Use of Health Information Exchange in the Continuity of Care as Viewed by Patients and Nurses

Patients' attitudes toward sharing their personal health information are critical for implementation of health information exchange. Nurses contribute significantly to information sharing within the care continuum in hospitals and community. This study aimed to examine the awareness and readiness of patients with chronic illness and nurses to the use health information exchange. A cross-sectional study was conducted among 314 inpatients with a chronic illness, 110 nurses working in internal wards, and 55 contact nurses working in a large health maintenance organization. The findings showed that the mean level of awareness was low across all three groups. Contact nurses expressed more positive attitudes than internal ward nurses or patients and were more willing than patients to share information with healthcare workers. Knowledge, attitudes, and being a nurse predicted the intention to share information with medical healthcare providers and with agents not involved in direct care. Before implementation of a health information exchange system, it is important to raise awareness, readiness, and intention to use it among the public, nurses, and other medical staff. Policy makers should organize national campaigns under the auspices of the Ministry of Health to present the advantages and provide detailed information about the system.

Patients' attitudes toward sharing their personal health information are critical for implementation of health information exchange. Nurses contribute significantly to information sharing within the care continuum in hospitals and community. This study aimed to examine the awareness and readiness of patients with chronic illness and nurses to the use health information exchange. A cross-sectional study was conducted among 314 inpatients with a chronic illness, 110 nurses working in internal wards, and 55 contact nurses working in a large health maintenance organization. The findings showed that the mean level of awareness was low across all three groups. Contact nurses expressed more positive attitudes than internal ward nurses or patients and were more willing than patients to share information with healthcare workers. Knowledge, attitudes, and being a nurse predicted the intention to share information with medical healthcare providers and with agents not involved in direct care. Before implementation of a health information exchange system, it is important to raise awareness, readiness, and intention to use it among the public, nurses, and other medical staff. Policy makers should organize national campaigns under the auspices of the Ministry of Health to present the advantages and provide detailed information about the system.
KEY WORDS: Contact nurses, Health information exchange, Medical data H ealth information exchange (HIE) is the sharing of medical data between various medical practitioners and organizations. 1 The information available in HIE can facilitate consistent treatment, improve patient safety, reduce care-related costs, and prevent medical errors in diagnosis and treatment. 2,3 Health information exchange systems are complex and may have unpredictable outcomes, both negative and positive. Disadvantages of using HIE include privacy issues, protection of personal data, and the need for personnel training. Over the last decade, the number of operational HIE organizations has risen steadily, and medical institutions' participation in HIEs has grown. 4 However, despite the global increase in HIE, its use is still limited. Among the barriers that delay the implementation of HIE are technological inhibitors, such as lack of sufficient technological infrastructure; environmental inhibitors, such as legal concerns and complexity in framing HIE agreements with partners; and organizational inhibitors, such as lack of adequate senior leadership support. 5 Moreover, a systematic review revealed that the most common obstacles to HIE use are the failure of organizations to integrate HIE into the workflow and missing data. Interestingly, the use of HIE by nonphysicians, such as nurses, may be more extensive. 6 A number of national governments are currently diverting substantial resources toward promoting the adoption of HIE. 6 Indeed, a systematic review revealed that the use of HIE in developed countries is increasing slowly over time. 7 In the United States, the Health Information Technology for Economics and Clinical Health Act of 2009 allocated financial incentives to encourage the establishment of HIE in medical institutions. Despite these measures, the level of HIE adoption by hospitals in the United States remains generally moderate. 8

