so if I can find a physician number, then I’ll just call the physician directly, or have them paged through that hospital system, if it’s, if I know that they’re working through, you know, general, you know, something like that, but most of the time, the patients come in after hours and so finding somebody that knows them is very difficult. ... To be honest, not very often are we then able to access those records in a timely fashion that would change our decision-making in the emergency department. Most often where it becomes relevant is if we know the patient is going to end up being admitted and then we get working on those records so that the admitting doctor then has access to those. MD, Germany: (asked how time impacts usability of past medical records) We have a problem now, and I need to solve the problem. And it takes too much time, and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital. MD, United States: (asked about the effect of a delay in information received) It is multifactorial, ranging from a lot of different things. In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting, you need to do it now, because there is an imminent issue that needs to be addressed. Difficulty Finding Relevant Information in Documents Received RN, Finland: (asked if he/she could use the EMR to find the right information) Because Pegasos [Finnish national EMR] is very “dull” system, because you can only scroll through it chronologically. You cannot go anywhere; you have to check chronologically. Interviewer: Can you search? RN: No! We have to scroll chronological and find the year/date. OK, you don’t have chest pain, you have had chest failure then. … I mean sometimes, the longest time that it takes me to check the patient from Pegasos take 46 minutes. It is a very long time. MD, United States: Inevitably, when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for. MD, Finland: (regarding using the Finnish HIE to find the right information) Yes, you can, but those are saved as links, and those links refer to one time of laboratory tests, so if I want to see the patient’s last week lab tests taken on Friday, and the results, let’s say, this week’s Wednesday, I can see them one page. But if I want to have some kind of reference to their blood sugar levels before that, for example blood sugar, last Friday, I would either have to open 10 or hundreds of links through Navitas. Barriers Selected Quotes Difficulty Finding and Accessing External Sources of Information RN, Finland: There are at least, I think, 10 ways to find or investigate, so it takes time. … That’s why it is great problem nowadays. RN, Finland: (asked where he could obtain information) We do have possibility to use, for example, Navitas [Finnish HIE] on the network, but it is very complicated because the passwords, and they are valid for short times, so you can’t use them. MD, Canada: (asked how ease of access affected attempts at obtaining information) One example I have is there is one radiology system that sometimes you can only see the dictations, and not the actual image. And so they sent us a piece of mail saying you can log into this website, and here is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information when I can access Netcare and get all of the information. ... It is just remembering all the steps and login. Delay in Receiving Information MD, Canada: (asked about ease and timing of EMR information access) Sometimes it can be hours before you’ll get any information back. Sometimes rarely the patient will have a name and network for the physician, and so if I can find a physician number, then I’ll just call the physician directly, or have them paged through that hospital system, if it’s, if I know that they’re working through, you know, general, you know, something like that, but most of the time, the patients come in after hours and so finding somebody that knows them is very difficult. ... To be honest, not very often are we then able to access those records in a timely fashion that would change our decision-making in the emergency department. Most often where it becomes relevant is if we know the patient is going to end up being admitted and then we get working on those records so that the admitting doctor then has access to those. MD, Germany: (asked how time impacts usability of past medical records) We have a problem now, and I need to solve the problem. And it takes too much time, and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital. MD, United States: (asked about the effect of a delay in information received) It is multifactorial, ranging from a lot of different things. In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting, you need to do it now, because there is an imminent issue that needs to be addressed. Difficulty Finding Relevant Information in Documents Received RN, Finland: (asked if he/she could use the EMR to find the right information) Because Pegasos [Finnish national EMR] is very “dull” system, because you can only scroll through it chronologically. You cannot go anywhere; you have to check chronologically. Interviewer: Can you search? RN: No! We have to scroll chronological and find the year/date. OK, you don’t have chest pain, you have had chest failure then. … I mean sometimes, the longest time that it takes me to check the patient from Pegasos take 46 minutes. It is a very long time. MD, United States: Inevitably, when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for. MD, Finland: (regarding using the Finnish HIE to find the right information) Yes, you can, but those are saved as links, and those links refer to one time of laboratory tests, so if I want to see the patient’s last week lab tests taken on Friday, and the results, let’s say, this week’s Wednesday, I can see them one page. But if I want to have some kind of reference to their blood sugar levels before that, for example blood sugar, last Friday, I would either have to open 10 or hundreds of links through Navitas. Theme 1: Difficulty in finding and accessing external sources of PMH. The majority of respondents (54%) reported difficulty knowing where the external PMH was located. First, they had to determine if the information was available through HIE or if they needed to pursue manual fax/phone. If it was electronic, some clinicians needed to search through multiple HIE systems, while others reported difficulty remembering multiple unique username and password combinations. They reported that there were too many electronic and/or paper resources that could contain the relevant information, such that they do not know where to look. A Canadian physician stated, “Here [in a different HIE] is a new username and password, and it’s not connected well enough. I’m not going to access this one website just for this one piece of information.” Clinicians who worked with HIE systems that utilized single sign-on, the ability to access independent software systems with a single username and password, reported easier access. Theme 2: Delay in receiving information. Sixty percent of respondents commented that even when they could access or receive usable information, the length of time it took to receive the information limited its use. A German doctor stated, “We have a problem now, and I need to solve the problem. And it takes too much time and it is too difficult to get the information. And if I have a patient now and a problem, I need to solve it. And after, I can look for the other [information]. But in the emergency department, hours are a long time, and I have to make the decision before I will probably get the information from another hospital.” A US doctor noted, “In an environment where time becomes a factor both in terms of it is measured and it is valued, sometimes it is easier to repeat a test here than it is to wait for a test that was done before to come from an outside hospital. Sometimes you do not have the luxury of waiting; you need to do it now because there is an imminent issue that needs to be addressed.” Theme 3: Difficulty finding relevant information in documents received. Once they received outside information, 37% of respondents reported difficulty finding the relevant information within the electronic database or document. A US physician reported, “Inevitably when you request full medical records, you get 600 pages of medical records, in which half a page of one is what you are looking for.” In terms of electronic data, some clinicians reported difficulty scrolling through many pages. A Finnish nurse reported, “Scrolling. I mean sometimes, the longest time that it takes me to check the information from Pegasos takes 46 minutes. It is a very long time.” Others reported the need to click on dozens of links to search for information. DISCUSSION As electronic health information exchange capabilities mature worldwide, it is valuable to assess the extent to which they are meeting the needs of frontline clinicians. We interviewed emergency room physicians and nurses in the United States, Canada, Denmark, Germany, and Finland in order to characterize the state of HIE in each country and to identify (1) the perceived benefits of access to complete PMH, (2) the conditions under which PMH is sought in the context of HIE, and (3) the challenges to accessing and using HIE capabilities. Each country had a different approach to HIE that dictated what information clinicians could access electronically. Despite these differences in HIE approaches, we found overlap in clinician views on HIE. Clinicians agreed that the benefits of access to PMH included appropriate and safer care, reduced patient time in EDs, and reduced labs and imaging orders. Conditions under which PMH was sought included moderate-acuity patients, patients with chronic medical conditions, and instances where accessing PMH was easy/convenient. Challenges to access and use included difficulty knowing where external information is located and how to access it, lack of single sign-on, delay in receiving information, and difficulty finding information. That we found broad agreement on the value of HIE to access PMH is not surprising. More surprising is that, even with different HIE approaches, challenges were similar and they shaped the conditions under which PMH was sought. This suggests a potential to engage in cross-country learning to increase frontline clinician use of HIE. It is particularly interesting that frontline clinicians in all 5 countries found common ground in identifying 2 key barriers to accessing past medical records from outside institutions: not knowing where to find the information and not being able to use the information that is available to them. These barriers cut across various boundaries of what information was accessible in the local EHR versus via HIE. The barriers also cut across the 2 predominant HIE structural approaches: centralized and decentralized. In a centralized system, a third-party information aggregator, separate from the local EHR, accepts information from local sources such as other hospital EHRs, pharmacy systems, and clinics. In a decentralized system, outside information is compiled and incorporated directly into the local EMR following an outside query.15 A centralized approach is employed in Alberta (Canada), Denmark, and Finland. A decentralized approach is employed in Germany and the United States. It therefore does not appear that any particular HIE approach has emerged as superior from the perspective of frontline clinicians and that all approaches need to address a key set of barriers to ensure that HIE capabilities are usable. As countries continue to invest in HIE, our findings suggest 2 key domains in which they should focus improvement efforts. First, clinicians across countries reported that they did not know where to go to find information, because information from different external organizations was accessible in different places. Making this problem worse, in many cases, clinicians were unaware of the organization(s) where patients had previously received treatment. This suggests that creating a single approach to accessing all external information would have substantial value. If that is not