Wednesday, October 23, 2013

Discerning the Evidence Base for Health Information Exchange (HIE)

Some of the most important projects in my career have come out of nowhere, almost by coincidence, but turning into major commitments as well as important endeavors for the field. I am about to begin a new project that originated in a similarly unexpected manner.

This project came about because our Department of Medical Informatics & Clinical Epidemiology (DMICE) is one of the 12 Evidence-Based Practice Centers (EPCs) funded by the Agency for Healthcare Research and Quality (AHRQ). Being an EPC gives these centers the opportunity to bid to perform "task orders," which mainly consist of "evidence reports" that usually consist of one or more systematic reviews and sometimes additional analysis. DMICE houses the Pacific Northwest EPC, which is a major activity of the "CE" part of DMICE.

Most of the AHRQ evidence reports focus on clinical topics, such as traumatic brain injury or myocardial infarction. AHRQ has commissioned a few reports on informatics-related topics over the years, such as telemedicine and health information technology. (I was principal investigator [PI] of the telemedicine reports it commissioned, which included an initial analysis focused on Medicare patients [1-2], a supplementary analysis on all patients, and an update [3-4].)

A couple months ago, the Director of our EPC informed me that AHRQ had released a "request for task order" (RFTO) seeking bids to prepare an evidence report on health information exchange (HIE). Needless to say, I jumped at the chance to serve as PI and prepare a proposal. I was then delighted to receive word in mid-September that our proposal had been selected for funding. We have a great team that combines informatics and evidence-based medicine expertise.

This 18-month project will become one of my major projects going forward. The timing could actually not be better, with the winding down of my big Office of the National Coordinator for Health IT (ONC) projects.

I am looking forward to undertaking this project. HIE is one of the most important activities of informatics now. The benefit of a standards-based, interoperable health IT ecosystem will not be realized unless, to quote former AHRQ Director Dr. Carolyn Clancy, "data follows the patient" wherever they go in the healthcare system. Or, as started by Dr. William Yasnoff, former Senior Federal Advisor for the National Health Information Infrastructure, there must be "anytime, anywhere access to data for patient care." Or even, as noted more recently by Dr. John Halamka, ACO = HIE + analytics. HIE has a growing accumulation of evidence concerning its effectiveness, obstacles, and sustainability.

We will follow the usual EPC approach in producing the evidence report. Our first activity will be to develop a set of key questions that the report will answer, embedded into a conceptual framework that shows the interrelationships among the questions. This process will be aided by engaging a set of "key informants" who represent various stakeholder groups, such as patients, providers, healthcare organizations, health policymakers, and vendors. They will help us in a process of "topic refinement" to specify the key questions [5].

Once our key questions are finalized, we will then perform a systematic review on each one. Systematic reviews differ from other kinds of topic reviews in that the questions are focused and amenable to being answered with scientific evidence [6]. They not only provide an inventory of existing scientific knowledge on a given topic but also inform us of the gaps in our knowledge.

Systematic reviews always begin with a comprehensive literature search, which casts a wide net for all possible evidence. The retrieved titles and abstracts are read and analyzed to determine which papers might meet inclusion criteria and should be pulled for reading of their full text. Those that meet the inclusion criteria are abstracted for the evidence, which is then is entered into evidence tables. If enough evidence from similar studies is retrieved, then a meta-analysis might be performed, where the data from each study is aggregated as if it were a single study. Meta-analysis summarizes the evidence as well as increases its statistical power.

This report will not focus solely on the evidence for the benefit of HIE. While that will clearly be an important part, we will also look at other aspects of HIE.

The first key question will likely concern the effectiveness of HIE. This will be assessed based on a variety of outcomes of its use, including healthcare process outcomes, intermediate outcomes, economic outcomes, clinical outcomes, and population-level outcomes. Other key questions will likely focus on:
  • Usage
  • Usability
  • Harms
  • Facilitators and barriers to successful use
  • Sustainability
We will also look at attributes of HIE that may influence success, such as the setting of HIE use, patient population(s), and others.

One of the challenges for defining evidence for HIE is that it is used as a means to other ends, usually improved clinical care. Since many other factors may influence care, it may be hard to tease out the true value of HIE. But we will aggregate all the evidence we can find to best discern the scientific picture of its value and limitations.


1. Hersh, WR, Helfand, M, et al. (2001). Clinical outcomes resulting from telemedicine interventions: a systematic review. BMC Medical Informatics and Decision Making. 1: 5.
2. Hersh, W, Helfand, M, et al. (2002). A systematic review of the efficacy of telemedicine for making diagnostic and management decisions. Journal of Telemedicine and Telecare. 8: 197-209.
3. Hersh, WR, Hickam, DH, et al. (2006). The evidence base of telemedicine: overview of the supplement. Journal of Telemedicine & Telecare. 12(Supp 2): 1-2.
4. Hersh, WR, Hickam, DH, et al. (2006). Diagnosis, access, and outcomes: update of a systematic review on telemedicine services. Journal of Telemedicine & Telecare. 12(Supp 2): 3-31.
5. Buckley, DI, Ansari, M, et al. (2013). The Refinement of Topics for Systematic Reviews: Lessons and Recommendations From the Effective Health Care Program. Rockville, MD, Agency for Healthcare Quality & Research.
6. Khan, K, Kunz, R, et al. (2011). Systematic Reviews to Support Evidence-Based Medicine, 2nd Edition. Boca Raton, FL, CRC Press.

No comments:

Post a Comment