BACKGROUND
On January 29, 2014, the Israeli Ministry of Health published an administrative circular describing a national computerized HIE project to which the health organizations would be able to connect digitally to share information. 9 Due to inconsistencies with the Health Insurance Law, this circular was canceled a short time after its publication. However, all the aspects of the circular are included in a national digital health project named "Eitan," recently announced by the Israeli Ministry of Health, 10 whereby all the medical files of Israeli citizens will be combined in a single database. Eitan is a closed and secured communication network that will allow information to be shared and transferred between hospitals and health maintenance organizations (HMOs); In Israel healthcare services are public and provided to all citizens by four HMOs. This project includes developing applications, deploying the system in information-sharing sites, and mapping the terminology of sites in fields such as laboratory results and diagnosis according to regulated catalog values. The terms in the database will be coded by health professionals including physicians, nurses, pharmacists, and laboratory workers. 11 The Ministry of Health 10 guidelines provide access to the data only to healthcare workers in hospitals by personal authorization. This access will be limited to patient's medical information during hospitalization, where the hospitalization data will include HMO-derived health information from the patient's medical records. To ensure security, specific authorization for access to the network will be given to the hospital teams involved in the patient's direct care. Permission holders are granted access to the network during the patient's hospitalization and for a specified period thereafter. The HMOs will receive medical summaries of patients' hospital visits for all insured members on the day of discharge. The information will later be integrated into the medical records in the HMOs. The Eitan system will not include sensitive information such as records of psychiatric treatment in units and clinics, pregnancy termination, laboratory results of HIV testing, genetic testing and counseling, surrogacy and adoption, egg and sperm donation, or treatment of sexual assault victims. All Israeli citizens will be provided with the option to be excluded from the HIE. 10 Currently, until the project is fully implemented, continuity of care between hospitalization and the community in Israel is mediated through contact nurses who coordinate the continuation of treatment after hospital discharge. Contact nurses are nurses who have access to HMO medical information but not to the hospitalization data, except for the hospital discharge letter. Similarly, while the patient is in the hospital, medical information from the community clinic may be lacking, forcing the staff to rely on the patient's selfreport rather than on medical records.
Patients' attitudes toward sharing their personal health information are critical for future implementation of the HIE; however, this aspect has been rarely examined. As a result of the current efforts made by HIE policy makers in the United States to increase public awareness, the United States is responsible for the few publications that have considered a patient's perceptions of the HIE. 12 Medford-Davis et al 13 found that the majority of 982 sampled patients in emergency departments in the United States were willing to share their medical information, although they retained reservations about privacy and security. About half the sample required a signed declaration concerning the identity of people having access to their health records and were not in favor of automatic sharing. Although healthcare teams are the primary users of HIE systems, only a few studies have examined their attitudes toward HIE and their intention to use it. 6 However, a systematic literature review concluded that the use of HIE holds the potential to promote care quality and reduce costs. 14 It seems logical that nurses should be fully involved in planning, implementing, and evaluating HIE systems since they play a key role in acquiring patients' health information in the hospital and community. However, a study conducted in the United States on nurses in emergency departments found that even when there was a system of computerized medical information sharing, in many cases, nurses failed to use it because of lack of access. 3 A study that compared differences in healthcare providers' perceptions and prior use of HIE found that prior use of HIE was associated with more positive perceptions of HIE. Nurses had expressed more concerns about the impact of HIE on patients as compared with physicians. In addition, nurses, as compared with other healthcare providers, held less positive perceptions regarding the advantages of HIE to the healthcare provider's work and the advantages of HIE to the population's health. However, nurses had the most positive perceptions of the advantages of HIE to patients' care. 15 Since nurses contribute significantly to information sharing within the care continuum in hospitals and community and strongly influence patient readiness with regard to information sharing, it is important to examine their attitudes and those of patients regarding HIE in the continuity of care. The objectives of this study are (1) to examine the attitudes of hospital and contact nurses as well as patients toward computerized HIE and (2) to assess their intention to use such a system.

Study Design
A cross-sectional quantitative study was conducted.

Data Collection
Data were collected using a questionnaire consisting of four parts. The questionnaire had two versions with content that differed only in the background data section, where one was addressed to patients and the second to nurses (see Supplemental Digital Content 1, http://links.lww.com/CIN/A138). The required sample size was obtained by means of the G*power program (Heinrich Heine University, Dusseldorf, Germany). 16 The sample size required for achieving power of 0.90 and α of .05 was 138 participants in each of the two groups of nurses and patients. Data were collected from a convenience sample consisting of 482 participants. Inclusion criteria for patients were having a chronic disease that was treated by their general physician in the community, being hospitalized for at least 48 hours, and being fluent in Hebrew. The sampled population included 314 inpatients with a chronic illness who were hospitalized in internal medicine departments of two hospitals in central Israel, and 110 nurses working in these departments. An additional 55 contact nurses working in a large HMO were also included.

