USING BEHAVIORAL HEALTH DATA FROM A HEALTH INFORMATION

EXCHANGE: AN EXAMINATION OF FACILITATORS AND BARRIERS

by

RANDYL A. COCHRAN

SUE S. FELDMAN, COMMITTEE CHAIR

DARRELL BURKE
ALLYSON G. HALL
NATALIYA V. IVANKOVA
BRIAN YEAMAN

A DISSERTATION

Submitted to the graduate faculty of The University of Alabama at Birmingham, in partial

fulfillment of the requirements for the degree of Doctor of Philosophy.

BIRMINGHAM, ALABAMA

2019
 ProQuest Number: 27549076

All rights reserved

INFORMATION TO ALL USERS

The quality of this reproduction is dependent on the quality of the copy submitted.

In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.

ProQuest 27549076

Published by ProQuest LLC ( 2020 ). Copyright of the Dissertation is held by the Author.

All Rights Reserved.

This work is protected against unauthorized copying under Title 17, United States Code
Microform Edition © ProQuest LLC.

ProQuest LLC
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106 - 1346
 USING BEHAVIORAL HEALTH DATA FROM A HEALTH INFORMATION
EXCHANGE: AN EXAMINATION OF FACILITATORS AND BARRIERS

RANDYL A. COCHRAN

ABSTRACT

Behavioral health disorders are common, and they frequently co-occur with chronic

physical illnesses. Behavioral health patients with chronic physical illnesses are three

times more likely to be readmitted to the hospital within 30 days of discharge than non-

behavioral health patients. Readmissions among behavioral health patients are costly:

$817 million in readmissions costs are related to mood and psychiatric disorders. High

readmission rates are attributed, in part, to poor exchange of health-related information

between various care providers. Health information exchanges (HIEs) are effective in

chronic disease management, but their effectiveness in integrated care delivery is unclear.

This study examined facilitators of and barriers to obtaining behavioral health

information from HIEs. The study employed a sequential explanatory mixed methods

design: the initial quantitative phase of the study used a validated survey instrument to

examine enabling and impeding factors for obtaining behavioral health information from

an HIE. The surveys were administered to healthcare providers in Alabama and

Oklahoma via email. The subsequent qualitative phase explored the identified facilitators

and barriers in greater depth and revealed other potential factors that affect the

acquisition and use of behavioral health data from an HIE. Semi-structured interviews

were conducted with a subsample of survey respondents to allow participants to elaborate

on factors identified from the survey. This study: 1) helped to gain an understanding of

the challenges and benefits of integrating care, particularly for patients with behavioral

ii
health disorders; 2) examined the role of health IT in integrated care delivery; and 3)

examined healthcare providers’ perspectives about using technology to integrate care.

Keywords: behavioral health, health information exchanges, integrated care delivery

iii
 DEDICATION

This dissertation is dedicated to my family, specifically to my parents, Timothy and Nelle

Cochran, and my grandmother, Gladys. Thank you for covering me with your prayers, for

loving me at my lowest points, and for believing in my ability to accomplish this goal. I

also dedicate this work to my closest friends, who offered constant support and

encouragement.

iv
 ACKNOWLEDGEMENTS

I would like to thank the University of Alabama at Birmingham for providing me

with the opportunity and resources to complete my doctoral studies. I also offer many

thanks to my dissertation chair, Sue Feldman, for helping me to refine my research idea,

for putting me in contact with all the right people, and for supporting me when the work

felt insurmountable. I have learned so much from you, and I look forward to continuing

to work with you in the future.

Additionally, I would like to thank Nataliya Ivankova for all of her guidance and

support as I completed my first mixed methods study; and to Brian Yeaman for his

unmatched enthusiasm for my research and for helping me secure the necessary data. I

would also like to thank Allyson Hall and Darrell Burke, who gave their time, support,

and encouragement as they served on my committee.

Thank you to the many friends/family who helped me to refine my survey

instrument, connected me to resources to help me with the transcription of my interviews,

let me practice and offered feedback for the final defense, and who celebrated even my

smallest wins: Thomas, Alyncia, Maya, Jeffrey, Courtney, Solomon, Jaquaye, Yul,

Astardii, Richard, Claudia, KaLia, & Hope, I can’t thank you enough.

I would like to thank two of my colleagues, Jessica H. Williams and William

Opoku-Agyeman, who have helped me to gain confidence in my abilities as a researcher.

Thank you so much for giving me the opportunity to work with and learn from you. I also

v
offer thanks to the friends I made in my program. The late nights, shared meals,

workouts, and venting sessions helped me to stay sane during this process, and I couldn’t

think of better people to have in my corner during this journey. I am also grateful to my

colleagues at Towson for all of their support as I cleared this final hurdle. Cassie, Mary

Helen, Wayne, Cyrus, Ming, and others: I appreciate all you’ve done to make Maryland

feel like home.

Last, but certainly not least, I express my gratitude to God for giving me the

strength to press on. Thank You for listening to my heart when words failed me, and

thank You for guiding me every step of the way.

vi
 TABLE OF CONTENTS
ABSTRACT........................................................................................................................ ii
DEDICATION ................................................................................................................... iv
ACKNOWLEDGEMENTS .................................................................................................v
LIST OF TABLES ............................................................................................................. ix
LIST OF FIGURES .............................................................................................................x
CHAPTER 1 ........................................................................................................................1
INTRODUCTION .......................................................................................................... 1
Statement of the Problem ............................................................................................ 1
Purpose Statement and Research Questions ............................................................... 7
Significance of the Study ............................................................................................ 9
Dissertation Overview ................................................................................................ 9
CHAPTER 2 ......................................................................................................................10
REVIEW OF THE LITERATURE .............................................................................. 10
Background ............................................................................................................... 10
Conceptual Framework: Guiding Theories ............................................................... 34
Conceptual Model ..................................................................................................... 44
Summary ................................................................................................................... 45
CHAPTER 3 ......................................................................................................................47
METHODS ................................................................................................................... 47
Study Sites: Overview............................................................................................... 47
Research Approach ................................................................................................... 48
Quantitative Phase .................................................................................................... 57
Qualitative Phase ...................................................................................................... 64
Data Analysis ............................................................................................................ 67
Integration and Meta-Inferences ............................................................................... 68
Quality Assurance ..................................................................................................... 69
Ethical Considerations .............................................................................................. 73
Summary ................................................................................................................... 74
CHAPTER 4 ......................................................................................................................75
RESULTS ..................................................................................................................... 75
Quantitative Phase .................................................................................................... 75
Qualitative Phase ...................................................................................................... 89
Integration ................................................................................................................... 101
Summary ................................................................................................................. 112
CHAPTER 5 ....................................................................................................................113
DISCUSSION, IMPLICATIONS, AND FUTURE RESEARCH .............................. 113
Discussion of the Findings ...................................................................................... 113
Contribution to Theory ........................................................................................... 121
Contribution to Practice .......................................................................................... 123
Contribution to Policy ............................................................................................. 124
Limitations of the Current Study ................................................................................ 125

vii
 Recommendations for Future Research ...................................................................... 127
Conclusion .................................................................................................................. 128
REFERENCES ................................................................................................................130

viii
 LIST OF TABLES

1. Table 1: Descriptive statistics for behavioral health

information exchange survey
participants…………………………………………………………76

2. Table 2: Spearman’s rank correlation between Behavioral

Intention, Use
Behavior, and independent
variables……………………………………………………………80

3. Table 3: Linear regression models examining the relationship

between behavioral
intention and independent
variables…………………………………………………................84

