Findings from 2017 on Health Information Management

OBJECTIVE: To summarize the recent literature and research and present a selection of the best papers published in 2017 in the field of Health Information Management (HIM) and Health Informatics.
METHODS: A systematic review of the literature was performed by the two HIM section editors of the International Medical Informatics Association (IMIA) Yearbook with the help of a medical librarian. We searched bibliographic databases for HIM-related papers using both MeSH descriptors and keywords in titles and abstracts. A shortlist of 15 candidate best papers was first selected by section editors before being peer-reviewed by independent external reviewers.
RESULTS: Health Information Exchange was a major theme within candidate best papers. The four papers ultimately selected as 'Best Papers' represent themes that include health information exchange, governance and policy issues, results of health information exchange, and methods of integrating information from multiple sources. Other articles within the candidate best papers include these themes as well as those focusing on authentication and de-identification and usability of information systems.
CONCLUSIONS: The papers discussed in the HIM section of IMIA Yearbook reflect the overall theme of the 2018 edition of the Yearbook, i.e., the tension between privacy and access to information. While most of the papers focused on health information exchange, which reflects the "access" side of the equation, most of the others addressed privacy issues. This synopsis discusses these key issues at the intersection of HIM and informatics. Georg Thieme Verlag KG Stuttgart.

Introduction

The issues of patient privacy and access to health information have always been central to the fields of Health Information Management (HIM) and Health Informatics. Health Information Managers often assume roles such as Chief Privacy Officer or other positions in healthcare organizations where they are advocates for patient privacy. Health and medical informatics professionals, on the other hand, have often focused on fostering broader access to health information for research and other secondary uses 1 2 , as well as on developing methods and models for health information exchange for clinical use 3 . At the same time, many informatics efforts have gone into developing new technological approaches to privacy and security protections when information is exchanged or shared 4 5 . Recent policy trends and changes in health information technology have made the inherent tension between these two goals more intense in recent years 6 . For instance, in the U.S., federal efforts to promote health information exchange, beginning with the Health Information Technology for Economic and Clinical Health (HITECH) Act 7 and continuing with the 21 st Century Cures Act have put pressure on electronic health records (EHRs) developers to make them improve the interoperability of their systems, and have incentivized healthcare organizations to implement health information technology (IT) and to engage in health information exchange 7 8 . Changes in the Common Law promoted by the Office of Human Research Protection have made the secondary use of health information easier as well 9 . At the same time, the Health Insurance Portability and Accountability Act (HIPAA) regulations have gotten more stringent in terms of accountability and penalties for privacy violations 10 . The articles that are included in this synopsis reflect the recent developments to address the challenges posed by public policy changes as well as the emergence and implementation of new health information technologies, functions, and capabilities.

Methods

At the end of December 2017, with the assistance of a medical librarian, the editors of the HIM section of the International Medical Informatics Association (IMIA) Yearbook conducted a search of HIM-related articles in both PubMed and Embase, using both MeSH descriptors and keywords in the titles and abstracts. The publication year was 2017 and did not include those articles that were e-published ahead of print. The query for PubMed was: “Health Information Management”[MSH] OR “Health Information Management” [tiab] OR “HIM J”[Journal] OR “JAHIMA”[Journal]”, which yielded 198 results. The query for EMBASE was ‘medical information system'/exp/mj OR “health information management”:ti,ab OR “clinical information system”:ti,ab OR “clinical pharmacy information systems”:ti,ab OR “health information exchange”:ti,ab OR “health information management”:ti,ab OR “health information manager”:ti,ab OR “health information network”:ti,ab OR “health information system”:ti,ab OR “health information systems”:ti,ab OR “IS-H med”:ti,ab OR “medical information service”:ti,ab OR 'Health Information Management Journal', which, yielded 382 articles. From these articles we excluded those with no title and/ or no abstract, which eliminated 63 articles, and finally we removed 100 duplicates from the remainder leaving 417 unique articles in English to review.

The 417 unique articles were rated by both section editors, who excluded articles that were opinion pieces or editorials, or articles where the full text of the article was not readily available. Each of the two section editors judged independently the relevance to the HIM field and the quality of the retrieved articles. Those that both co-editors rated as not appropriate were excluded automatically. The rest of the articles were discussed and disagreements adjudicated to arrive at 15 candidate best articles that, based primarily on the abstracts, were judged to be of good quality and to reflect the diverse aspects of the theme of the 2018 edition of the Yearbook. The full texts of these 15 articles were then rated independently by both section editors, one of the Yearbook editors, and at least two external peer reviewers. One of the articles, in hindsight, was not relevant to the theme of this year's Yearbook and is not discussed in this synopsis.

