RESEARCH NOTES
Pharmacists’ familiarity, utilization, and beliefs about Health Information Exchange: A survey of pharmacists in an Indiana pharmacy organization Allison D. Held, Lacie J. Woodall, and John B. Hertig
Abstract Objective: To gauge pharmacists’ familiarity, utilization, and beliefs about Health Information Exchange (HIE). Methods: A survey questionnaire was developed by the authors in Qualtrics (Provo, UT) and administered to 358 Indiana Pharmacists Alliance (IPA) members via email listserv in May and August 2013. The questionnaire consisted of 18 questions on familiarity, utilization, and beliefs about HIE. Results: The response rate was 19% (67/358). Pharmacy practice experience of respondents ranged from 0 to 5 years (18%, n = 12) to more than 20 years (61%, n = 41). More than one-half (70%) of respondents practiced in hospital settings. Many respondents (75%) were familiar with the concept of HIE; 54% currently use some type of HIE technology. Nearly all respondents felt that data in electronic health records (EHRs) should be shared between pharmacists and other health care providers. Respondents identified improved coordination of care as the greatest potential benefit, and difficulty implementing and maintaining technology as the greatest barrier of HIE. Conclusion: Many respondents were familiar with HIE and in favor of sharing patient records between providers. Respondents agreed that HIE has the potential to improve coordination of care but were concerned about implementing and maintaining technology. Larger pharmacy samples should be studied to determine how the results of this study compare to pharmacy populations at state and national levels. Keywords: Health Information Exchange, technology, electronic health records, pharmacists, meaningful use. J Am Pharm Assoc. 2014;54:625–629. doi: 10.1331/JAPhA.2014.14080 Journal of the American Pharmacists Association
T
he Office of the National Coordinator for Health Information Technology (ONC) was developed in an effort to combat rising health care costs and improve the safety and efficiency of health care in the United States.1 In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized providers to implement health information technology and adopt electronic health records (EHRs) in many practice settings. Among various funding areas is health information exchange (HIE), defined by the Agency for Healthcare Research and Quality (AHRQ) as “the process of sharing health care data among individuals, institutions and health care service providers in order to improve the process, quality, cost, and safety of health care.”2 Goals of expanding HIE include standardizing interoperability of data exchange at local, state, and national levels, promoting patients’ involvement in their own health care, reducing medical and medication errors through provider communication and information sharing, reducing health care costs through avoiding duplication of services, and improving automation of administrative functions.1 To encourage the development of statewide HIE networks, ONC created the State HIE Cooperative Agreement Program in 2010. Among HIE state leaders, Indiana sustains the largest and most established HIE organization in the United States.3 Indiana Health Information Exchange (IHIE) connects 94 hospitals and 25,000 participating physicians to serve 10 million patients. One example of an IHIE system is the Indiana Network for Patient Care, which provides physicians with patient information from more than 90% of hosReceived April 29, 2014, and in revised form May 29, 2014. Accepted for publication June 28, 2014. Published online in advance of print October 10, 2014. Allison D. Held, PharmD, is Visiting Scientist Fellow, Eli Lilly and Company, Indianapolis, IN. Lacie J. Woodall, PharmD, is Postgraduate Year 1 Pharmacy Resident, Johnson City Medical Center, Johnson City, TN. John B. Hertig, PharmD, MS, CPPS, is Associate Director of Center for Medication Safety Advancement, Courtesy Clinical Assistant Professor of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, IN. Correspondence: John B. Hertig, PharmD, MS, CPPS, 6640 Intech Blvd., Suite 120, Indianapolis, IN 46278–2012. Fax: 317-275-2375. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Previous presentations: American Society of HealthSystem Pharmacists Midyear Clinical Meeting, Orlando, FL, December 10, 2013; and the Indiana Pharmacist Alliance Spring Meeting, Indianapolis, IN, April 16, 2014. Acknowledgments: To John Cowan, Patty Elsner, Jaclyn Jeffries, Susan Kidwell, Amy Sheehan, and Erica Treadway for reviewing the survey instrument.
