Patient Privacy, Consent, and Identity Management in Health Information Exchange: Issues for the Military Health System.

The Military Health System (MHS) and the Veterans Health Administration (VHA) have been among the nation's leaders in health information technology (IT), including the development of health IT systems and electronic health records that summarize patients' care from multiple providers. Health IT interoperability within MHS and across MHS partners, including VHA, is one of ten goals in the current MHS Strategic Plan. As a step toward achieving improved interoperability, the MHS is seeking to develop a research roadmap to better coordinate health IT research efforts, address IT capability gaps, and reduce programmatic risk for its enterprise projects. This article contributes to that effort by identifying gaps in research, policy, and practice involving patient privacy, consent, and identity management that need to be addressed to bring about improved quality and efficiency of care through health information exchange. Major challenges include (1) designing a meaningful patient consent procedure, (2) recording patients' consent preferences and designing procedures to implement restrictions on disclosures of protected health information, and (3) advancing knowledge regarding the best technical approaches to performing patient identity matches and how best to monitor results over time. Using a sociotechnical framework, this article suggests steps for overcoming these challenges and topics for future research.

Implementation of an electronic referral system for outpatient specialty care.

Poor communication between primary care and specialists often leads to delays, inefficiencies and suboptimal patient outcomes. This study examined implementation of an electronic referral system (eReferral) that creates direct communication between primary care providers and specialist reviewers. Semi-structured interviews were conducted to assess factors affecting the success of eReferral implementation; transcripts were analyzed using qualitative methods. Primary and specialty care providers were enthusiastic about the system. Primary care providers had favorable attitudes despite a number of challenges including increased workload due to a shift in tasks from specialists and administrative personnel, poor connectivity, and insufficient hardware. System acceptance was driven by perceptions of improved access to specialty care, better appointment tracking, and improved communication between primary and specialty care providers. Synergy among development processes, implementation practices, and technical factors, including human-centered design, iterative development, a phased rollout, and an intuitive user interface, also fostered uptake of the system.

Meaningful use of electronic prescribing in 5 exemplar primary care practices.

PURPOSE: Successful use of electronic prescribing (e-prescribing) is a key requirement for demonstrating meaningful use of electronic health records to qualify for federal incentives. Currently, many physicians who implement e-prescribing fail to make substantial use of these systems, and little is known about factors contributing to successful e-prescribing use. The objective of this study was to identify successful implementation and use techniques. METHODS: We conducted a multimethod qualitative case study of 5 ambulatory primary care practices identified as exemplars of effective e-prescribing. The practices were identified by a group of e-prescribing experts. Field researchers conducted in-depth interviews and observed prescription-related workflow in these practices. RESULTS: In these exemplar practices, successful use of e-prescribing required practice transformation. Practice members reported extensive efforts to redesign work processes to take advantage of e-prescribing capabilities and to create specific e-prescribing protocols to distribute prescription-related work among practice team members. These practices had substantial resources to support e-prescribing use, including local physician champions, ongoing training for practice members, and continuous on-site technical support. Practices faced considerable challenges during use of e-prescribing, however, deriving from problems coordinating new work processes with pharmacies and ineffective health information exchange that required workarounds to ensure the completeness of patient medical records. CONCLUSIONS: More widespread implementation and effective use of e-prescribing in ambulatory care settings will require practice transformation efforts that focus on work process redesign while being attentive to effects on patient and pharmacy involvement in prescribing. Improved health information exchange is required to fully realize expected quality, safety, and efficiency gains of e-prescribing.

A Web-based tool for assessing and improving the usefulness of community health assessments.

BACKGROUND: Little information is available on characteristics of successful and unsuccessful community health assessment (CHA) reports. METHODS: A consensus process identified criteria for assessing CHA success from a literature review, analysis of CHAs on the Internet, and consultation with experts. Criteria were then turned into questionnaire items. Using these items, a Web-based tool was developed to gather responses from 110 users and potential users about the strengths and weaknesses of CHAs from six New York counties and three from other states. FINDINGS: Respondents tended to rate CHAs positively, with high scores for including important aspects of health, using consistent formats, reproducibility by photocopy, and supporting grant applications. Community health assessments were given low scores because of a lack of focus on positive characteristics and documentation of methods, and failure to indicate relationships among indicators, include narrative and graphics, and be similar to other community planning tools in use. CONCLUSIONS: Community health assessment reports should state their goals and purpose; include the most important aspects of the community's health; allow comparisons with other communities, other benchmarks, and, over time, present data in meaningful subgroups of population; provide sufficient focus on positive characteristics; and document the process and methods that are used to create the CHA.