4. Table 4: Path analysis of constructs tested in the conceptual

model………………………………………………………………86

5. Table 5: Final coding structure for the qualitative

phase……………………………………………………………….90

6. Table 6: Joint display of the quantitative constructs and

qualitative themes related to factors that facilitate or impede
behavioral health information exchange via an
HIE………………………………………………………………..102

ix
 LIST OF FIGURES

1. Figure 1: Original UTAUT

model...............................................................................................36

2. Figure 2: Extended UTAUT

model………………………………………………………….......40

3. Figure 3: Diffusion of
Innovation…………………………………………………….......42

4. Figure 4. A depiction of Reed’s Law and the increase in network

value……………………………………………………………...44

5. Figure 5: Conceptual model that was tested in this

study……………………………………………………………...45

6. Figure 6. Study procedural

diagram……………………………………………………..……56

7. Figure 7: Level of computer experience among survey

participants………………………………………………….…...79

8. Figure 8: Measurement model for the

study………………………………………………………..……81

9. Figure 9: Factor loadings for the measurement

model……………………………………………………………82

10. Figure 10: Conceptual model with path coefficients for the
hypothesized relationships…………………………………......88

x
 CHAPTER 1

INTRODUCTION

Statement of the Problem

Behavioral health encompasses the state of an individual’s mental and emotional

welfare, as well as actions that impact wellness (SAMHSA). Behavioral health disorders

include substance use disorders, serious psychological distress, suicide, and mental

disorders. For the purposes of this study, behavioral health disorders encompass mood

and substance use disorders. Behavioral health disorders have an adverse effect on an

individual’s welfare, ability to function, quality of life, and life expectancy; patients who

have these disorders are considered a vulnerable population that requires team-based care

to achieve optimal health outcomes (Mechanic, 2012; Farmanova, Baker, & Cohen,

2019). These disorders are common: a quarter of a million new people suffer each year,

and nearly half of the population will meet the criteria for some sort of a mental illness at

some point in their lifetime (American Hospital Association, 2012; Miller, Glover, &

Gordon, 2014; Cifuentes et al., 2015). By 2020, behavioral health disorders are projected

to be the leading cause of worldwide disability, surpassing all physical ailments (Crowley

& Kirschner, 2015).

The extant literature demonstrates that there is a complex connection between

poor physical health and mental health (Kutlubaev & Hackett, 2014; Shi, Yang, Zeng, &

Wu, 2017; Thayabaranathan et al., 2018). Many individuals diagnosed with a behavioral

health disorder also suffer from chronic physical illnesses (American Hospital

Association, 2012; Miller et al., 2014). A national survey indicated that nearly 70% of

1
adults who have been diagnosed with a mental illness have a medical comorbidity, and

29% of adults with a medical illness have a behavioral health comorbidity (Goodell,

Druss & Walker, 2011; Office of the National Coordinator for Health Information

Technology). Among a sample of 263 patients with a chronic illness (diabetes), 82% also

had a behavioral health comorbidity (Wu et al., 2018). The “inter-relatedness of mental

illness and chronic disease” is one of the contributing factors to the inefficient use of

healthcare services (e.g., increased inpatient hospital utilization) (Perrin, Reimann,

Capobianco, Wahrenberger, Sheitman, & Steiner, 2018, p. 240; Miller et al., 2014, p. 4;

Schiefelbein, Olson, & Moxham, 2014). Another factor that contributes to this pattern of

health services utilization among patients with behavioral disorders is the low rate of

primary care utilization (Alakeson, Frank, & Katz, 2010). Lastly, patterns of healthcare

utilization by these individuals are complicated by the fact that those taking antipsychotic

medications may experience exacerbation of other physiological illnesses (Alakeson et

al., 2010).

Patients with behavioral health disorders are three times more likely to be

readmitted to the hospital 30 days post-discharge than patients who do not have a

behavioral health disorder (Tamasi, 2015; Chen, Novak, Barath, Goldman, & Mortensen,

2018). Researchers have found that individuals with behavioral disorders who also suffer

from other chronic diseases (e.g., asthma, arthritis, coronary artery disease, and diabetes)

report more symptoms and have worse clinical outcomes than patients who do not have a

behavioral health comorbidity (Ghitza, Wu, & Tai, 2013; Katon, Lin, & Kroenke, 2007).

The rising prevalence of chronic diseases over the last 20 years makes the effective

treatment of these disorders a concern for healthcare organizations. However, the issues

2
of multimorbidity and fragmented delivery systems present challenges that these

organizations must overcome (Buja et al., 2018). These challenges have a particular

effect on behavioral health patients. Primarily because patients with behavioral health

issues are less likely to comply with discharge treatment recommendations, post-

discharge medical complications are more common (Ghitza et al., 2013; Katon et al.,

2007) and contribute to significantly higher hospital readmission rates among this group

(Tamasi, 2015). Blount and colleagues (2007) propose, “It is in the area of behavioral

health that the U.S. health care system could find the largest potential payoff in reduction

of morbidity and mortality and the largest increase in the cost-effectiveness of care” (p.

291). Findings from a recent study lend credence to this idea: data from a behavioral

health/primary care collaborative care model demonstrated that integrated care delivery

was associated with a savings of $860.16 per member per year (10.8% savings) when

compared to the control group (Ross et al., 2019).

Hospital readmissions have been identified as an aspect of healthcare that is in

need of attention (Burgess & Hockenberry, 2014). For example, readmissions related to

mood and psychiatric disorders cost a total of $817 million, approximately 5% of the

total (Hines, Barrett, Jiang, & Steiner, 2014). More recent data from the Hospital

Readmissions Reduction Program (HRRP), as reported by a number of authors, indicate

that many patients (28%) hospitalized for heart failure, acute myocardial infarction

(AMI), and pneumonia also suffered from a behavioral health comorbidity (Ahmedani et

al., 2015; Benjenk & Chen, 2018); these patients are at high risk for readmission with 30

days (Ahmad et al., 2013; Pederson et al., 2016; Benjenk & Chen, 2018).

3
 The integration of behavioral and general health services is being considered

more seriously in the healthcare industry, particularly as the field of healthcare becomes

more complex and fragmented (Ross et al., 2019). Poor integration of care has been

associated with adverse events in healthcare settings (Gandhi et al., 2018). The U.S.

healthcare system has made some progress on the development of integrated care, but it

continues to present substantial challenges (Gandhi et al., 2018). Early interventions have

been linked to improvements in mental health, quality of life, and daily functioning in

patients who suffer from heart disease (Benjenk & Chen, 2018). Several individuals are

involved in the process of care delivery (e.g., physicians, nurses, social workers, and

specialists); new processes and technologies will become necessary for seamless care

delivery, particularly when treating patients with complex chronic conditions (Gandhi et

al., 2018).

Integrated care is broadly defined as “a well planned and well organized set of

services and care processes, targeted at the multi-dimensional needs/problems of an

individual client, or a category of people with similar needs/problems” (Nies & Berman,

2004; Vestjens, Cramm, Birnie, & Nieboer, 2018, p. 175). In the context of behavioral

health, integrated care encompasses the coordinated delivery of general medical and

behavioral health care (SAMHSA-HRSA Center for Integrated Health Care Solutions,

2016; Delaney et al., 2018). Through integrated care, healthcare providers offer treatment

wherever patients seek care; identify patients who are at risk and provide preventive or

early intervention for various problems; and coordinate care for patients with complex

needs (McGovern, Dent, & Kessler, 2018).