j apha.org
N OV/D EC 2014 | 54:6 |
JAPhA 625
RESEARCH NOTES
pharmacists and health information exchange
pital care in the Indianapolis area, including radiology, operative notes, pathology reports, medication records, and discharge summaries. Physicians’ beliefs about HIE have been assessed within several statewide HIE networks. A survey of physicians in Massachusetts regarding their use and attitudes toward HIE found that more than 70% of physicians had a positive attitude about HIE and believed it could reduce health care costs, improve quality of patient care, and save time.4 However, physicians were concerned about patient privacy and cost of HIE technology. A survey assessing behavioral health providers’ beliefs about HIE in Nebraska showed that most providers are supportive of HIE and believe it will improve care and communication but are concerned about the cost and time burden of implementing the technology.5,6 While physicians’ beliefs about HIE have been explored, pharmacists’ beliefs about HIE are not welldefined in the literature. One study that assessed EHR adoption by Nebraska pharmacists demonstrated that pharmacists were not widely using EHRs in 2008, and the ones who were, practiced primarily in hospital settings.7 Very few pharmacists had access to EHRs for their patients created by other providers, but many felt they should have access to these records. The study demonstrated low uptake of EHRs, but the authors discussed the importance of pharmacist knowledge and participation in HIE networks as physicians continue to adopt these technologies. In the development of a statewide HIE/EHR system in Arizona, a pharmacy focus group identified e-prescribing as an important feature because it would likely reduce medication errors and improve communication with physicians.8 In addition, the Pharmacy Health Information Technology Collaborative provides a national platform for collaboration and representation of all pharmacy practice areas in the implementation and growth of HIE.9 In an era of mandated health care technology growth, pharmacists’ involvement in HIE is imperative to all areas of health care delivery. As the medication use experts, pharmacists serve a major role in the exchange of patient information to nearly all settings. The impact of HIE on pharmacy practice offers opportunities for pharmacists to expand their clinical services and build relationships with providers, but pharmacists’ current involvement in HIE may be limited by their type of practice setting or the perceived barriers of HIE in pharmacy.
Objective The objective of this cross-sectional study was to gauge pharmacists’ familiarity, utilization, and beliefs about HIE among members of an Indiana pharmacy organization.
626 JAPhA | 5 4:6 | NOV /DE C 2 0 1 4
ja p h a.org
Methods A survey questionnaire was developed by the authors in Qualtrics (Provo, UT). Questions were derived from previously validated physician surveys4–6 and one pharmacist survey.7 A pilot survey instrument was reviewed by a panel of five pharmacists representing academia, community practice, hospital practice, and one pharmacy student. Reviewers provided feedback to improve clarity and applicability of questions. The questionnaire consisted of 18 questions assessing respondents’ demographics, familiarity with and use of HIE supporting technology, and beliefs about HIE. The study received exempt status through Purdue University Institutional Review Board. Survey respondents were provided with the AHRQ definition2 of HIE on each page of the questionnaire and asked to consider this definition of HIE as well as any personal experiences with HIE as they answered the questions. The survey was administered two times (May and August 2013) to Indiana Pharmacists Alliance (IPA) members via e-mail and a listserv containing 358 active e-mail addresses as of May 2013. IPA active membership information, including member e-mail addresses, is updated annually when membership is renewed. No incentives were provided to survey respondents. Data collection ended September 30, 2013. Post hoc analysis of subgroups, such as early versus late responders, was not performed. Student IPA members were excluded from data analysis because of the small number of student respondents (n = 16). No statistical tests were performed on collected data.
Results The response rate was 19% (67/358). Respondents represented a range of pharmacy practice settings and years of experience (Table 1). Many were familiar with the concept of HIE before this survey, and more than onehalf currently use HIE-supporting technology in practice. All respondents believed the benefits of HIE outweigh or potentially outweigh the barriers. A majority of respondents identified improved coordination of care as the greatest potential benefit of HIE and difficulty implementing and maintaining technology as the greatest potential barrier (Table 2).