Research Instrument
The first part of the survey examined the background variables of the participants, including age, sex, marital status, education, and degree of religiosity. In addition, the questionnaire designed for the nurses included questions about job position, seniority in nursing, and professional education. Two additional items addressed the awareness of the intention to implement HIE in Israel and queried the source of this knowledge. The second part of the questionnaire examined knowledge, attitudes, readiness to use HIE, and intention to use the system. Knowledge was measured by 19 items examining knowledge about computerized HIE. The construction of this section was based on the literature 14,17 and the Ministry of Health administrative circular. 9 The questionnaire presented items that examined knowledge regarding the operation of and the domains to be included in the HIE. Participants were asked to indicate whether each item was correct or incorrect or to record that they did not know the answer. The sum of the correct answers was calculated, with a higher score indicating a higher level of knowledge. The possible scores ranged between 0 and 19.

Attitudes Toward the Health Information Exchange
The construction of this part was based on the literature 3, 15 and on a validated instrument that examines attitudes toward HIE. 17 The questionnaire was face validated by four head nurses working either in internal wards or at an HMO. All four nurses were experts in nursing informatics and had knowledge about the nature of HIE. The judges were asked to indicate whether the items in the questionnaire examined attitudes toward HIE. Only items approved by all the judges were included in the questionnaire. The final questionnaire included 12 statements examining attitudes toward the impact of the HIE on treatment. For each state-ment, the participants were asked to indicate their agreement on a 5-point scale ranging from 1 (do not agree at all) to 5 (completely agree). An average score of all items was calculated. The Cronbach's alpha of the scale was .849.

Readiness to Share Medical Information Through Health Information Exchange
In this part, the respondents were asked to indicate their readiness to share their medical information through HIE with a list of 14 medical and medical agents not involved in direct care. This list was compiled according to the guidelines of the Israeli Ministry of Health. 9 Factor analysis using varimax rotation revealed two constructs. The first was a readiness to share personal medical information with medical healthcare providers represented by seven agents: community clinics, other hospitals, private physicians, physicians from a different hospital, clinic nurses, nurses from another hospital, and other health professionals (physical therapist, social worker occupation therapist, and dietitians). The second was a readiness to share personal medical information with medical agents not involved in direct care. These were represented by six agents, including psychologists, pharmacists, genetic counselors, risk management units at the hospital, laboratory managers, and medical researchers. The Cronbach's alpha of the first construct was .887, and of the second, .865.

Intention to Use Health Information Exchange
At the end of the questionnaire, there was one general question asking nurses how much they would use the computerized HIE, and the patients to what extent they agreed that information about them could be used as part of the HIE. This was answered on a scale of 1 (not at all) to 10 (absolute agreement).

Procedure
Before data collection, the research team held meetings with the departmental managers and head nurses to explain the purpose of the research. All participants gave their approval to the research. In the internal wards, questionnaires were distributed by four research assistants to patients with chronic diseases hospitalized for at least 48 hours and to nurses working on the same wards. In the HMO, questionnaires were distributed by email to contact nurses who work as nurse coordinators between hospitalized patients and the community. Before completing the questionnaire, participants received a brief explanation of the study objectives. The research assistants were available to answer questions and collected the completed questionnaires.

Data Analysis
Data were analyzed using IBM SPSS English version 25.0 software (IBM Inc., Armonk, NY, USA). Participants' characteristics were presented using means and frequencies. Differences between the groups were analyzed using one-way analysis of variance. Scheffe tests were performed post hoc Volume 41 | Number 1 to reveal the source of any differences. Multiple linear regressions were performed to assess the associations between knowledge, attitudes, and sociodemographics, and both the readiness to share information on HIE and intention to use HIE. Only variables that were related to the dependent variable in preliminary tests were entered to the regression. Factor analysis with varimax rotation was performed to confirm clusters of agents with whom there was a readiness to share personal medical information on HIE.