The four HIM-related ‘Best Papers’ were selected based primarily on having a high average rating from the reviewers. Other factors included the consensus of reviewers for including the paper as one of the best papers, as well as diversity of research approaches and settings.

The survey paper for the 2018 HIM section 11 presents a complementary focus to the research articles in that the survey paper focuses primarily on public policy issues related to privacy, access, and disclosure of health information. The authors, Kloss, Brodnik, and Rinehart-Thompson, performed a scoping literature review that examined regulations, policies, and laws related to access and disclosure of information, as well as practices designed to protect privacy and address problems with information privacy. Their review covers policies across multiple countries, and includes comparisons across country laws and practices. They noted key information and data governance issues that must be addressed and identified areas that are still in need of research, especially with the development of new technologies, new approaches and mechanisms of access to information, as well as current and contemplated legislation. Below we discuss the major themes illustrated by the 15 candidate best papers.

Results

Health Information Exchange Policies and Governance

Several articles addressed policy and governance issues in health information exchange (HIE) that must be considered for HIE to be successful and viable over the long-term in providing access to health information 12 13 14 . The articles represented examples of health information exchange conducted in three different countries (Korea, Switzerland, and the U.S.) but many of the issues are common to all. There are legal and regulatory issues that must be dealt with related to information access and sharing, and policies surrounding standards, both in terms of data elements and interoperability 12 . The article by De Pietro and Francetic discusses changes in the laws that helped to promote the use of EHRs and health information exchange in Switzerland 13 . They also note that the Swiss health system as a whole is very fragmented which adds to the difficulties of health information exchange. This fragmentation is not unique to Switzerland, although the ways in which it is displayed may be, and policies to address such fragmentation are needed in many countries. One of the key policy issues to address surrounds patient consent. The study by Downing et al. , one of the 2018 best papers, discussed in more detail below, collected data on consent policies across 11 health systems and examined the relationship between the method for obtaining consent and the actual volume of information exchanged 14 . The researchers found that incorporating consent for HIE as part of the consent for treatment process, rather than requiring a separate consent each time health exchange was desired, led to an increased volume of information exchange. Similarly, they found that automating the process of obtaining records from another institution led to a similar outcome of more data exchanged. Given the importance of developing policies around consent for HIE, Downing et al.'s conclusions can be very useful in establishing reasonable policies that incorporate appropriate privacy protections, yet do not create unnecessary barriers to exchange.

Architectures for Information Integration and Health Information Exchange

Several of the 15 candidate best papers conceptualized and/or developed different architectures for integrating and exchanging health information. There was a focus on methods for integrating and making patient's personal health records (PHRs) accessible to their health care providers. The field of health information management has long had an interest in PHRs 15 and with the growing interest in patient-reported outcomes and their integration into EHRs 16 , innovative strategies are needed to address incorporating PHR data into routine clinical care. One approach is to integrate information in the cloud. Bell et al. , developed a conceptual model based on cloud-based platforms for making immunization data from multiple sources accessible to patients and providers 17 . Miyaji et al. , used the multiparty private set interaction protocol as a method of integration of data 18 . Abdulnabi et al. , suggested using smartphones to provide a distributed method of health information exchange, since most patients have access to smartphones 19 . Roehrs et al. , another of the 2018 best papers, discussed in more detail below, developed and evaluated what the authors refer to as OminiPHR, which is also a distributed model, but uses blockchain technology 20 . Blockchain, while not currently used extensively in healthcare, has received considerable attention for potential healthcare applications and the article by Roehrs et al. , suggests using it to make personal health record data accessible to patients and providers 21 . Collectively, these studies illustrate the challenges in creating efficient and workable solutions to integrating PHR and EHR data.

Authentication and De-Identification

In addition to developing methods for integrating data in the context of health information exchange, privacy and security issues must be addressed. Assuring privacy and security of healthcare data, whether access is through health information exchange or other means, is a focus of several articles. Park and Park 22 and Mohit et al. 23 developed innovative authentication approaches to address the major security issue of assuring that only those with the right to access information can obtain it. Aslam et al. , reviewed a variety of authentication schemes, developed a new metric to evaluate these approaches, and suggested that patients and physicians might need different levels of authentication. They suggested two-factor authentication for patients, but three-factor approaches for health care providers 24 .