Discussion Most respondents were familiar with HIE, suggesting implementation of HIE-supporting technology is in progress in many settings. However, 25% of respondents were not familiar with HIE before the survey. Unfamiliarity may be due to implementation of EHRs as a rate-limiting step in the development of HIE networks. This study highlights the issue that some practice settings have not adopted an EHR system and are still using some paper records. However, the growth of EHRs Journal of the American Pharmacists Association
pharmacists and health information exchange
Table 1. Characteristics of respondents and familiarity with health information exchange Characteristic Response Practice setting Hospital Community chain/grocery Community independent Academia Ambulatory Managed care Other Long-term care Years of experience >20 11–20 6–10 0–5 Precept students Yes No Gender Women Men Familiar with the concept of HIE Yes No Currently using HIE supporting technology Yes No Do not know Institution adoption status of EHRs and HIE EHR with HIE Do not know Partial EHR; some paper records EHR without HIE Not applicable No EHR
RESEARCH NOTES
No. 47 3 4 5 3 3 1 1 41 7 7 12 45 22 35 32 50 17 34 19 10 34 9 8 5 4 3
% 70 4 6 7 4 4 1 1 61 10 10 18 67 33 52 48 75 25 54 30 16 54 14 13 8 6 5
Abbreviations used: EHR, electronic health record; HIE, health information exchange.
in pharmacy settings in recent years appears to be substantial, as Fuji et al. found that only 12% of pharmacist respondents had adopted an EHR system in 2008.7 HIE may struggle to advance until institutions adopt EHRs and work through the barriers associated with EHR systems. As EHR technology becomes a requirement by the Centers for Medicare and Medicaid Services (CMS) in 2015, CMS providers will be penalized for not implementing EHRs.10 As settings make this transition, awareness of HIE is also expected to rise. An encouraging finding of this study was overwhelming agreement that EHRs should be shared among providers and pharmacists no matter who originally created the record. This finding was similar to the EHR survey study of pharmacists7 and suggests pharmacists are interested in increasing communication with other providers. Considering that survey literature on HIE has focused on physician populations, it was important to explore how pharmacists feel about physician acceptance of HIE. More respondents felt that physician acceptance of HIE determines pharmacist adoption of HIE. Although pharmacists may welcome the use of HIE supporting technology, the majority of respondents in this study felt Journal of the American Pharmacists Association
they must wait for HIE to advance in physician settings before it can be realized in pharmacy settings. The majority of respondents were unsure if their personal beliefs about HIE differed from their management’s beliefs. Because HIE infrastructure can be costly and challenging to implement, pharmacists may face organizational opposition if advocating for the implementation of HIE-supporting technology. Discussions with those in charge of the implementation may be important so that pharmacy management knows this topic would be met with acceptance. All respondents felt the benefits of HIE outweigh or may potentially outweigh the barriers of HIE, suggesting respondents recognize how sharing information between practice settings and providers can improve quality of care and safety for patients. Respondents identified improvement in coordination of care as the greatest potential benefit of HIE. Improving coordination of care is becoming a crucial area of focus in health care and was identified as a key benefit of HIE by physicians as well.5 Many respondents also identified improving patient safety as a potential benefit of HIE. Pharmacists recognize how medication errors result from inadequate j apha.org
N OV/D EC 2014 | 54:6 |
JAPhA 627
RESEARCH NOTES
pharmacists and health information exchange
Table 2. Respondents’ beliefs about health information exchange Belief Response Pharmacists should have access to Yes EHRs created by other health care No providers Other providers should have access to Yes EHRs created by pharmacists No Physician acceptance of HIE determines Yes pharmacist use of HIE-supporting No technology Personal beliefs about HIE compared to Do not know organization or management’s beliefs My beliefs are similar to my organization/management’s about HIE My beliefs differ from my organization/management’s I am in charge of HIE decisions Benefits of HIE outweigh the barriers Yes of HIE Potentially No Identify the greatest potential benefit Improve coordination of care of HIE Improve patient safety Improve communication with providers Improve access to patient records Improve tracking medication history Increase opportunities for interventions Other Improve workflow Improve patient privacy/security Reduce health care costs Difficulty implementing/maintaining HIE Identify the greatest potential barrier of HIE Risk to patient privacy/security Company/organization acceptance of HIE Greater legal vulnerability Increased time constraints Technology costs Reliance on technology Other Disruption of workflow Misuse by third-party payers
No. 58 1
% 98 2
59 0 36 23
100 0 61 39
31 24 2 2 45 14 0 29 14 4 4 3 3 2 0 0 0 24 9 8 4 4 4 2 2 1 1
53 41 3 3 76 24 0 49 24 7 7 5 5 3 0 0 0 41 15 14 7 7 7 3 3 2 2
Abbreviations used: EHR, electronic health record; HIE, health information exchange.
