Patient Satisfaction as it Relates to Health Information Exchange Usage
Capstone Proposal
for
Master of Science
Health Data Analytics and Informatics
Concentration of Healthcare Informatics
Leisa Payton
University of Denver University College
March 14, 2021
Faculty: Maria Creavin, RD, SM, MAS
Director: Bobbie Kite, PhD, MHS
Dean: Michael J. McGuire, MLS
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Reason(s) for Selecting Capstone Subject
I have always been interested in the effects of information technology on humans. In
healthcare, there is a wide array of problems that can be investigated using informatics and the
vast majority of data starts with a patient interaction. When visiting new physicians, I have
been disappointed to be greeted with a clipboard of papers to fill out, even if I have asked for
my records to be transferred. This may be especially inconvenient for patients that have a long
history of illness or a long list of prescriptions to remember. Luckily, the patient may have the
opportunity to opt-in to Health Information Exchange (HIE), which is a way for providers to
access and share patient history electronically. For some patients, having their health data
accessible through HIE will lead to a better medical experience and higher satisfaction. My
project will investigate this correlation, using informatics to interpret both quantitative and
qualitative methods, providing invaluable skills for my healthcare informatics career.
Problem Statement and Proposed Thesis Statement
Despite the passage of the Health Information Technology for Economic and Clinical
Health Act (HITECH) to promote the adoption and meaningful use of health information
technology, many hospitals have yet to adopt an HIE. In 2021, there are currently 115 hospitals
in Colorado (American Hospital Directory 2020) and as of 2019 only 89 were connected via one
or both of the two health information exchanges in Colorado, Quality Health Network (QHN)
and Colorado Regional Health Information Organization (CORHIO) (Drees 2019). Whether it be
because of lack of interoperability or privacy concerns, absence of an HIE could directly or
indirectly impact patients’ perspectives of their hospital care. Medicare reimbursements are
affected by the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
Survey, a data collection methodology that is used to measure patients' perspectives of hospital
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care. This paper will explore whether Colorado hospitals can increase patient satisfaction and
related HCAHPS scores by adopting an HIE.
Goals and Objectives
The existing body of knowledge on this topic is general (i.e. interventions to improve
patient satisfaction) or outdated. The goal of my project is to determine if hospital patient
satisfaction is tied to the organization’s HIE usage. My research objectives are to use the eight
HCAHPS domains’ scores as well as qualitative methods to determine whether there is an
increase, decrease or absence of change in overall patient satisfaction when compared to the
adoption of an HIE. The business application is to determine if it is worthwhile to adopt HIE in
hospitals in order to affect patient satisfaction in a positive manner.
Preliminary Literature Review
The Road to Health Information Exchange
Health information exchange is defined as the process of electronically exchanging
patient information among different hospitals, physicians, and other healthcare providers in a
community at the point of care (Wu and LaRue 2017, 410). Before any research can begin on
the relationship between HIE and patient satisfaction, one must understand the barriers and
facilitators of HIE adoption in the United States. The 2009 HITECH mandated building a
nationwide health information communication infrastructure with the intent of “Meaningful
Use” of Electronic Health Records (EHRs). Some of the challenges include privacy and security,
interoperability, funding, governance and complex systems. HIE adoption promoters include
technical assistance, financial incentives, single database and login, and engaging with and
understanding end-users’ perspectives (Wu and LaRue 2017, 413-414). HIE can occur on the
national or regional level, with the regional health information organization (RHIO) being a third
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party that facilitates information exchange among entities within a community, county or state
(Esmaeilzadeh and Mirzaei 2018, 410-411). A study performed from 2017 to 2018 in the US
found that patients’ willingness to opt-in to HIE are influenced by different HIE structures and
business practices, and that patients perceived regional patient-centered HIE models as being
more private (Esmaeilzadeh and Mirzaei 2018, 414-416). The regional model in Colorado is
Colorado Regional Health Information Organization (CORHIO). The most efficient and cost
effective way for patients to access their health records through CORHIO is by using a secure
patient portal, which is integrated with other healthcare management tools (Peterson 2012,
55).