4
 The extant literature supports the use of integrated care to meet the needs of

chronically ill patients, including those with behavioral health disorders, in an effort to

treat medical comorbidities and wellness issues within these patients (Ouwens,

Wallersheim, Hermens, Hulscher, & Grol, 2005; Alexander, de Silva, Clarke, Peachey, &

Manikam, 2018; Delaney et al., 2018). A seamless, whole-person approach to care has

been shown to be associated with lower costs and better quality of care (Cifuentes et al.,

2015). Rosenthal (2018) emphasized the importance of collaborative care when treating

chronic diseases like diabetes; he stated that a similar approach should be applied to

behavioral health disorders, including substance use disorders (Rosenthal, 2018).

Findings from a recent study (Chen et al., 2018) examined the effects of local health

departments’ provision of mental health services on hospital readmissions in Maryland.

Prevention, promotion, and coordination activities were associated with a reduced

likelihood for 30-day all-cause readmissions among adults (Chen et al., 2018).

Additionally, the provision of coordinated multidisciplinary care for stroke victims who

suffer from anxiety and depression has been associated with reduced incidence of death

and disability, as well as better quality of life (Thayabaranathan et al., 2018). Integrated

care relies on the cooperation of a team of healthcare professionals, and “complete,

current, just-in-time information” enables the team to work together to offer the most

appropriate care to patients (Cifuentes et al., 2015, p. S64). The adoption of integrated

care can assist in creating a more comfortable environment to treat multiple comorbidities

(Imboden & Fehr, 2018).

A key factor that has been linked to patterns of high 30-day readmission rates is

the inadequate exchange of health-related information between various care providers,

5
which leads to poor coordination of care and poor communication between care providers

and patients (Hesselink et al., 2014). Behavioral health patients, particularly those who

have a severe mental illness require a higher level of coordinated care delivery (Perrin et

al., 2018). This level of care requires better communication between general medical and

behavioral health care providers. It is believed that health information technology (IT)

can facilitate the integration of services in the healthcare arena. The literature suggests

that proper exchange of health information has many benefits, including safer, more

efficient care that effectively manages both the behavioral and physical health needs of

individual patients (Druss & Mauer, 2010; Vest & Gamm, 2010; Office of the National

Coordinator for Health Information Technology). The effectiveness of these technologies

has been studied in areas such as chronic disease management (Bates & Bitton, 2010;

Cifuentes et al., 2015). However, the role of health IT in facilitating integrated care

delivery is not yet clear (Cifuentes et al., 2015).

There are several barriers to information exchange, particularly as it relates to

behavioral health information, but research suggests that using electronic health records

(EHRs) to enable the exchange of health-related information between various care

providers can facilitate the coordination of care and reduce 30-day hospital readmission

rates (Vest et al., 2014; Golden, Emery-Tiburcio, Post, Ewald, & Newman, 2019).

However, behavioral health and general health care providers do not use the same clinical

language, codes, or data reporting requirements (Cifuentes et al., 2015). Furthermore,

there are more stringent regulations on the exchange of behavioral health data when

compared to general health information (Cifuentes et al., 2015; Campbell et al., 2019).

Taken together, these factors create a substantial barrier to exchanging behavioral health

6
information and delivering integrated care, thus making it difficult to address the

healthcare utilization and high readmission rates so often seen by those with a behavioral

health diagnosis.

Purpose Statement and Research Questions

The fragmentation within the American healthcare system exists in large part

because of the lack of coordination between general health and specialty care services. In

addition to separate funding streams for medical and behavioral health services, various

entities (e.g., general medical health insurance plans and government agencies) have

traditionally outsourced behavioral health services to restricted networks, such as

managed behavioral health organizations (Blount et al., 2007; Maryland Department of

Health, 2012; Thalmayer et al., 2018). This method is referred to as behavioral health

carve-outs (Blount et al., 2007; Thalmayer et al., 2018). The carve-out system has been

linked to reduced access to behavioral health services: over 70% of individuals with

behavioral health issues fail to receive treatment for their illnesses, and only a fifth of

those who do receive treatment (6% of patients overall) receive evidence-based care

(Blount et al., 2007, p. 293; Kessler et al., 2003; Narrow, Rae, Robins, & Regier, 2002;

Thalmayer et al., 2018)). As such, the purpose of this study was to identify and explain

factors that facilitate and impede the use of behavioral health information from a health

information exchange (HIE). In the context of this study, HIEs are defined as

organizations and systems that facilitate the exchange of health-related data (HIMSS).

Three research questions support the study purpose and address the study aims. To

address the research questions and study aims, a sequential explanatory mixed methods

research design was utilized. This design enables the researcher to examine trends in the

7
quantitative data; the subsequent qualitative phase provides further insight into the

quantitative trends that emerge (Subedi, 2016). The research questions include one

quantitative question followed by supporting hypotheses; one qualitative question; and

one overarching question connecting the quantitative and qualitative questions. The first

question is quantitative:

• QUAN-RQ1: What factors influence intention to use behavioral health

information obtained from HIEs in hospitals?

The following hypotheses, which correspond to the first research question, were derived

from the literature and further explained in the literature review section.

• H1: Performance expectancy has a positive (+) impact on intention to use

behavioral health information obtained from an HIE.

• H2: Effort expectancy has a positive (+) impact on intention to use behavioral
health information obtained from an HIE.

• H3: Social influence has a positive (+) impact on intention to use behavioral
health information obtained from an HIE.

• H4: Perceived risk has a negative (-) impact on intention to use behavioral health
information obtained from an HIE.

• H5: Trust has a positive (+) impact on intention to use behavioral health
information obtained from an HIE.

• H6: Trust has a negative (-) impact on perceived risk of using behavioral health
information obtained from an HIE.

• H7: Trialability has a (+) impact on intention to use behavioral health information
obtained from an HIE.

• H8: Intention to use has a positive (+) impact on use behavior of behavioral health
information obtained from an HIE.

To further explore the quantitatively identified factors on behavioral intention, the

following qualitative research question was posed:

8
 • QUAL-RQ1: From the healthcare providers’ perspective, what are the facilitators
of and barriers to obtaining and using behavioral health information from an HIE?

Finally, the overarching mixed methods question to be addressed by this study,

connecting the quantitative and the qualitative questions, is as follows:

• MM-RQ1: How do the interview results help explain the quantitative findings
about factors that facilitate and impede obtaining and using behavioral health
information from an HIE?

Significance of the Study

This study examined facilitators of and barriers to obtaining behavioral health

information from an HIE. The research on integrating behavioral health information into

the provision of medical care is limited, and the topic has yet to be examined from a

theoretical perspective. This study is relevant to both the health services and health

information technology (health IT) arenas: it is applicable to the health services literature

because it emphasizes the importance of a whole-person approach to care. Likewise, the

study is applicable to the health IT arena because it examines the role of technology in

delivering integrated care to some of the most difficult-to-treat patients.

Dissertation Overview

Chapter 1 provided an overview of the study. Subsequent chapters are as follows:

Chapter 2 reviews the extant literature that led to the development of this study, and it

establishes the theoretical framework that guided the development of the research

questions and hypotheses. Chapter 3 details the methods employed for the study. Chapter

4 presents the findings from both the quantitative and qualitative phases of the study, as

well as the integration of these findings to generate meta-inferences. Finally, a discussion

of the results, limitations, and implications of the study is provided in Chapter 5.

