Nursing Leadership Informing Community Health Information Exchange Strategy

by | May 18, 2025 | Health

 

You are in the chief nursing officer role and have been asked by your healthcare system to represent the hospital on the board of a new not-for-profit entity established by your community to build and manage the HIE within your region. Your region has been awarded a federal grant of $250,000 to build the HIE to serve the community. At the first board meeting of diverse stakeholders, including payers, providers, hospitals, public health, and healthcare consumers, the group must advise the chief executive on what type of exchange the group believes is needed. The chief executive indicates that a basic exchange using the Direct Project protocols for the size of the community is likely to exceed the federal grant dollars, and as such, the group needs to align on a value proposition of what the community needs. This is hoped to result in the community being willing to pay for the additional costs.

The community has a population of more than 250,000, with a significant indigent population that tends to use the ED as an access to care for routine healthcare needs. Hospital staff also suspect that they have drug seekers going from one ED to the next seeking additional medications, yet do not have the information to confirm this suspicion or to track patients from one institution to another.

The community has two major healthcare systems that are heatedly competitive and unlikely to be willing to share data in a central data repository. Providers in the community compromise one large-practice consortium and multiple independent providers. The large group of providers is demanding that some sort of exchange be established to support their referral base. As a result, there is heated debate as to whether the community aligns with a business and infrastructure strategy.

Based on information within Chapter 11, consider the following questions:

1. Based on the needs of the community noted in the case study, what is your recommendation as to the best infrastructure and technical exchange model that the community should promote?

2. What are some of the barriers consistent with other communities’ failures that might be issues for your community and how do you overcome those issues?

Sample solution

Dante Alighieri played a critical role in the literature world through his poem Divine Comedy that was written in the 14th century. The poem contains Inferno, Purgatorio, and Paradiso. The Inferno is a description of the nine circles of torment that are found on the earth. It depicts the realms of the people that have gone against the spiritual values and who, instead, have chosen bestial appetite, violence, or fraud and malice. The nine circles of hell are limbo, lust, gluttony, greed and wrath. Others are heresy, violence, fraud, and treachery. The purpose of this paper is to examine the Dante’s Inferno in the perspective of its portrayal of God’s image and the justification of hell. 

In this epic poem, God is portrayed as a super being guilty of multiple weaknesses including being egotistic, unjust, and hypocritical. Dante, in this poem, depicts God as being more human than divine by challenging God’s omnipotence. Additionally, the manner in which Dante describes Hell is in full contradiction to the morals of God as written in the Bible. When god arranges Hell to flatter Himself, He commits egotism, a sin that is common among human beings (Cheney, 2016). The weakness is depicted in Limbo and on the Gate of Hell where, for instance, God sends those who do not worship Him to Hell. This implies that failure to worship Him is a sin.


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God is also depicted as lacking justice in His actions thus removing the godly image. The injustice is portrayed by the manner in which the sodomites and opportunists are treated. The opportunists are subjected to banner chasing in their lives after death followed by being stung by insects and maggots. They are known to having done neither good nor bad during their lifetimes and, therefore, justice could have demanded that they be granted a neutral punishment having lived a neutral life. The sodomites are also punished unfairly by God when Brunetto Lattini is condemned to hell despite being a good leader (Babor, T. F., McGovern, T., & Robaina, K. (2017). While he commited sodomy, God chooses to ignore all the other good deeds that Brunetto did.

Finally, God is also portrayed as being hypocritical in His actions, a sin that further diminishes His godliness and makes Him more human. A case in point is when God condemns the sin of egotism and goes ahead to commit it repeatedly. Proverbs 29:23 states that “arrogance will bring your downfall, but if you are humble, you will be respected.” When Slattery condemns Dante’s human state as being weak, doubtful, and limited, he is proving God’s hypocrisy because He is also human (Verdicchio, 2015). The actions of God in Hell as portrayed by Dante are inconsistent with the Biblical literature. Both Dante and God are prone to making mistakes, something common among human beings thus making God more human.