Health Information Exchange and Patient Satisfaction
Research has been done that reviews the evidence and complexities regarding
determinants of patient satisfaction (Berkowitz 2016;Batbaatar et al. 2017) and the relationship
between HIE usage and patient-provider communication and patient satisfaction in hospitals
(Vest and Miller 2011). Others have conducted quantitative studies that use scoring systems
such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),
Survey of Healthcare Experiences of Patients (SHEP), and Healthcare Effectiveness Data and
Information Set (HEDIS) to determine patient satisfaction performance (Anhang Price et al.
2018;Legler et al. 2019). A systematic literature review looked at studies involving hospital
patients with interventions targeting at least 1 of the 11 HCAHPS domains and determined that
more stringent research is needed to identify effective and generalizable interventions to
improve patient satisfaction (Davidson et al. 2017, 597). The aforementioned topics provide a
basis for, but do not specifically seek to find a correlation between HIE usage and HCAHPS
patient satisfaction scores in Colorado hospitals.
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Implementation is not Adoption – How to Measure Usage
When considering HIE usage at Colorado hospitals, one must look at a quantitative
method of measuring “levels” of usage of HIE and keep in mind that implementation is not
adoption (Haugen and Fred 2016, 454). Characteristics of successful HIE usage like user logon
statistics, data types accessed by users and reasons for use and associated outcomes can be
measured. For example, HIE use in emergency departments and ambulatory clinics focuses on
patients where missing information may be available in the exchange and relates to other
elements including the roles of people with access, the setting, and other site specific issues
that could affect routine system use (Johnson et al. 2011, 690). A longitudinal study done from
2011-2017 found that not only did HIE usage increase over the time period, but the most
notable change (+29 percent) in HIE use occurred in the inpatient setting. Usage was measured
using access log files from the Indiana Network for Patient Care (INPC), a mature statewide
community HIE network. The log files portray an objective method to measure HIE usage
(Rahurkar et al. 2020, 2). These same types of log files could be used to measure CORHIO or
QHN HIE usage in Colorado.
Project Description
Part One: Design of Project
This research project will explore whether patient satisfaction in Colorado hospitals is
related to health information exchange (HIE) usage. Using a quasi-experimental design with HIE
adoption as the intervention, HCAHPS scores can be compared pre- and post-intervention.
Necessary attention will be made to moderators such as patient satisfaction scores measured
during the COVID-19 pandemic and other confounding variables (like hospital expansion or
organizational changes). Case study strategy will be used to delve into understanding HIE usage
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within the hospital system and to draw upon the qualitative and quantitative data concurrently.
The case study will allow insights into this relationship and serves exploratory, descriptive and
explanatory purposes.
Mixed-methods will be used to measure levels of HIE usage at Colorado hospitals, with
quantitative data being derived from HIE usage logs and qualitative data coming from
discussions with employees regarding HIE usage directly. Interviews will be conducted with end
users at hospitals (such as nurse informaticists) and results will be described as themes or codes
to be analyzed quantitatively. From CORHIO and QHN, quantitative data such as user login
statistics or access log files can be used to measure HIE usage. By collecting and analyzing both
methods concurrently, the research can be concluded in a reasonable timescale and provide a
deeper insight into the relationship between the dependent variable, patient satisfaction and
the independent variable, HIE usage.
Secondary research will be conducted to discover the obstacles of HIE adoption,
understand the regional health information exchange model in Colorado (CORHIO and QHN),
review complexities regarding determinants of patient satisfaction and explain current scoring
systems such as HCAHPS, SHEP, and HEDIS. By using a mixture of information both internal and
external to the organizations, it is possible to draw conclusions about patient satisfaction as it
relates to HIE usage.
Part Two: Data Collection
The population for my research is “all Colorado hospitals” and that will also be the
sampling frame, assuming that data regarding the usage of HIE from CORHIO and QHN can be
obtained as well as the HCHAPS scores for the sample. To get to the 1% margin of error for
probability sampling, I will need a sample of at least 110 of the 114 hospitals in Colorado. A
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survey of secondary data will be necessary to use the data from CORHIO, QHN and HCAHPS.
The HCAHPS scores and rankings will be taken from the U.S. Government website
https://healthdata.gov/ and the logs of HIE usage will be obtained from CORHIO and QHN
directly. HCAHPS has a predetermined format, but it’s possible that data from the HIE could be
in a raw format and will need further cleansing and formatting to get in a useable format. These
longitudinal data sources can be combined to get quantifiable statistics for Colorado hospitals.