In addition to authentication issues, some of the privacy issues involve de-identification. This may be particularly important with sensitive information such as substance abuse or mental illness which often have more stringent privacy regulations. Using Natural Language Processing techniques, Lee et al., developed and tested a novel approach to the de-identification of psychiatric notes 25 . As concerns about cybersecurity increase and as more and more electronic health information is generated, shared, and exchanged, the development, implementation, and evaluation of new approaches to authentication and de-identification will become even more important.

Implementation of Health Information Exchange

In addition to the foundational research needed to develop viable methods of HIE, research is also needed on strategies for implementation. The final set of papers from this year's selection illustrates a variety of approaches, settings, and technologies for health information exchange. One of the studies, by Klein et al., discussed in more detail in the best paper summaries, was done across nine hospitals within the US department of Veterans’ Affairs (VA) 26 . Within the VA system, patients’ information is accessible to all clinicians who need it, but there is an increasing need for exchange of data with private physicians outside the VA. The method of exchange decided upon was ‘consumer-mediated’ in that patients were taught how to download their VA health information so they could make it accessible to their outside providers. Klein et al., also evaluated the extent to which VA information was valuable to outside (non-VA) providers. The researchers found that most of the patients printed out the information for their outside providers, rather than exchanging it electronically. They also found that the outside providers appreciated having access to the data. This study illustrates that there are still challenges to the electronic exchange of information, but it is encouraging that if the information is easily accessible, even if not electronically, it is appreciated and used.

The last two papers focused on the importance of medication information. One of them, by Boockvar et al. , also included as one of the best papers, was a cluster-randomized controlled trial examining the impact of the availability of pharmacy insurance claims data on medication discrepancies discovered during the medication reconciliation process for hospitalized patients 27 . They found that this data improved the medication reconciliation process in that when pharmacy claims data were available, there were more discrepancies discovered between pre-admission and inpatient medications. The discovery of these discrepancies and their reconciliation is important to improve patient safety. The final study by Hohmeier et al. , looked at the reverse aspect of medication reconciliation 28 . These researchers examined how data on the patient's hospital course could impact what the community pharmacist does. This study was a qualitative study which examined how pharmacists utilize the data from a health information exchange. The authors found that it was feasible to integrate the data from HIE into the workflow of community pharmacists, and that pharmacists found that doing so aided identification of medication discrepancies. However, they also found that there was often a lag between patient discharge from the hospital and information availability from HIE. These three studies illustrate that health information exchange is becoming more feasible, that the data are perceived as useful, and that use of the data can improve patient safety. However, they also show that there are still limitations that must be addressed if the potential of HIE is going to be realized.

Conclusion

The set of papers in this year's HIM section of the Yearbook provide insights on the challenges of making health information easily accessible to providers and patients, keeping it secure, assuring privacy, fitting the exchange of information into the workflows of all who need it, and making optimal use of the data. Some of the papers addressed the developments of new technologies for data integration, authentication, and de-identification, while others focused on policy issues, implementation issues, and outcomes of the use of the data. This set of papers is a start, but more research on all of these areas — policies, technologies, implementation, and outcomes — is needed for health information exchange to realize its potential of providing secure access to information when and where it is needed.

Table 1

Best paper selection of articles for the IMIA Yearbook of Medical Informatics 2018 in the section ‘Health Information Management'. The articles are listed in alphabetical order of the first author's surname.

SectionHealth Information Management
▪ Boockvar KS, Ho W, Pruskowski J, DiPalo KE, Wong JJ, Patel J, Nebeker JR, Kaushal R, Hung W. Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial. J Am Med Inform Assoc 2017 Nov 1;24(6):1095-101.
▪ Downing NL, Adler-Milstein J, Palma JP, Lane S, Eisenberg M, Sharp C; Northern California HIE Collaborative, Longhurst CA. Health information exchange policies of 11 diverse health systems and the associated impact on volume of exchange . J Am Med Inform Assoc 2017 Jan;24(1):113-22.
▪ Klein DM, Pham K, Samy L, Bluth A, Nazi KM, Witry M, Klutts JS, Grant KM, Gundlapalli AV, Kochersberger G, Pfeiffer L, Romero S, Vetter B, Turvey CL. The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange. Telemed J E Health 2017 Apr;23(4):264-27.
▪ Roehrs A, da Costa CA, da Rosa Righi R. OmniPHR: A distributed architecture model to integrate personal health records. J Biomed Inform 2017 Jul;71:70-81.