feasible, clinicians need more training on where to go to access information from various external organizations. For example, clinicians could receive context-sensitive popup instructions within the EMR on how to access various HIE approaches. In addition, simple reference cards could be available at EHR terminals that list the different HIE approaches available, when they should be used (eg, based on places where patients previously received treatment or the type of PMH the clinician is seeking), and how to access them. These strategies would be facilitated by ensuring that any HIE approach could be accessed without requiring clinicians to enter additional username and password information, either by integrating it into the local EHR or by enabling single sign-on. Second, not only do clinicians need more streamlined access to the information, but information needs to be presented in a way that is usable. Having access to hundreds of pages of text does not allow emergency room clinicians to quickly use the information they need in that fast-paced environment. Clinicians should be able to quickly search for and find the type of information they are seeking, and trend data across multiple encounters. This would be greatly facilitated by focusing on access to organized data. When presented with organized data, clinicians can sort information by data type (notes, labs, imaging, medications, etc.), trend structured data (eg, lab values), and search through multiple encounters. With unorganized data, clinicians generally needed to scroll through pages (sometimes >100) of medical record information with limited ability to search, sort, or organize. The example that came closest to enabling clinicians to go to a single place for all external information and emphasized access to structured data was Netcare in Alberta, Canada. Netcare is a third-party information aggregator that aggregates data from most hospitals, pharmacies, and clinics in Alberta. As a result, clinicians only need to access one source outside their local EHR to get information. In addition, Netcare includes single sign-on, direct access to a given patient’s Netcare information when the provider is in the patient’s record in the local EHR, and use of structured data that can be searched, trended, etc. One physician went so far as to say that Netcare was her primary source of PMH. Although other countries have sought to develop a national system similar to Netcare, they rely more heavily on unstructured data, making them less usable. For example, comparing Netcare to Navitas, Finland’s regional database, the latter combines all structured data (eg, labs, vitals) and unstructured data (eg, physician notes) from single encounters into unstructured text reports (though the reports have structured headers, such as time and specialty, that can be searched). To access information from those reports, clinicians must click on a hyperlink. This prevents searching within reports, trending data between reports, or sorting information by type. This comparison highlights the potential for cross-country learning to facilitate improvements to HIE capabilities and maximize effectiveness of HIE for frontline clinicians. LIMITATIONS This study has several key limitations. First, the sample size was limited to 3 hospitals within each country and a small sample of physicians and nurses within each hospital. While we attempted to select regions that were representative of the countries in terms of HIE capabilities, no region perfectly represents any country. However, the purpose of this project was not to do a generalizable assessment of HIE by country. Instead, we hoped to gain insight from frontline clinicians based on their experiences, and compare the similarities and differences. Second, interviews were semistructured, allowing for some flexibility based on the natural flow of the conversation. As such, some follow-up was required to complete or clarify responses to some questions. Finally, in some cases, the understanding by frontline clinicians of what could and could not be accessed via HIE was inaccurate (ie, they had the ability but were not aware of it). We chose to report findings as conveyed by our respondents, but noted where these varied from what was technically available as reported by country experts. CONCLUSION Despite significant investment in eHealth in general and HIE in particular, we lack data on frontline clinician experiences with HIE. In this study, we interviewed frontline clinicians in emergency settings in 5 countries about their HIE experiences. Overall, we found that no country has yet to achieve the full benefits of optimal health information exchange in which physicians and nurses can receive and use PMH in an efficient and effective manner regardless of where their patients have previously received care. We also found that, despite different approaches to HIE, clinician experiences and reported challenges were remarkably similar. This suggests that countries need to continue to work to improve HIE, and that doing so collaboratively would be valuable. CONFLICT OF INTEREST The authors of this manuscript have no conflicts of interest to declare. ACKNOWLEDGMENTS This work would not have been possible without the time and expertise of our international colleagues. We would like to acknowledge the contribution of Timo Lukkarinen, Tinja Lääveri, Hannele Hyppönen, Christian Nohr, Jørn Munkhof Møller, Jennifer Zelmer, Lee A. Green, Ursula Hertha Hübner, Moritz Esdar, and Laura Naumann for providing guidance, insights into local Health IT policy and use, and assistance in identifying clinicians and coordinating interviews in our selected countries. FUNDING This work was supported in part by the University of Michigan Medical School. ROLE OF THE FUNDER/SPONSOR The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; or decision to submit the manuscript for publication. 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Journal

Journal of the American Medical Informatics AssociationOxford University Press

Published: Feb 2, 2018

References