Analysis will be done to determine if the data meets the needs of my project.
For the qualitative data, interviews conducted will be one-to-one semi-structured/indepth where open-ended questions are asked (see Appendix). The conversation allows for an
open format and care will be taken to not lead the participant and to remain objective.
Purposive, homogeneous, non-random sampling for the case study will be used because
random selection of hospitals may not be possible. However, participants in similar roles within
each organization can be selected to allow for collection of in-depth information within a
particular group. Before the interview, the purpose of the study will be revealed to the
participant and the participant’s permission to record the interview will be needed. The
interview process is considered “human subject research” and will need to be approved by the
Internal Review Board (IRB).
Part Three: Data Analysis and Application
The numerical data of the HCAHPS scores will be compared to categorical data from HIE
usage logs (levels of usage: high, medium low or years/months of usage). The relationship
between these variables can be shown using a line graph, scatter plot or contingency table.
SPSS or Excel can be used to perform chi square analysis to determine if the HCAHPS scores and
the levels of usage (ordinal values) are independent. Pearson’s correlation coefficient can be
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performed on HCAHPS scores and number of months of HIE usage to assess the strength of the
relationship.
As patterns are discovered during the interview process, they will be grouped into
themes and those relationships will be tested. The quantitative data will be used to develop
and test an explanation for the correlation between HIE usage and HCAHPS scores and to
ensure that the data is reflecting reality. The conversations can be broken into categories and
used for thematic analysis (i.e. “patient satisfaction”) or narrative analysis (i.e. “our plan for HIE
adoption”). To ensure validity of the interview data and avoid bias, participants will answer
open-ended and probing questions framed from different perspectives allowing the participant
to describe their real life experiences with HIE and patient satisfaction.
Patient satisfaction is an important measurement of a hospital’s success. If correlation
can be shown between HIE usage and patient satisfaction as measured by HCAHPS scores, this
can serve as an impetus to Colorado hospitals to implement and adopt HIE.
Anticipated Challenges or Problems
The most obvious challenge for this project is showing there is a real correlation
between HIE usage and patient satisfaction. It will be important to point out any confounding
variables that may have affected the study outcome. The determination of confounders is an
important part of the interview process. Perhaps the participant thinks that the new CEO or
the new facility has made the biggest impact on patient satisfaction. The thematic analysis will
have to consider these narratives in an objective manner to ensure valid data for testing the
relationship of the variables. Also, even though the participants will be chosen from nonrandom sampling, it could be difficult to schedule enough interviews with different hospitals to
be valid and reliable.
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This study is being proposed on the assumption that HIE log usage data can be obtained
from CORHIO and QHN in some format. It’s possible that zero data may be procured during the
study timeframe due to confidentiality or proprietary matters. In that case, a revision of the
project strategy will be necessary, perhaps moving to use of a survey rather than the HIE logs.
Survey questions will need to be devised and submitted to the IRB. It’s also possible that data
will be in a raw form and need considerable time to cleanse and format.
Possible Project Outcomes or Anticipated Results
The Capstone project should show a positive relationship between HIE usage in
Colorado hospitals and patient satisfaction, therefore providing further evidence that HIE
should be adopted. The data analysis will demonstrate that as HIE usage increases, HCAHPS
patient satisfactions scores go up, and the themes discovered during the interview process can
support this relationship. It is possible that the interviews bring to light confounding factors for
an increase in patient satisfaction outside of HIE usage. It would be an unanticipated outcome
for the research to show no correlation between the two variables, or alternatively, show a
negative relationship between HIE usage and patient satisfaction.
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Project Schedule
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Appendix
Questions for Interview Participants
1. What is your current job role? Describe your responsibilities.
2. How do you feel you play a part in making sure patients are satisfied with their hospital
experience?
3. What do you think are the biggest contributors to patient satisfaction at your
organization?
4. What role, if any, do you think Health Information Exchange plays in patient
satisfaction?
5. How would you quantify your level of Health Information Exchange (CORHIO/QHN)
usage on a daily basis?
6. Can you tell me about your experience [refer to previous conversation topic]?
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