9
 CHAPTER 2

REVIEW OF THE LITERATURE

Background

In the context of the current study, it is necessary to understand what constitutes a

behavioral health disorder and the prevalence of these disorders. Furthermore, it is

important to understand how behavioral health disorders adversely impact patient

outcomes. This section of the paper: 1) defines “behavioral health” and discusses the

prevalence of behavioral health disorders; 2) examines literature on hospital readmissions

as a measure of quality; 3) outlines the prevalence of hospital readmissions among

patients with a behavioral health disorder; and 4) provides detail about the development

of health IT and its role in healthcare. Within this section of the paper, various challenges

associated with the electronic exchange of behavioral health information are considered.

Understanding Behavioral Health

Davis and colleagues (2013) define behavioral health care as a “broad term used

to encompass care for patients around mental health and substance abuse conditions,

health behavior change, life stressors and crises, as well as stress-related physical

symptoms” (Davis et al., 2013, p. 588; Crowley & Kirschner, 2015, p. 300). Within the

broad spectrum of behavioral health conditions, there are two common subsets of

disorders: mental illnesses and substance use disorders (American Hospital Association,

2012; Crowley & Kirschner, 2015). The Centers for Disease Control and Prevention

(CDC) define mental illnesses as conditions that disrupt a person’s mood, thoughts,

feelings, ability to relate to others, and level of daily functioning (Centers for Disease

10
Control and Prevention; Crowley & Kirschner, 2015). An individual is diagnosed with a

severe mental illness if he or she is 18 years of age or older and has suffered from a

mental, emotional, or behavioral disorder that inhibits functioning or interferes with one

or more major life activities within the past 12 months (SAMHSA). People with these

disorders, in addition to suffering from poorer health and a lower quality of life overall,

also receive a lower quality of care than patients without these disorders (Mechanic,

2012). An individual is diagnosed with a substance use disorder when the repeated use of

alcohol and/or drugs impairs health status and ability to function (e.g., failure to complete

tasks at work, school, or home) (SAMHSA). This study included both mental illnesses

and substance use disorders in its definition of behavioral health.

Behavioral health disorders are associated with greater mortality, more healthcare

spending, and higher rates of physical illness (Crowley & Kirschner, 2015). More

specifically, patients with serious mental illnesses have worse health outcomes, greater

emergency department (ED) utilization, and higher hospitalization rates than patients

who do not suffer from these disorders (Chang, Vinzon, Cohen, & Young, 2019;

Schmidt, Behar, Barrera, Cordova, & Beckum, 2018). Generally, these patients fail to use

primary care services and seek preventive care (Chang et al., 2019).

Chronic medical conditions that co-occur with behavioral health disorders further

complicate matters. Severe mental illness is associated with a higher risk for diabetes,

which is also a risk factor for developing cardiovascular disease (Mangurian et al., 2017).

Furthermore, patients with severe mental illness experience greater difficulty recognizing

signs of physical illness and taking care of themselves than other patients (Chang et al.,

2019; Houben et al., 2019). Such co-occurring diseases are further complicated by the use

11
of antipsychotic medications, which are reported to have numerous adverse effects on

one’s health status and even more so on an already compromised health status (e.g.,

increased risk of developing diabetes and/or sudden death) (Bradford et al., 2013;

Mangurian et al., 2017; Houben et al., 2019). An estimated 34 million adults in the

United States reported having co-occurring physical and behavioral health disorders over

a period of 12 months (Crowley & Kirschner, 2015). These and other complications, such

as rural hospital closures and limited access to quality care, contribute to poor health

outcomes for behavioral health patients (Crowley & Kirschner, 2015). Investing in

mechanisms to improve coordination of care could improve health outcomes and quality

of care for this population, which represents a substantial sector of society.

The literature is mixed on the types of care models that best support behavioral

health patients with or without co-occurring medical issues. Integrative care models, such

as collaborative care and fully integrated healthcare services, have demonstrated

effectiveness in treating patients with behavioral health disorders and co-occurring

medical conditions (Falconer, Kho, & Docherty, 2018; Schmidt et al., 2018). These

models can improve the quality of care by delivering treatments that align with the

patients' clinical needs (Schmidt et al., 2018). However, some studies have indicated that

other care models (e.g., co-location of mental health and primary care and case

management) have not produced meaningful improvements in healthcare costs or patient

outcomes (Chang et al., 2019). A systematic review revealed that among four randomized

controlled trials (RCTs), two of the studies showed minor improvements in physical

health; the other two studies showed no significant changes in physical health (Bradford

et al., 2013). Furthermore, there were improvements in seeking preventive care (e.g.,

12
getting vaccinations). However, none of the studies examined the effect of these

interventions on functional or clinical outcomes (Bradford et al., 2013).

When selecting an integrated care approach, communication and information

sharing are essential to its success. In the process of establishing an integrated care clinic

within a community mental health center (CMHC), Annamalai and colleagues (2018)

learned the importance of establishing effective communication channels between two

sets of clinical providers when treating patients with complex medical and behavioral

needs (Annamalai et al., 2018). For example, behavioral health service providers were

responsible for sharing information about any changes in medications that a patient was

taking; likewise, providers of general medical services were responsible for manually

copying and transmitting any notes related to clinic visits to behavioral health service

providers (Annamalai et al., 2018). Although this study did not provide an extensive

report of health outcomes for patients with a behavioral health diagnosis, the researchers

discovered that both access to and quality of care improved. These improvements were

attributed, in part, to the exchange of patient information between general medical and

behavioral health service providers (Annamalai et al., 2018).

Hospital Readmissions as a Quality Metric

Hospital readmission rates have been deemed an appealing indicator of healthcare

quality for a number of reasons: they are costly, they are easy to compute, and many are

deemed preventable (Ashton & Wray, 1996; Distel, Casey, & Prasad, 2016). In the early

1980s, health services researchers became interested in hospital readmissions among the

Medicare population (Burgess & Hockenberry, 2014). The Medicare prospective

payment system (PPS) for inpatient hospital reimbursement was phased in between

13
October 1, 1983 and September 30, 1984. The goal of the new reimbursement model was

to improve efficiency in healthcare by administering fixed payments for the treatment of

cases in specific diagnosis-related groups (DRGs) (Manton, Woodbury, Vertrees, &

Stallard, 1993). The intent of PPS was to reduce the growth of health care-related

spending. However, a common concern was that the new reimbursement model would

also have an adverse impact on quality of care (Manton et al., 1993).

The relationship between cost and quality has been inconsistent in the healthcare

literature. A systematic review of the literature suggests that 34% of the studies reported

that higher cost is associated with higher quality; 30% reported an inverse relationship

between cost and quality; and 36% reported an inconclusive or no association between

cost and quality (Hussey, Wertheimer, & Mehrotra, 2013). Likewise, the Medicare PPS

findings were equally unclear. A study conducted by RAND revealed that, overall, PPS

did not result in significant declines in quality of care within hospitals; in fact, quality of

care improved in some cases (e.g., for patients with congestive heart failure and acute

myocardial infarction) (Draper et al., 2006). For example, mortality rates declined within

five patient groups; process measures of care improved; hospital readmission rates

remained unchanged. However, the study uncovered that there was a 22% rise in

Medicare patients discharged from the hospital in unstable condition (Draper et al., 2006,

pg. 2). Irrespective of the emphasis on quality, the increase in Medicare patients

discharged prematurely is cause for concern.