communication and data exchange between providers. Additionally, respondents specified implementing and maintaining HIE supporting technology as the greatest potential barrier of using HIE. Although establishing HIE networks from a technological and interorganizational standpoint may seem daunting, it is important to consider that there are numerous HIE networks that are fully operational today.3,9
Limitations Although many practice settings were represented, the sampling frame resulting from using the IPA listserv may limit the representation of pharmacists to only one Indiana pharmacy organization. As of May 2013, there were 6,870 pharmacists employed in Indiana.11 The sample size of 358 IPA members represents only 5% of the 628 JAPhA | 5 4:6 | NOV /DE C 2 0 1 4
ja p h a.org
Indiana pharmacist population, and the response rate of this study was also lower than previous studies.4,5,7 To generalize the results of this study to larger pharmacy communities, the sample would need to be expanded to larger pharmacy populations. Another limitation of the study was collection of data that did not allow for comparison of subgroups. It is important to note that student IPA members were excluded from data analysis because of the low number of respondents (n = 16). There may be differences between practice settings that could be detected with a larger sample size. As with other electronically distributed surveys, bias of participants willing to participate in surveys is a potential limitation of the study, especially because the survey topic was related to electronic technology.
Journal of the American Pharmacists Association
pharmacists and health information exchange
Conclusion This study represents one of the first attempts at examining pharmacists utilization and beliefs about HIE. Respondents were interested in using HIE-supporting technology but realize that there are many challenges that come with integrating it into practice. Future investigation of HIE in the pharmacy community should explore whether the results from this small pharmacy population apply to pharmacy populations on state and national levels, as well as what differences may exist between demographics in pharmacy populations. References 1. HealthIT.gov. Health Information Exchange. www.healthit.gov/ providers‐professionals/health‐information‐exchange. Accessed January 3, 2014. 2. Agency for Healthcare Research and Quality. Evaluation Toolkit. http://healthit.ahrq.gov/sites/default/files/docs/page/Revised_ HIE_Toolkit.pdf. Accessed January 2, 2014. 3. Indiana Health Information Exchange. Indiana Network for Patient Care. www.ihie.org/indiana‐network‐for‐patient‐care. Accessed September 28, 2014.
RESEARCH NOTES
5. Shank N. Behavioral health providers’ beliefs about health information exchange: a statewide survey. J Am Med Inform Assoc. 2012;19(4):562–569. 6. Shank N, Willborn E, Pytlikzillig L, et al. Electronic health records: eliciting behavioral health providers’ beliefs. Community Ment Health J. 2012;48(2):249–254. 7. Fuji KT, Gait KA, Siracuse MV, et al. Electronic health record adoption and use by Nebraska pharmacists. Perspect Health Inf Manag. 2011;8:1d. 8. Warholak TL, Murcko A, McKee M, et al. Results of the Arizona Medicaid health information technology pharmacy focus groups. Res Social Adm Pharm. 2011;7(4):438–443. 9. Pharmacy Health Information Technology Collaborative. www. pharmacyhit.org. Accessed September 28, 2014. 10. Centers for Medicare and Medicaid Services. EHR Incentive Programs. www.cms.gov/Regulations‐and‐Guidance/Legislation/ EHRIncentivePrograms/index.html. Accessed September 28, 2014. 11. Bureau of Labor Statistics. May 2013 State Occupational Employment and Wage Estimates, Indiana. www.bls.gov/oes/2013/ may/oes_in.htm&29‐0000. Accessed September 28, 2014.
4. Wright A, Soran C, Jenter CA, et al. Physician attitudes toward health information exchange: results of a statewide survey. J Am Med Inform Assoc. 2010;17(1):66–70.