Ethical Considerations
The study was approved by (1) the Helsinki committees of the two hospitals where data were collected (2958-16-SMC and 0033-16-MMC); (2) the Helsinki committee of the HMO (bb0023/16); and (3) the ethics committee of Tel-Aviv University (01062016). Before questionnaire completion, all participants received a short explanation about the aims of the study and were promised confidentiality; after, they gave their verbal consent to participate in the study. The verbal consent was approved by the Helsinki committees.

RESULTS
The research sample consisted of a total of 479 participants, comprising 314 inpatients living with a chronic disease (diabetes, heart disease, or hypertension) and hospitalized in internal wards, 110 nurses working on these wards, and 55 contact nurses working in a large HMO. The demographic characteristics of the participants are presented in Table 1. The results indicated that most of the participants (nurses or patients) were unaware of HIE.
One-way analysis of variance tests were used to compare the mean levels of knowledge about HIE, attitudes toward HIE, readiness to share information via the HIE, and intention to share information on HIE of the three groups (contact nurses, internal ward nurses, and patients). The results are presented in Table 2.
The level of knowledge was generally similar and rather low in all three groups, with no significant differences. As presented in Table 2, the results indicated that the attitudes of the three groups toward HIE were quite positive (above average). The difference between the groups was significant (F = 11.25; P < .001). A post hoc Scheffe test revealed that the source of the difference was that contact nurses held significantly more positive attitudes toward HIE than either internal ward nurses or patients. The results also indicated a relatively high degree (above average) of readiness to share personal medical information via HIE with medical healthcare providers. A comparison showed a significant difference between the readiness of the three groups to share information (F = 16.78; P < .001). A post hoc Scheffe test revealed that the source of the difference was that contact nurses were significantly more willing to share personal medical information with healthcare workers through HIE than internal ward nurses or patients.
The readiness to share personal medical information through HIE with medical agents not involved in direct care was rather low in all the groups, although the differences between the groups were significant (F = 8.07; P < .001). The results of a post hoc Scheffe test showed that the source of the difference was that the two groups of nurses were significantly more willing than the patients to share personal medical information with medical agents not involved in direct care through HIE ( Table 2).
The expressed intention to use HIE for sharing personal medical information was pretty high, with significant differences between groups (F = 9.825; P < .001). Again, the source of the difference as revealed by the post hoc Scheffe test was that the contact nurses were significantly more in favor of using HIE for sharing personal medical information than internal ward nurses or the patient group.
Multivariate linear regressions were performed to examine the variables predicting the readiness to share information on HIE with medical healthcare providers, medical agents not involved in direct care, and the intention to use HIE. The variables entered into the model were religion (Jewish/not Jewish), role (nurse vs patients and contact nurses vs hospital nurses and patients), attitudes, and knowledge. Table 3 shows that a positive attitude, less knowledge, and being a nurse (both groups) were associated with more readiness to share information with both healthcare providers and with medical agents not involved in direct care, as well as with more intention to use HIE.