The 1999 Institute of Medicine (IOM) report, To Err is Human, highlighted the

substandard quality of health care services in the United States. The timing of this report

led the U.S. healthcare system into the 21st century with an increased focus on quality

14
improvement, particularly with regard to cutting costs and reducing hospital readmissions

(Burgess & Hockenberry, 2014; Fontanarosa & McNutt, 2013). In retrospect, almost two

decades later, this report has served as one of the most significant drivers behind quality

improvement efforts in healthcare. One such quality improvement effort is the Medicare

Hospital Readmission Reduction Program (HRRP), which was established in 2012 (Kash

et al., 2019).

The Affordable Care Act (ACA) acknowledged hospital readmissions as an aspect

of the health care system that needs to be addressed, and the HRRP (ACA Section 3025)

imposed financial penalties on hospitals for “perceived ‘avoidable’ [30-day]

readmission” for Medicare patients (Tamasi, 2015). The aim of the HRRP is to minimize

the occurrence of hospital readmissions, as they are both stressful for patients and costly

for hospitals. Despite the implementation of the HRRP, nearly 79% of participating

hospitals faced financial penalties in 2017, totaling $529 million, an increase of $108

million from 2016 (Kash et al., 2019).

Kash and colleagues (2017) conducted a systematic review of the literature to

determine how frequently HIEs are utilized in efforts to reduce hospital readmissions.

One hundred six (106) studies used readmissions within 30 days of discharge as the

outcome of interest. Out of 106 studies, only 13 (12%) of the articles considered HIEs as

a tool to reduce 30-day hospital readmission rates or as a key strategy in hospital

readmission reduction strategies (Kash, Baek, Davis, Champagne-Langabeer, Langabeer,

2017). An updated systematic review (Kash et al., 2019) indicated that the use of HIEs in

hospital readmission reduction programs remains low (14%). The majority of these

programs targeted patients with heart disease and lung disease; 11 of the programs

15
reported a reduction in 30-day readmission rates ranging from 0.5% to 21.1%. The mean

reduction was 8.2% (Kash et al., 2017). These findings suggest that the use of HIEs could

be effective in reducing hospital readmission rates. However, the small number of studies

that examine HIEs as a component of hospital readmission reduction strategies indicates

that there is a need for additional research in this area.

Hospital Readmissions and Behavioral Health Disorders

The literature suggests that behavioral health disorders are significant drivers of

hospital readmissions (Benzer, Sullivan, Williams, & Burgess, 2012; Burgess &

Hockenberry, 2014). Poor health outcomes among patients with behavioral health

challenges are well documented in the literature, and they are particularly common when

general medical and behavioral health services are delivered separately (Burgess &

Hockenberry, 2014; Vest & Gamm, 2010; Perrin et al., 2018). Hospital readmissions are

regaining attention in the health services arena, particularly with regard to factors

associated with behavioral health disorders that drive readmissions (Burgess &

Hockenberry, 2014). The renewed attention is through the lens of the complexities often

presented by those with behavioral health disorders. Complications such as poverty,

homelessness, and lack of social support are thought to create barriers to effective and

efficient care for which solutions do not seem simple (Burgess & Hockenberry, 2014).

Of the approximately 3.3 million hospital readmissions documented in 2011,

Medicaid accounted for 20.6% of readmissions and 18.4% of readmission-related costs;

Medicare accounted for the largest share of readmissions and readmission-related costs

(55.9% and 58.2%, respectively); and private insurance accounted for 4.9% of

readmissions and 3.7% of readmission-related costs (Hines et al., 2014). Among the

16
Medicaid population, mood and psychotic disorders were associated with the highest 30-

day all-cause readmission rates (77,400 total readmissions); alcohol-related disorders

accounted for 20,500 readmissions (Hines et al., 2014). Taken together, behavioral health

disorders resulted in $729 million in readmission-related costs among Medicaid

beneficiaries (Hines et al., 2014; Table 3). The total readmission-related costs for the 10

conditions with the most all-cause 30-day readmissions among Medicaid beneficiaries in

2011 is over $2 billion (Table 3). It is clear that behavioral health disorders are

substantial contributors to readmissions and costs among the Medicaid population.

Although behavioral health disorders were not identified as a primary contributor

to readmissions among the Medicare population in the above referenced study, another

study suggests that at least 10% of those over age 65 suffer from clinical depression, a

sub-diagnosis of behavioral health disorders (Mechanic, 2012, p. 377). Furthermore,

nearly 40% of nursing home residents are diagnosed with depression (Abdeljalil et al.,

2019). Both Medicaid and Medicare beneficiaries have been found to experience higher

30-day readmission rates associated with mood disorders (14.4% and 16.0%,

respectively) than privately insured patients or the uninsured (9.1% and 10.4%,

respectively) (Heslin & Weiss, 2015, pg. 7).

Among privately insured patients, mood disorders were the second largest

contributor to all-cause readmission rates, accounting for 19,600 readmissions and $135

million in readmission-related costs (Hines et al., 2014). Readmission-related costs for

the privately insured totaled over $2 billion in 2011 (Hines et al., 2014, Table 4). Based

on these findings, behavioral health disorders have a smaller impact on readmissions and

costs among the privately insured than among Medicaid beneficiaries. However, the fact

17
that mood disorders were the second largest driver of readmissions among this group

suggests that privately insured individuals could benefit from an interdisciplinary

approach to care.

Health Information Technology and Exchange: Development and Definitions

The aforementioned IOM Report, To Err is Human, suggests that 44,000 to

98,000 patients die annually as a result of medical errors (Institute of Medicine, 1999). In

an effort to address this staggering problem, a 2004 Executive Order required progress

toward Electronic Health Records (EHRs) for all Americans. The goal of this initiative

was to eliminate paper health records and adopt information technology to facilitate

better communication of health-related care. David Blumenthal stated, “Information

should follow the patient, and artificial obstacles- technical, business related,

bureaucratic- should not get in the way” (Blumenthal, 2009; Tzeel, Lawnicki, & Pemble,

2011, p. 207). Health IT, such as EHRs, reduces the amount of time healthcare providers

spend searching for data and enables care providers to access patients’ medical history

and to avoid duplication of services (Tzeel et al., 2011). These benefits span the general

and behavioral health populations to contribute to increased quality and lower cost of

care (Tzeel et al., 2011). Furthermore, as healthcare becomes more patient-centered, the

flow of health-related information is crucial for providers and health systems.

Current patient-centered health systems models aim to meet five goals: 1)

individual empowerment; 2) longitudinal composite health record; 3) record accessibility;

4) security and privacy of information and data; and 5) interoperability of records with

shared meaning (Demetriades, 2005). Health researchers have asserted that health IT can

help to meet these goals and yield improvements in healthcare efficiency and

18
effectiveness. Despite the general consensus on this point, care providers have been slow

to embrace the technology (Blumenthal, 2010; Jha et al., 2009). In an effort to address

low rates of health IT adoption and implementation, the Health Information Technology

for Economic and Clinical Health (HITECH) Act was signed into law on February 17,

2009, as part of the American Recovery and Reinvestment Act of 2009 (hhs.gov). The

purpose of the HITECH Act is to encourage adoption and meaningful use of health IT

(hhs.gov). More specifically, the Act aims to make interoperability of EHRs a critical

national goal (cdc.gov). The HITECH Act provides financial incentives for technology

adoption: nearly $30 billion were earmarked as incentives for healthcare providers to

adopt EHRs through the meaningful use program (Gordon & Catalini, 2018). As a result

of HITECH, many states have been able to implement health IT that facilitates the

exchange of medical records between different types of healthcare organizations (Gordon

& Catalini, 2018). As of 2017, the United States had reached $7.1 billion in health IT

investments, thus signifying a growing commitment to improving patient outcomes while

reducing healthcare costs (Wilson & Khansa, 2018).