The Bridge • 2011 • Louisiana • Arie Spitzfaden
Journal of the American Pharmacists Association
j apha.org
N OV/D EC 2014 | 54:6 |
JAPhA 629
Pharmacists’ familiarity, utilization, and beliefs about Health Information Exchange: A survey of pharmacists in an Indiana pharmacy organization Allison D. Held, Lacie J. Woodall, and John B. Hertig
Abstract Objective: To gauge pharmacists’ familiarity, utilization, and beliefs about Health Information Exchange (HIE). Methods: A survey questionnaire was developed by the authors in Qualtrics (Provo, UT) and administered to 358 Indiana Pharmacists Alliance (IPA) members via email listserv in May and August 2013. The questionnaire consisted of 18 questions on familiarity, utilization, and beliefs about HIE. Results: The response rate was 19% (67/358). Pharmacy practice experience of respondents ranged from 0 to 5 years (18%, n = 12) to more than 20 years (61%, n = 41). More than one-half (70%) of respondents practiced in hospital settings. Many respondents (75%) were familiar with the concept of HIE; 54% currently use some type of HIE technology. Nearly all respondents felt that data in electronic health records (EHRs) should be shared between pharmacists and other health care providers. Respondents identified improved coordination of care as the greatest potential benefit, and difficulty implementing and maintaining technology as the greatest barrier of HIE. Conclusion: Many respondents were familiar with HIE and in favor of sharing patient records between providers. Respondents agreed that HIE has the potential to improve coordination of care but were concerned about implementing and maintaining technology. Larger pharmacy samples should be studied to determine how the results of this study compare to pharmacy populations at state and national levels. Keywords: Health Information Exchange, technology, electronic health records, pharmacists, meaningful use. J Am Pharm Assoc. 2014;54:625–629. doi: 10.1331/JAPhA.2014.14080 Journal of the American Pharmacists Association
T
he Office of the National Coordinator for Health Information Technology (ONC) was developed in an effort to combat rising health care costs and improve the safety and efficiency of health care in the United States.1 In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized providers to implement health information technology and adopt electronic health records (EHRs) in many practice settings. Among various funding areas is health information exchange (HIE), defined by the Agency for Healthcare Research and Quality (AHRQ) as “the process of sharing health care data among individuals, institutions and health care service providers in order to improve the process, quality, cost, and safety of health care.”2 Goals of expanding HIE include standardizing interoperability of data exchange at local, state, and national levels, promoting patients’ involvement in their own health care, reducing medical and medication errors through provider communication and information sharing, reducing health care costs through avoiding duplication of services, and improving automation of administrative functions.1 To encourage the development of statewide HIE networks, ONC created the State HIE Cooperative Agreement Program in 2010. Among HIE state leaders, Indiana sustains the largest and most established HIE organization in the United States.3 Indiana Health Information Exchange (IHIE) connects 94 hospitals and 25,000 participating physicians to serve 10 million patients. One example of an IHIE system is the Indiana Network for Patient Care, which provides physicians with patient information from more than 90% of hosReceived April 29, 2014, and in revised form May 29, 2014. Accepted for publication June 28, 2014. Published online in advance of print October 10, 2014. Allison D. Held, PharmD, is Visiting Scientist Fellow, Eli Lilly and Company, Indianapolis, IN. Lacie J. Woodall, PharmD, is Postgraduate Year 1 Pharmacy Resident, Johnson City Medical Center, Johnson City, TN. John B. Hertig, PharmD, MS, CPPS, is Associate Director of Center for Medication Safety Advancement, Courtesy Clinical Assistant Professor of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, IN. Correspondence: John B. Hertig, PharmD, MS, CPPS, 6640 Intech Blvd., Suite 120, Indianapolis, IN 46278–2012. Fax: 317-275-2375. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Previous presentations: American Society of HealthSystem Pharmacists Midyear Clinical Meeting, Orlando, FL, December 10, 2013; and the Indiana Pharmacist Alliance Spring Meeting, Indianapolis, IN, April 16, 2014. Acknowledgments: To John Cowan, Patty Elsner, Jaclyn Jeffries, Susan Kidwell, Amy Sheehan, and Erica Treadway for reviewing the survey instrument.