DISCUSSION
The current study revealed a low level of knowledge about HIE among hospital and contact nurses, as well as among hospitalized patients with a chronic illness. Despite this low level of knowledge, both nurses and patients held a positive attitude toward HIE. This confirms the strong public support for HIE that has been reported previously and is probably the result of a perception that it will improve treatment and care, even though security and privacy concerns have consistently been seen as major barriers. 13,18,19 The higher willingness of all participants in the current study to share personal medical information with healthcare workers (such as nurses and physicians), rather than with medical agents not involved in direct care, such as pharmacists, might reflect such concerns. In this context, Sittig et al 20 highlighted the shared responsibility of government regulators and national and international policymakers for health information technology safety. Interestingly, both groups of nurses in the current study (contact and internal wards) were more willing than the patients to share information with medical agents not involved in direct care. This finding can be explained by the standards on which the nursing clinical decisionmaking process is based, with respect to effective communication, knowledge sharing, and information sharing with multidisciplinary teams. 21,22 Contact nurses held the most positive attitudes toward HIE, were more willing to share information with healthcare workers through HIE, and had a significantly higher intention to use HIE than the other two groups. Contact nurses in the community are responsible for coordinating the continuation of home care of people with chronic illness after hospital discharge. In an aging population, the number of chronically ill patients increases, hospital stays shorten, and the quantity of hospital beds decreases, making information exchange very relevant for discharge planning and home care. 23 Hence, as the main professionals involved in the process of discharge, contact nurses need to cooperate with health and nonhealth professionals to develop, improve, and redesign community services. 24 Health information exchange is therefore perceived by these nurses as favorable, applicable, and a valuable resource to facilitate their work. Being a nurse (regardless of role, ie, contact nurse or internal ward nurse) was connected in the current study to a greater intention to use HIE. Nurses are aware of the part they play in updating and integrating medical information into technology systems 25 and frequently encounter difficulties associated with missing data. 3 For example, medical staff in hospitals require information about the medication that patients receive at home. Even though the patient's report is not always reliable, in the present reality, it may be the only source of information. The nurses therefore appreciate that if HIE was in use, this information would be available and accurate.
The literature reveals that like Israel, many other countries face challenges raised by the implementation of the HIE system. A recent review that included studies from the United States, France, Sweden, Canada, New Zealand, and South Korea concluded that to enhance the adoption of HIE, policy makers should emphasize the HIE benefits to patients and address their concerns. 12 Importantly, our present results indicated that positive attitudes toward HIE predicted more intention to use the system. Hence, to promote the assimilation of HIE by caregivers and increase the acceptance by patients, policy makers should target the attitudes of potential users and provide them with information that will emphasize the advantages of the system. This process is necessary since the results of this study indicate that the introduction of the planned HIE system is likely to elicit objection and fear. A similar response was seen when a biometric ID system was recently launched in Israel. In this case, the initiative had taken several years to implement because of an activist objection campaign that scared the public and delayed the application for several years. 26 We recommend that to minimize objection to the introduction of HIE systems, the public's knowledge gap must be filled by a campaign emphasizing the advantages of HIE.

LIMITATIONS
The current study did not examine the types of chronic illnesses or the health status of the patients surveyed, both of which may affect the study's findings. In addition, although the attitudes instrument was constructed for the present study, construct validity was not determined in the present study. It is recommended to conduct further studies to examine the construct validity of the questionnaire. In addition, according to the power analysis, the sample size required was 138 participants in each of the two groups: nurses and patients. The sample included 314 inpatients and 165 nurses. The nurses sample consisted of two groups, and each was smaller than n = 138; some of the analyses were carried out on each group of nurses separately, which may have affected the validity of the results. However, there are only 300 contact nurses working in the HMO, and a sample size of n > 30 is considered adequate for statistical validity. Data were collected in only two hospitals, which could have influenced the attitudes or readiness to share health information of both the nurses and the patients. However, the large sample and that contact nurses who experience the difficulties of retaining the continuity of care were most positive, and the differences found between research groups hint to reliability of the results and to the construct validity. Nonetheless, a follow-up study should take into account the characteristics of the patients together with the location of the hospital site and the nurses' work environment.

CONCLUSIONS
Worldwide integration of HIE into hospitals and communities is a challenging task 1 and depends on patient's' perceptions. 27 There are many obstacles that must be taken into consideration before integrating HIE, and these include the opinions of the public and healthcare providers. Resources should be allocated to develop methods of documentation and preservation of medical information at all endpoints in an effective and secure manner. In addition, it is necessary to explain the HIE system and disseminate relevant information to the public and to healthcare teams. Conferences highlighting the clinical, organizational, and financial benefits of HIE should be held for the benefit of healthcare organizations. 19 We recommend policy makers to organize a national campaign under the auspices of the Ministry of Health to present the advantages of HIE, provide informed knowledge, and refute misconceptions.