Health IT is regarded as a necessary component to decrease costs and improve

patient safety and quality of care; furthermore, it is essential for the delivery of integrated

care (Druss & Mauer, 2010; Furukawa, Raghu, Spaulding, & Vinze, 2008). Various

sources define health IT as “the application of information processing involving both

computer hardware and software that deals with the storage, retrieval, sharing, and use of

health care information, data and knowledge for communication and decision making”

(Goldschmidt, 2005; Thompson & Brailer, 2004; healthit.gov). Health IT encompasses a

19
variety of technologies, including electronic prescribing (e-prescribing), EHRs, billing

processes and communication platforms (healthit.gov).

Healthcare Information and Management Systems Society (HIMSS) defines an

EHR as a digital record of patient health information generated by one or more

encounters in any care delivery setting over time (Ghitza, Sparenborg, & Tai, 2011).

Within an EHR system, patient data are securely stored and exchanged between various

care providers (Tai, Boyle, Ghitza, Kaplan, Clark, & Gersing, 2012). EHRs contain

individual patients’ health information, lab results, and treatment plans. These systems

allow care providers to keep track of processes and outcomes of patient care, establish

best practices, and facilitate discovery and innovation in the field of medicine; they also

facilitate the provision of coordinated care (healthit.gov; Tai et al., 2012; Bruns et al.,

2018).

As early as the 1980s, some of the nation’s leading healthcare organizations

demonstrated that EHRs could enhance both the quality and efficiency of care

(Kuperman, 2011). Despite their potential, individual EHR systems could not resolve the

fragmented nature of healthcare service delivery (Blumenthal, 2009; Kuperman, 2011).

Most systems lack in interoperability and therefore do not automatically permit the level

of information exchange that is needed for unobstructed health data exchange (Adler-

Milstein, Bates, & Jha, 2011). Despite the substantial increase in digital health records,

the exchange of health-related information has been delayed, largely due to barriers

related to technology, organizational operations, and privacy concerns (Gordon &

Catalini, 2018).

20
 HIMSS defines interoperability as the ability of different IT systems to

communicate, share data, and make use of the data that have been shared (HIMSS;

Gordon & Catalini, 2018). Ghitza and colleagues (2011) detail three critical elements of

interoperability: 1) the EHR systems enable the electronic collection and storage of

patient data (e.g., medications, allergies, medical history); 2) the systems make the data

available to various types of care providers upon request after applying necessary privacy

and security controls; and 3) the systems facilitate evidence-based decision-making

(Ghitza et al., 2011). Taking these elements into consideration, EHR systems are

considered interoperable when data can be exchanged and presented in a way that the

intended user can easily comprehend (Berryman, Yost, Dunn, & Edwards, 2013; Cothren,

2017). Interoperable systems enable the effective exchange of health information

(Berryman et al., 2013). However, almost two decades later, EHR vendors still struggle

to make systems that are interoperable (Reisman, 2017).

Research indicates that interoperability can yield several benefits, including

improved healthcare quality and efficiency, as well as reduced duplication of clinical

interventions and associated healthcare costs (Holmgren, Patel, & Adler-Milstein, 2017;

Gordon & Catalini, 2018). Interoperability is one of the greatest challenges in the area of

information exchange, but progress is being made (Reisman, 2017). As of 2014, only

24.5% of hospitals in the U.S. were successfully locating, transferring, and integrating

information into the EHRs (Holmgren et al., 2017). One year later, that amount increased

to 29.7% (Holmgren et al., 2017). It is possible that the technology has caught up to the

need and interoperability will increase at a faster pace than 5% annually; however the

barriers extend beyond technical.

21
 In general, there are several barriers to interoperability. These include the

requirement for data sharing agreements, algorithms for patient matching, governance,

and agreed-upon standards and procedures between the various institutions involved in

data exchange (Gordon & Catalini, 2018). Another reason why interoperability is

difficult to achieve is that there is not a standard language that all EHR systems can

comprehend (Wilson & Khansa, 2018), and this challenge is exacerbated when providers

try to include behavioral health data. According to Mr. Paul Brannan, the former health

IT coordinator for the state of Alabama, general and behavioral health systems are

incompatible, in large part because behavioral health systems rely heavily on written,

annotated notes. This statement aligns with the findings of the Holmgren et al. (2017)

study, in which the researchers suggest that healthcare organizations’ primary focus is on

transferring patient information between hospitals and not on ensuring that the

information can be used in clinical decision making (Holmgren et al., 2017).

Madden and colleagues (2016) compared information obtained from an EHR

system to the more complete data that can be obtained from insurance claims (Madden,

Lakoma, Rusinak, Lu, & Soumera, 2016). The researchers focused specifically on

diagnoses, hospital visits, and treatment related to depression and bipolar disorder. The

findings of the study revealed that for patients with depression and bipolar disorder, days

in outpatient behavioral care were missing 60% and 54% of the time, respectively;

furthermore, mental health diagnoses were missing for 27.3% of patients with depression

and for 27.7% of patients with bipolar disorder (Madden et al., 2016). This study

highlights the challenges that EHR systems face in adequately capturing information

related to behavioral health diagnoses and treatment. In a similar vein, Bruns and

22
colleagues (2018) point to the lack of fit between behavioral health information (which

tends to be more narrative or unstructured in nature) and the structured format of EHR

systems (Bruns et al., 2018). Interoperability and the provision of coordinated care

require standard terminology, data structure, and security frameworks so that all of the

necessary data are captured (Cothren, 2017). When data are missing from the patient

record, the likelihood of harm to the patient (e.g., through medication errors) increases

(Madden et al., 2016) and integrated care is halted (Monica, 2017). Essentially, the lack

of interoperability restricts timely information exchange and threatens information

security (Wilson & Khansa, 2018).

Early considerations of the exchange of health-related information focused on

how exchange of patient information within an organization could yield better patient

experience of care (specifically with regard to quality and satisfaction), lower costs, and

improved population health. This triad has come to be known as the Triple Aim

(Berwick, Nolan, & Whittington, 2008; Institute for Healthcare Improvement).

Government agencies and healthcare organizations have looked to health information

exchange as a facilitator to achieving the Triple Aim (Gordon & Catalini, 2018). Health

information exchange (HIE) is defined as “the process of sharing patient-level electronic

health information between different organizations” (Vest & Gamm, 2010, p. 288;

Downing et al., 2016). Organizations that enable the digital exchange of health-related

data are also known as HIEs; they are also referred to as Health Information

Organizations, or HIOs (Callan et al., 2014). For the purposes of this paper, the latter

definition of HIE was employed.

23
 HealthIT.gov identifies three methods of electronic health information exchange.

The first is Directed Exchange, which allows healthcare providers to send and receive

secure health information electronically in order to facilitate coordinated care. Query-

based Exchange allows providers to search for or request specific patient information

from others who provide care for a particular patient. Finally, Consumer Mediated

Exchange enables individual patients to control the exchange and use of their health

information among providers (healthIT.gov). When discussing the enablers of the

exchange of patient information, primarily EHRs, proponents argue that enabling the

effective exchange of patient information between multiple providers could improve

patient safety and quality of care, which could reduce healthcare costs (Kaelber & Bates,

2007; Vest & Gamm, 2010; Hu, Sparenborg, & Tai, 2011; Treku & Xiao, 2018).

Additionally, sharing patient information among multiple providers can prove beneficial

in emergency situations that require prompt diagnosis and treatment (Hu et al., 2011).