To wrap it up, Dante portrays God is more human since He commits the same sins that humans commit: egotism, hypocrisy, and injustice. Hell is justified as being a destination for victims of the mistakes committed by God. The Hell is presented as being a totally different place as compared to what is written about it in the Bible. As a result, reading through the text gives an image of God who is prone to the very mistakes common to humans thus ripping Him off His lofty status of divine and, instead, making Him a mere human. Whether or not Dante did it intentionally is subject to debate but one thing is clear in the poem: the misconstrued notion of God is revealed to future generations.

 

References

Babor, T. F., McGovern, T., & Robaina, K. (2017). Dante’s inferno: Seven deadly sins in scientific publishing and how to avoid them. Addiction Science: A Guide for the Perplexed, 267.

Cheney, L. D. G. (2016). Illustrations for Dante’s Inferno: A Comparative Study of Sandro Botticelli, Giovanni Stradano, and Federico Zuccaro. Cultural and Religious Studies, 4(8), 487.

Verdicchio, M. (2015). Irony and Desire in Dante’s” Inferno” 27. Italica, 285-297.

This is a complex but crucial situation for the community’s healthcare future. As the Chief Nursing Officer representing the hospital, my priority is to advocate for an HIE infrastructure that not only meets the immediate grant limitations but also provides significant value to all stakeholders, especially the vulnerable patient populations and the hospital’s ability to deliver safe and efficient care.

Here’s my response based on Chapter 11 considerations:

1. Recommendation for the Best Infrastructure and Technical Exchange Model:

Given the needs of the community, the federal grant limitations, and the competitive landscape, I recommend promoting a hybrid approach that initially focuses on a directed exchange model (using Direct Project protocols) while strategically planning and building towards a more robust query-based exchange in the near future.

This is a complex but crucial situation for the community’s healthcare future. As the Chief Nursing Officer representing the hospital, my priority is to advocate for an HIE infrastructure that not only meets the immediate grant limitations but also provides significant value to all stakeholders, especially the vulnerable patient populations and the hospital’s ability to deliver safe and efficient care.

Here’s my response based on Chapter 11 considerations:

1. Recommendation for the Best Infrastructure and Technical Exchange Model:

Given the needs of the community, the federal grant limitations, and the competitive landscape, I recommend promoting a hybrid approach that initially focuses on a directed exchange model (using Direct Project protocols) while strategically planning and building towards a more robust query-based exchange in the near future.

Here’s why:

  • Addressing Immediate Needs with Directed Exchange (Direct Project):

    • The immediate need to track patients across institutions, particularly suspected drug seekers using the ED frequently, can be partially addressed through secure direct messaging of patient summaries and relevant encounter information between hospitals. This allows for a more informed assessment of a patient’s history, even without a central repository.
    • The large provider consortium’s demand for referral support can be met by enabling secure electronic referrals and the sharing of relevant patient information (e.g., consultation notes, lab results) directly between referring and receiving providers. This streamlines the referral process and improves care coordination.
    • For public health, directed exchange can facilitate the secure transmission of syndromic surveillance data and communicable disease reports from hospitals and potentially large practices to the public health department.

  • Strategic Path Towards a Query-Based Exchange:

    • Recognizing the limitations of a purely directed exchange (it requires knowing who to send information to), the long-term goal should be to establish a query-based exchange. This model allows authorized users to search for and retrieve patient information across participating organizations.
    • Given the competitive nature of the two major healthcare systems and their reluctance to share data in a central repository, a federated query model might be the most politically feasible starting point for a query-based exchange. In this model, each organization maintains control over its own data, but agrees to participate in a shared infrastructure that allows authorized users to query across their systems.
    • The initial $250,000 grant can be strategically used to build the foundational infrastructure for the directed exchange (e.g., establishing secure connections, implementing Direct Project protocols, providing initial training). This will demonstrate tangible value and build momentum for future expansion.
    • The value proposition for the community to invest additional funds will be the enhanced capabilities of the query-based exchange, specifically:
      • Improved Care for the Indigent Population: A query-based system can provide a more complete picture of an indigent patient’s healthcare history, regardless of where they received care. This can lead to more informed treatment decisions in the ED, potentially reducing unnecessary tests and admissions, and facilitating connections to appropriate primary care resources.
      • Enhanced Patient Safety: Access to a comprehensive patient history through query can reduce medication errors, prevent redundant tests, and improve the coordination of care for patients with complex conditions.
      • Support for Population Health Initiatives: Over time, with broader participation, a query-based exchange can provide valuable data for population health analysis, identifying trends and informing interventions to improve community health outcomes.