j apha.org
N OV/D EC 2014 | 54:6 |
JAPhA 625
RESEARCH NOTES
pharmacists and health information exchange
pital care in the Indianapolis area, including radiology, operative notes, pathology reports, medication records, and discharge summaries. Physicians’ beliefs about HIE have been assessed within several statewide HIE networks. A survey of physicians in Massachusetts regarding their use and attitudes toward HIE found that more than 70% of physicians had a positive attitude about HIE and believed it could reduce health care costs, improve quality of patient care, and save time.4 However, physicians were concerned about patient privacy and cost of HIE technology. A survey assessing behavioral health providers’ beliefs about HIE in Nebraska showed that most providers are supportive of HIE and believe it will improve care and communication but are concerned about the cost and time burden of implementing the technology.5,6 While physicians’ beliefs about HIE have been explored, pharmacists’ beliefs about HIE are not welldefined in the literature. One study that assessed EHR adoption by Nebraska pharmacists demonstrated that pharmacists were not widely using EHRs in 2008, and the ones who were, practiced primarily in hospital settings.7 Very few pharmacists had access to EHRs for their patients created by other providers, but many felt they should have access to these records. The study demonstrated low uptake of EHRs, but the authors discussed the importance of pharmacist knowledge and participation in HIE networks as physicians continue to adopt these technologies. In the development of a statewide HIE/EHR system in Arizona, a pharmacy focus group identified e-prescribing as an important feature because it would likely reduce medication errors and improve communication with physicians.8 In addition, the Pharmacy Health Information Technology Collaborative provides a national platform for collaboration and representation of all pharmacy practice areas in the implementation and growth of HIE.9 In an era of mandated health care technology growth, pharmacists’ involvement in HIE is imperative to all areas of health care delivery. As the medication use experts, pharmacists serve a major role in the exchange of patient information to nearly all settings. The impact of HIE on pharmacy practice offers opportunities for pharmacists to expand their clinical services and build relationships with providers, but pharmacists’ current involvement in HIE may be limited by their type of practice setting or the perceived barriers of HIE in pharmacy.
Objective The objective of this cross-sectional study was to gauge pharmacists’ familiarity, utilization, and beliefs about HIE among members of an Indiana pharmacy organization.
626 JAPhA | 5 4:6 | NOV /DE C 2 0 1 4
ja p h a.org
Methods A survey questionnaire was developed by the authors in Qualtrics (Provo, UT). Questions were derived from previously validated physician surveys4–6 and one pharmacist survey.7 A pilot survey instrument was reviewed by a panel of five pharmacists representing academia, community practice, hospital practice, and one pharmacy student. Reviewers provided feedback to improve clarity and applicability of questions. The questionnaire consisted of 18 questions assessing respondents’ demographics, familiarity with and use of HIE supporting technology, and beliefs about HIE. The study received exempt status through Purdue University Institutional Review Board. Survey respondents were provided with the AHRQ definition2 of HIE on each page of the questionnaire and asked to consider this definition of HIE as well as any personal experiences with HIE as they answered the questions. The survey was administered two times (May and August 2013) to Indiana Pharmacists Alliance (IPA) members via e-mail and a listserv containing 358 active e-mail addresses as of May 2013. IPA active membership information, including member e-mail addresses, is updated annually when membership is renewed. No incentives were provided to survey respondents. Data collection ended September 30, 2013. Post hoc analysis of subgroups, such as early versus late responders, was not performed. Student IPA members were excluded from data analysis because of the small number of student respondents (n = 16). No statistical tests were performed on collected data.
Results The response rate was 19% (67/358). Respondents represented a range of pharmacy practice settings and years of experience (Table 1). Many were familiar with the concept of HIE before this survey, and more than onehalf currently use HIE-supporting technology in practice. All respondents believed the benefits of HIE outweigh or potentially outweigh the barriers. A majority of respondents identified improved coordination of care as the greatest potential benefit of HIE and difficulty implementing and maintaining technology as the greatest potential barrier (Table 2).