Even so, the exchange of patient information becomes more challenging when behavioral

health data are included.

Behavioral health data consist of information regarding mental illnesses and

substance use disorders, both of which are subject to scrutiny and stigma (Tai et al.,

2012). Federal laws have been enacted to ensure confidentiality of patient records that

include information related to substance use, mental health disorders, and sensitive

diagnoses, such as HIV/AIDS. These stringent regulations are often a source of confusion

for healthcare providers. For example, many providers are unsure about whether they are

allowed to exchange behavioral health information and are concerned about the ethical

issues that could arise from doing so (Cothren, 2017). In addition to the ambiguity of

24
these regulations, lack of trust in other providers to ensure the privacy and security of the

information, and difficulties in obtaining patient authorization create barriers to

information sharing between behavioral health and general medical practitioners (Belfort,

Bernstein, & Ingargiola, 2014).

Congress acknowledged that the stigma surrounding substance use and the fear of

prosecution and loss of employment were factors that inhibited treatment-seeking

behavior. As a mechanism to protect people from real or perceived prejudices

surrounding substance use disorders, the secretary of the U.S. Department of Health and

Human Services (HHS) enacted 42 CFR Part 2 in 1987. 42 CFR Part 2, in conjunction

with the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and

Rehabilitation Act of 1970 and the Drug Abuse Prevention, Treatment, and

Rehabilitation Act of 1972, protects the privacy of substance use patients (Health

Information & the Law). Under 42 CFR Part 2, alcohol and substance use programs that

receive federal funding are prohibited from disclosing patient data (e.g., via an HIE) if: 1)

the data would identify the patient as a substance abuser or 2) the data were obtained by a

substance use program for the purposes of treatment, diagnosis, or referral (North

Carolina Department of Information Technology). Providers must obtain written patient

authorization before sharing information regarding treatment, payment, or other

operations related to substance use disorders (Awad, 2013). Regarding the 42 CFR Part 2

regulation, Belfort and colleagues (2014) state the following: “While the Part 2

regulations are stringent, they are not applicable to general medical providers who deliver

a mix of substance abuse and other health care services.” (p. 3). 42 CFR Part 2, as stated

above, applies only to alcohol and drug use programs that receive federal assistance

25
(Belfort et al., 2014). However, federal assistance is broadly defined, and it includes

Medicare and Medicaid, grants, and tax-exempt status (Belfort et al., 2014). Given the

lack of clarity about the exchange of such sensitive information, it is understandable that

healthcare providers are hesitant to exchange this data.

Mental health data related to patients’ medications, treatment plans, and clinical

test results are treated as protected health information and are generally protected under

the Privacy Rule (hhs.gov; North Carolina Department of Information Technology). This

information is excluded from the 42 CFR Part 2 regulation. Disclosure of this information

is permitted for the purposes of treatment and care management activities; in these

scenarios, the Health Insurance Portability and Accountability Act (HIPAA) does not

impede information exchange between behavioral health and general medical care

providers (Belfort et al., 2014).

Psychotherapy notes, on the other hand, contain sensitive information that the

patient has chosen to share with a trusted mental health professional. When sensitive

information is disclosed improperly, there is an increased risk for potential discrimination

and stigma (Saks, Grando, Murcko, & Millea, 2018). As such, psychotherapy notes are

kept separate from the rest of the patient’s medical record, and unless there is a threat of

immediate harm or abuse, patient authorization is required before these notes can be

disclosed for treatment purposes to any healthcare provider other than the therapist who

took the notes (hhs.gov; 45 CFR 164.508(a)(2)). These regulations complicate the sharing

of behavioral health information and create an environment where the coordination

between behavioral health and general medical care is at risk because providers are

reluctant to share data freely for fear of violating health information privacy laws (Belfort

26
et al., 2014). It is worth noting that even when consent for information exchange has been

obtained, behavioral health, substance abuse, and sensitive diagnoses information

requires an authorization. Differing from a consent, which provides global permission, an

authorization provides time-limited and specific permission (i.e. data may be exchanged

with a specific person and during a specified period of time).

The current push for integrated care delivery has provided an impetus to modify

existing regulations surrounding behavioral health information exchange. While many

stakeholders in the behavioral and general health arenas are concerned that relaxing

existing standards could have adverse effects (e.g., discrimination in housing,

employment, education, and other settings, as well as possible HIPAA violations), others

have argued that the 42 CFR Part 2 regulation impedes both integrated care delivery and

research (Office of the Federal Register). On March 21, 2017, the updated 42 CFR Part 2

regulation went into effect. This final rule was enacted to enable patients with substance

use disorders to engaged in and benefit from health system delivery improvements, such

as integrated care models, while protecting patient privacy (Office of the Federal

Register).

Additionally, SAMHSA issued a supplemental notice of proposed rulemaking

(SNPRM) on January 18, 2017. The notice proposed further changes that would facilitate

the disclosure of behavioral health information for the purposes of payment and

operations (Office of the Federal Register). During this time, initiatives to improve

behavioral health data exchange took place at both the state and federal levels (Monica,

2017). In January 2018, SAMHSA implemented the new changes via a final rule.

Reducing the barriers to information sharing could be a necessary step in alleviating the

27
burden that care providers face with regard to the increase in health-related information

that can be exchanged (Snell, 2018).

In June 2018, the House of Representatives passed the Overdose Prevention and

Patient Safety (OPPS) Act (H.R. 6082), which was designed to update 42 CFR Part 2 to

align with HIPAA (Raths, 2018; Rosenthal, 2018). One of the central goals of the Act is

to allow care providers to have appropriate access to patients’ entire medical record,

including information related to substance use disorders (Raths, 2018: 1). Under the

OPPS Act, disclosure of information related to substance use diagnoses and treatment

would still be prohibited outside of the healthcare system; there would also be stronger

provisions against the use of substance use treatment records in criminal proceedings

(Rosenthal, 2018). In other words, the goal of the new legislation is not to prosecute or to

increase stigmatization of patients who seek treatment for a substance use disorder.

Instead, the goal is to improve access to quality care while safeguarding against

stigmatization (Rosenthal, 2018). Representatives who supported the update to the

existing 42 CFR Part 2 regulation emphasized the importance of having a complete

picture of a patient’s medical history in order to deliver effective care (Raths, 2018).

Furthermore, they argued that without this update, the Part 2 regulation acts as one of the

most significant barriers to treating substance use disorders (Raths, 2018). Organizations

such as the American Society of Addiction Medicine and the American Psychiatric

Association (APA) are in support of relaxing the 42 CFR Part 2 regulation, posting that

doing so can improve patient outcomes (Rosenthal, 2018). The APA stated that relaxing

the regulation “will ensure that patients are not harmed due to a provider not receiving

28
some medical information” and will facilitate in the provision of coordinated care

(Knopf, 2018, pg. 3).

Relaxation of 42 CFR Part 2 has been met with some opposition and concern.

