I'm a huge supporter of information technology. I've spent almost my entire career creating systems in order to improve outcomes for pediatric patients. But that doesn't mean I don't carry a healthy skepticism for how much of a difference HIT is actually making in practice. The evidence for how much health information exchanges are impacting care is somewhat equivocal as well. A new study is being discussed as showing HIEs can significantly reduce hospital admissions. It's worth reviewing in detail. "The potential for community-based health information exchange systems to reduce hospital readmissions":
Background Hospital readmissions are common, costly, and offer opportunities for utilization reduction. Electronic health information exchange (HIE) systems may help prevent readmissions by improving access to clinical data by ambulatory providers after discharge from the hospital.
Objective We sought to determine the association between HIE system usage and 30-day same-cause hospital readmissions among patients who consented and participated in an operational community-wide HIE during a 6-month period in 2009–2010.
Methods We identified a retrospective cohort of hospital readmissions among adult patients in the Rochester, New York area. We analyzed claims files from two health plans that insure more than 60% of the area population. To be included in the dataset, patients needed to be continuously enrolled in the health plan with at least one encounter with a participating provider in the 6?months following consent to be included in the HIE system. Each patient appeared in the dataset only once and each discharge could be followed for at least 30?days.
Readmissions are one of the most popular metrics being promoted as a measure of quality in the health care system. Measures which might reduce such readmissions would be welcome, as payments might depend on keeping reasmissions to a minimun.
Some have postulated that a lack of information might drive a number of admissions. Doctors might put patients into he hospital because they don't have a clear picture of what's going on, or because they think patients might need tests or checks that they are unaware have already been done. With better information, therefore, some readmissions might be prevented. If HIEs can deliver this information, then they might be a means to achieve better quality.
This study was a retrospective cohort analysis of patients in two health plans who live in Rochester, New York. To be included in the cohort, patients had to be continuously enrolled and have been seen at least once by a participating provider in the last six months. The main outcome of interest was whether a patient was readmitted to the hospital within 30 days of being discharged. The main predictor of interest was whether a provider had accessed patient information in the HIE in the month after discharge.
The researchers found that patients whose information was accessed by a provider had significantly lower odds (aOR 0.43) of readmission when compared to patients whose information was not accessed. They further estimated that the reduced readmissions for the health system were just over $600,000.
On its face, these findings seem like great news, for patients, for HIEs, and for the health care system. But there are some reasons to take them with a grain of salt. This is an observational study, and causality cannot be assumed. We don't know that the HIE is what led to a reduction in readmissions. This is also a study of a relatively small set of patients in a health care market that is reasonable contained.
The larger issue is one of confounding, however. It's entirely possible that accessing the HIE could be a marker for a more attentive physician, a more robust medical home, or a patient who was being managed more closely. In that case, the HIE isn't the cause of the reduced readmission - it's merely a signal that better care was occurring. This is important, because the creation and maintenance of HIEs is not insubstantial. They take time, money, and a large amount of effort.
Pretty much all of these issues are noted in the discussion of the manuscript, so none of these are to fault the paper or the authors. But some are over-interpreting this study to "prove" that HIEs are a success. Almost all of want them to be. But the siren song of HIT that improves access, reduces spending, and improves quality has lured many before with promises that have failed to achieve their potential.
This study shows that it's very possible that HIEs could lead to improved quality and increased savings. Whether they are truly the cause of these findings will need further work with more robust, prospective work.
From the editors: Learn about more new health information technology research at AcademyHealth’s 2015 Annual Research Meeting and discuss health information exchanges with delivery system leaders at AcademyHealth’s inaugural Concordium conference.