Discussion Most respondents were familiar with HIE, suggesting implementation of HIE-supporting technology is in progress in many settings. However, 25% of respondents were not familiar with HIE before the survey. Unfamiliarity may be due to implementation of EHRs as a rate-limiting step in the development of HIE networks. This study highlights the issue that some practice settings have not adopted an EHR system and are still using some paper records. However, the growth of EHRs Journal of the American Pharmacists Association
pharmacists and health information exchange
Table 1. Characteristics of respondents and familiarity with health information exchange Characteristic Response Practice setting Hospital Community chain/grocery Community independent Academia Ambulatory Managed care Other Long-term care Years of experience >20 11–20 6–10 0–5 Precept students Yes No Gender Women Men Familiar with the concept of HIE Yes No Currently using HIE supporting technology Yes No Do not know Institution adoption status of EHRs and HIE EHR with HIE Do not know Partial EHR; some paper records EHR without HIE Not applicable No EHR
RESEARCH NOTES
No. 47 3 4 5 3 3 1 1 41 7 7 12 45 22 35 32 50 17 34 19 10 34 9 8 5 4 3
% 70 4 6 7 4 4 1 1 61 10 10 18 67 33 52 48 75 25 54 30 16 54 14 13 8 6 5
Abbreviations used: EHR, electronic health record; HIE, health information exchange.
in pharmacy settings in recent years appears to be substantial, as Fuji et al. found that only 12% of pharmacist respondents had adopted an EHR system in 2008.7 HIE may struggle to advance until institutions adopt EHRs and work through the barriers associated with EHR systems. As EHR technology becomes a requirement by the Centers for Medicare and Medicaid Services (CMS) in 2015, CMS providers will be penalized for not implementing EHRs.10 As settings make this transition, awareness of HIE is also expected to rise. An encouraging finding of this study was overwhelming agreement that EHRs should be shared among providers and pharmacists no matter who originally created the record. This finding was similar to the EHR survey study of pharmacists7 and suggests pharmacists are interested in increasing communication with other providers. Considering that survey literature on HIE has focused on physician populations, it was important to explore how pharmacists feel about physician acceptance of HIE. More respondents felt that physician acceptance of HIE determines pharmacist adoption of HIE. Although pharmacists may welcome the use of HIE supporting technology, the majority of respondents in this study felt Journal of the American Pharmacists Association
they must wait for HIE to advance in physician settings before it can be realized in pharmacy settings. The majority of respondents were unsure if their personal beliefs about HIE differed from their management’s beliefs. Because HIE infrastructure can be costly and challenging to implement, pharmacists may face organizational opposition if advocating for the implementation of HIE-supporting technology. Discussions with those in charge of the implementation may be important so that pharmacy management knows this topic would be met with acceptance. All respondents felt the benefits of HIE outweigh or may potentially outweigh the barriers of HIE, suggesting respondents recognize how sharing information between practice settings and providers can improve quality of care and safety for patients. Respondents identified improvement in coordination of care as the greatest potential benefit of HIE. Improving coordination of care is becoming a crucial area of focus in health care and was identified as a key benefit of HIE by physicians as well.5 Many respondents also identified improving patient safety as a potential benefit of HIE. Pharmacists recognize how medication errors result from inadequate j apha.org
N OV/D EC 2014 | 54:6 |
JAPhA 627
RESEARCH NOTES
pharmacists and health information exchange
Table 2. Respondents’ beliefs about health information exchange Belief Response Pharmacists should have access to Yes EHRs created by other health care No providers Other providers should have access to Yes EHRs created by pharmacists No Physician acceptance of HIE determines Yes pharmacist use of HIE-supporting No technology Personal beliefs about HIE compared to Do not know organization or management’s beliefs My beliefs are similar to my organization/management’s about HIE My beliefs differ from my organization/management’s I am in charge of HIE decisions Benefits of HIE outweigh the barriers Yes of HIE Potentially No Identify the greatest potential benefit Improve coordination of care of HIE Improve patient safety Improve communication with providers Improve access to patient records Improve tracking medication history Increase opportunities for interventions Other Improve workflow Improve patient privacy/security Reduce health care costs Difficulty implementing/maintaining HIE Identify the greatest potential barrier of HIE Risk to patient privacy/security Company/organization acceptance of HIE Greater legal vulnerability Increased time constraints Technology costs Reliance on technology Other Disruption of workflow Misuse by third-party payers
No. 58 1
% 98 2
59 0 36 23
100 0 61 39
31 24 2 2 45 14 0 29 14 4 4 3 3 2 0 0 0 24 9 8 4 4 4 2 2 1 1
53 41 3 3 76 24 0 49 24 7 7 5 5 3 0 0 0 41 15 14 7 7 7 3 3 2 2
Abbreviations used: EHR, electronic health record; HIE, health information exchange.