Justification: This hybrid approach acknowledges the immediate financial constraints and political realities while laying a strategic foundation for a more comprehensive and valuable HIE in the future. Starting with a directed exchange addresses some key immediate needs and allows the community to gain experience and demonstrate the benefits of electronic information sharing. This can then build trust and support for the more complex and costly query-based infrastructure.

2. Potential Barriers and Strategies to Overcome Them:

Based on Chapter 11 and common challenges faced by other communities, our region might encounter the following barriers:

  • Lack of Trust and Competition: The heated competition between the two major healthcare systems is a significant barrier. They may be hesitant to share patient data, even in a federated model, due to concerns about losing competitive advantage or data security.

    • Overcoming Strategy:
      • Focus on Shared Value and Patient Benefit: Emphasize the benefits of the HIE for the community as a whole, particularly the vulnerable populations. Frame data sharing as a way to improve patient safety, reduce costs associated with redundant care (especially in the ED), and enhance the quality of care across the region.
      • Establish Clear Governance and Data Use Agreements: Develop a robust governance structure with representation from all stakeholders, including legal counsel, to establish clear rules for data access, security, privacy, and usage. These agreements must address concerns about competitive sensitivity and ensure compliance with HIPAA and other relevant regulations.
      • Phased Implementation with Early Wins: Start with the directed exchange, which involves more controlled data sharing for specific purposes (referrals, ED summaries). Demonstrating the value and security of this initial phase can build trust and encourage participation in the more open query-based system later.

  • Financial Sustainability: The initial $250,000 grant is unlikely to be sufficient for a comprehensive HIE. Securing ongoing funding and developing a sustainable business model will be crucial.

    • Overcoming Strategy:
      • Demonstrate Early Value to Justify Community Investment: The initial directed exchange should focus on use cases that provide clear and measurable benefits (e.g., reduced ED visits for routine care, streamlined referrals). This data can be used to make a compelling case for community investment in the more advanced query-based capabilities.
      • Explore Diverse Funding Sources: Investigate potential funding from payers (who could benefit from reduced costs and improved quality), participating providers (who could see efficiencies and improved care coordination), and state or federal programs.
      • Develop a Fee Structure that is Equitable and Sustainable: Once the query-based exchange is established, a transparent and fair fee structure for accessing and using the HIE services will be necessary for long-term sustainability. This structure should consider the different needs and financial capacities of various stakeholders.

  • Lack of Engagement and Buy-in from Independent Providers: The large practice consortium is demanding an exchange, but the multiple independent providers may be less enthusiastic or lack the resources to participate.

    • Overcoming Strategy:
      • Highlight the Value Proposition for Independent Providers: Emphasize how the HIE can support their referral base, improve communication with specialists, and potentially reduce administrative burden.
      • Provide Technical Assistance and Support: Offer affordable and user-friendly technology solutions and provide technical support to help independent providers connect to the HIE.
      • Incentivize Participation: Explore potential incentives for early adoption and active use of the HIE, such as reduced connection fees or access to valuable data insights.

  • Technical Complexity and Interoperability Challenges: Building an HIE that can effectively connect diverse systems with varying levels of technical sophistication can be complex. Ensuring data standards and interoperability will be critical.

    • Overcoming Strategy:
      • Adopt Nationally Recognized Standards: Adhere to established data standards (e.g., FHIR) and interoperability frameworks to facilitate seamless data exchange between different systems.
      • Prioritize Interoperability in Technology Selection: When selecting technology vendors and infrastructure components, prioritize those with a proven track record of interoperability and adherence to industry standards.
      • Provide Technical Support and Training: Offer ongoing technical support and training to participating organizations to ensure their systems can effectively connect and exchange data.

By proactively addressing these potential barriers through clear communication, collaborative governance, a phased implementation approach, and a focus on demonstrating tangible value, our community can increase the likelihood of successfully establishing a sustainable and impactful HIE.

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