title: Bridging organizational divides in health care: an ecological view of health information exchange.
abstract: BACKGROUND
  The fragmented nature of health care delivery in the United States leads to fragmented health information and impedes patient care continuity and safety. Technologies to support interorganizational health information exchange (HIE) are becoming more available. Understanding how HIE technology changes health care delivery and affects people and organizations is crucial to long-term successful implementation.
  
  
  OBJECTIVE
  Our study investigated the impacts of HIE technology on organizations, health care providers, and patients through a new, context-aware perspective, the Regional Health Information Ecology.
  
  
  METHODS
  We conducted more than 180 hours of direct observation, informal interviews during observation, and 9 formal semi-structured interviews. Data collection focused on workflow and information flow among health care team members and patients and on health care provider use of HIE technology.
  
  
  RESULTS
  We structured the data analysis around five primary information ecology components: system, locality, diversity, keystone species, and coevolution. Our study identified three main roles, or keystone species, involved in HIE: information consumers, information exchange facilitators, and information repositories. The HIE technology impacted patient care by allowing providers direct access to health information, reducing time to obtain health information, and increasing provider awareness of patient interactions with the health care system. Developing the infrastructure needed to support HIE technology also improved connections among information technology support groups at different health care organizations. Despite the potential of this type of technology to improve continuity of patient care, HIE technology adoption by health care providers was limited.
  
  
  CONCLUSIONS
  To successfully build a HIE network, organizations had to shift perspectives from an ownership view of health data to a continuity of care perspective. To successfully integrate external health information into clinical work practices, health care providers had to move toward understanding potential contributions of external health information. Our study provides a foundation for future context-aware development and implementation of HIE technology. Integrating concepts from the Regional Health Information Ecology into design and implementation may lead to wider diffusion and adoption of HIE technology into clinical work.
authors.affiliation: Vanderbilt Implementation Sciences Laboratory, Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States. kim.unertl@vanderbilt.edu.
authors.forename: Kim M
authors.initials: KM
authors.lastname: Unertl
authors.forename: Kevin B
authors.initials: KB
authors.lastname: Johnson
authors.forename: Cynthia S
authors.initials: CS
authors.lastname: Gadd
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Lorenzi
keywords: community networks; ethnography; health information systems; information ecology; information sharing; organizational models; qualitative research