communication and data exchange between providers. Additionally, respondents specified implementing and maintaining HIE supporting technology as the greatest potential barrier of using HIE. Although establishing HIE networks from a technological and interorganizational standpoint may seem daunting, it is important to consider that there are numerous HIE networks that are fully operational today.3,9
Limitations Although many practice settings were represented, the sampling frame resulting from using the IPA listserv may limit the representation of pharmacists to only one Indiana pharmacy organization. As of May 2013, there were 6,870 pharmacists employed in Indiana.11 The sample size of 358 IPA members represents only 5% of the 628 JAPhA | 5 4:6 | NOV /DE C 2 0 1 4
ja p h a.org
Indiana pharmacist population, and the response rate of this study was also lower than previous studies.4,5,7 To generalize the results of this study to larger pharmacy communities, the sample would need to be expanded to larger pharmacy populations. Another limitation of the study was collection of data that did not allow for comparison of subgroups. It is important to note that student IPA members were excluded from data analysis because of the low number of respondents (n = 16). There may be differences between practice settings that could be detected with a larger sample size. As with other electronically distributed surveys, bias of participants willing to participate in surveys is a potential limitation of the study, especially because the survey topic was related to electronic technology.
Journal of the American Pharmacists Association
pharmacists and health information exchange
Conclusion This study represents one of the first attempts at examining pharmacists utilization and beliefs about HIE. Respondents were interested in using HIE-supporting technology but realize that there are many challenges that come with integrating it into practice. Future investigation of HIE in the pharmacy community should explore whether the results from this small pharmacy population apply to pharmacy populations on state and national levels, as well as what differences may exist between demographics in pharmacy populations. References 1. HealthIT.gov. Health Information Exchange. www.healthit.gov/ providers‐professionals/health‐information‐exchange. Accessed January 3, 2014. 2. Agency for Healthcare Research and Quality. Evaluation Toolkit. http://healthit.ahrq.gov/sites/default/files/docs/page/Revised_ HIE_Toolkit.pdf. Accessed January 2, 2014. 3. Indiana Health Information Exchange. Indiana Network for Patient Care. www.ihie.org/indiana‐network‐for‐patient‐care. Accessed September 28, 2014.
RESEARCH NOTES
5. Shank N. Behavioral health providers’ beliefs about health information exchange: a statewide survey. J Am Med Inform Assoc. 2012;19(4):562–569. 6. Shank N, Willborn E, Pytlikzillig L, et al. Electronic health records: eliciting behavioral health providers’ beliefs. Community Ment Health J. 2012;48(2):249–254. 7. Fuji KT, Gait KA, Siracuse MV, et al. Electronic health record adoption and use by Nebraska pharmacists. Perspect Health Inf Manag. 2011;8:1d. 8. Warholak TL, Murcko A, McKee M, et al. Results of the Arizona Medicaid health information technology pharmacy focus groups. Res Social Adm Pharm. 2011;7(4):438–443. 9. Pharmacy Health Information Technology Collaborative. www. pharmacyhit.org. Accessed September 28, 2014. 10. Centers for Medicare and Medicaid Services. EHR Incentive Programs. www.cms.gov/Regulations‐and‐Guidance/Legislation/ EHRIncentivePrograms/index.html. Accessed September 28, 2014. 11. Bureau of Labor Statistics. May 2013 State Occupational Employment and Wage Estimates, Indiana. www.bls.gov/oes/2013/ may/oes_in.htm&29‐0000. Accessed September 28, 2014.
4. Wright A, Soran C, Jenter CA, et al. Physician attitudes toward health information exchange: results of a statewide survey. J Am Med Inform Assoc. 2010;17(1):66–70.
The Bridge • 2011 • Louisiana • Arie Spitzfaden
Journal of the American Pharmacists Association
j apha.org
N OV/D EC 2014 | 54:6 |
JAPhA 629