Patients, particularly those who are seeking treatment for a substance use disorder, fear

that allowing their behavioral health data to be shared could result in discrimination,

persecution, and loss of employment (Tai et al., 2012; Lardiere, 2013; Knopf, 2018;

Woods, 2018). Methadone patients, for example, have expressed concerns about the

changes in the 42 CFR Part 2 regulations: most are willing to share the fact that they are

seeking treatment for opioid addiction with a trusted physician, but they are hesitant to

have this information included in digital patient records (Knopf, 2018). Patients seeking

treatment for a substance use disorder want to be able to determine who has access to this

sensitive information (Knopf, 2018). Additionally, a number of grassroots organizations

that focus on substance use recovery have voiced opposition against the new legislation

(Rosenthal, 2018). A program director of a substance use treatment center in Georgia

argued that the proposed changes to 42 CFR Part 2 could discourage patients, both

current and prospective, from seeking treatment, and many will relapse and die (Knopf,

2018). In response to these regulatory changes, Jocelyn Woods, the executive director of

the National Alliance for Medication Assisted Recovery (NAMA Recovery) argued,

“Eliminating Part 2 in the middle of an opioid epidemic because sharing [health]

information is difficult is reckless, especially when the impact is unknown.” (Woods,

2018, pg. 2).

In addition to these tensions, behavioral health care providers have also identified

potential barriers and challenges associated with sharing behavioral health data, including

29
additional costs and time burdens, access and vulnerability issues, and reduced workflow

and control (Shank, 2011). For these reasons, behavioral health organizations have

typically been excluded from the meaningful use incentive program, and in many cases, a

vital portion of the patient’s medical history is missing (Lardiere, 2013; Bruns et al.,

2018). Despite these numerous challenges, researchers have found evidence to suggest

that a majority of patients support the sharing of behavioral health information (Kozubal

et al., 2013).

Improving Care for Behavioral Health Patients with Chronic Comorbid Conditions:
Opportunities and Challenges

Patients with a behavioral health diagnosis along with chronic comorbid

conditions present several challenges to healthcare providers. It is a well-established

premise in the medical community that even common mental health disorders, such as

depression and anxiety, complicate the treatment of general health disorders (DiMatteo,

Lepper, & Croghan, 2000). Medication adherence is low among patients with psychiatric

disorders, particularly those with more severe diagnoses (e.g., schizophrenia) (Kane,

Kishimoto, & Correll, 2013, Table 3). A meta-analysis (DiMatteo et al., 2000) revealed

that patients diagnosed with depression have greater odds (OR= 3.03) of non-adherence

than patients who do not have depression. Furthermore, the odds of non-adherence

among patients with depression did not differ significantly by medical condition: for

example, non-adherence to treatment for end-stage renal failure was not significantly

different from non-adherence to treatment for general medical care (DiMatteo et al.,

2000). Noncompliance results in suboptimal treatment outcomes (Morisky, Green, &

Levine, 1986; DiMatteo et al., 2000).

30
 Additionally, patients with mental illnesses (especially severe mental illness) are

generally poor historians with regards to their health. Altered self-awareness has been

found to be one of the key symptoms of schizophrenia: hallucinations, delusional

thoughts, and under-awareness are common among this group (Frith, 1979; Frith, 2014;

Bedford & David, 2014). Patients with a diagnosis of schizophrenia demonstrated an

impaired ability to remember information related to their mental health (Bedford &

David, 2014). Relying on these patients to recount information related to their health

history (e.g., diagnoses, prescriptions, treatment plans) could lead to worse outcomes.

Battersby and colleagues (2018) acknowledged that, in part because of the fragmentation

between the general medical and behavioral health treatment sectors, it is difficult to

improve the physical health of patients with severe mental illnesses (Battersby et al.,

2018).

These challenges provide an opportunity to explore mechanisms to improve care

for patients with co-occurring behavioral health problems and chronic illnesses.

CurrentCare, the statewide HIE for Rhode Island, became the first in the nation to include

behavioral health and substance use treatment information in data exchange, thus

reaching a significant milestone in healthcare (Bresnick, 2013). Laura Adams, president

and CEO of the Rhode Island Quality Institute (RIQI) stated the following: “For the first

time, behavioral health and substance abuse data are integrated, enabling care of the

whole person, and bringing providers together in the service of this goal” (Bresnick,

2013). Various studies have demonstrated that permitting the exchange of patient

information between different providers can improve outcomes. In general, it has been

found to be associated with lower odds of hospital readmission and substantial cost

31
savings (Kozubal et al., 2013; Ben-Assuli, Shabtai, Leshno, & Hill, 2014; Vest, Kern,

Silver, & Kaushal, 2014).

Kozubal and colleagues (2013) examined the effect of accessible psychiatric

records on patient care outcomes. Specifically, the aim of the study was to determine

whether making patients’ psychiatric records accessible to non-psychiatric physicians

would improve coordination of care and subsequent outcomes. Kozubal et al. (2013)

suggests that the use of a full EHR system that allowed unrestricted access of non-

psychiatric physicians to behavioral health records was associated with a 31% to 39%

reduction in hospital readmission rates in a sample of 18 high-performing U.S. hospitals.

This particular study was limited by its small sample size; however, the findings indicate

that the relationship between access to behavioral health information and hospital

readmission rates is worthy of expanding the definition of access to behavioral health

information and conducting further empirical studies.

Cifuentes and colleagues (2015) observed the experiences of practices (eight

primary care practices and three community mental health centers, or CMHCs) that

aimed to integrate behavioral health and primary care between 2012 and 2014. The

practices participated in the Advancing Care Together (ACT) initiative, which adopts

appropriate, evidence-based strategies to provide a full continuum of care to patients

suffering from behavioral health disorders. In this particular study, the researchers

examined the role of EHR systems and considered challenges, workarounds, and

solutions that emerged as a result of health IT utilization. The practices faced three

common challenges: 1) the EHR systems could not properly track certain types of

behavioral health data (e.g., patient health questionnaire, psychotherapy notes); 2) the

32
systems could not facilitate cooperation among multidisciplinary teams; and 3) the

systems could not share information with other types of technology, such as tablets.

In response to these challenges, the practices instituted four EHR workarounds: 1)

double documentation and duplicate data entry; 2) scanning and transporting documents;

3) reliance on patient or clinician recall for inaccessible information; and 4) use of

freestanding tracking systems (Cifuentes et al., 2015). However, these workarounds

generated a number of issues, including delays, a need for additional resources (e.g., staff

and time), and inaccurate or incomplete information. A more recent study (Bruns et al.,

2018) also referenced potential barriers to behavioral health information exchange: these

included time and effort to train practitioners and implement the necessary technology;

lack of technical support; lack of enthusiasm to participate in behavioral health

information exchange; and financial barriers (Bruns et al., 2018).

To respond to the barriers to the effective exchange of behavioral health

information, the practices who participated in the Cifuentes et al. (2015) study developed

the following solutions: 1) create new data fields to capture behavioral health data; 2)

upgrade EHR systems so that both behavioral health and general medical information

could be tracked properly, and 3) transition to a unified EHR system that would enable

providers to document behavioral health and general medical information (Cifuentes et

al., 2015). The solutions improved care coordination efforts.

The extant research on behavioral health information exchange is sparse. Much of

the available literature addresses the rate of adoption of EHR systems within behavioral

health practices and barriers to use this technology (Bruns et al., 2018). Research

indicates that EHR systems could help primary care and behavioral health care providers

33
to provide seamless, coordinated care to their patients, but there is little research that

focuses on the impact of these systems on practice, process, and patient outcomes (Bruns

et al., 2018).

Conceptual Framework: Guiding Theories

The following sections will examine the theories that comprise the conceptual

model for this study. The unified theory of acceptance and use of technology, diffusion of

innovation theory, and Reed’s Law of group-forming networks were employed.

Unified Theory of Technology Acceptance and Use

The unified theory of acceptance and use of technology (UTAUT) is applied in

the research literature to examine how technologies become widely adopted. To develop

the theory, Venkatesh, Morris, Davis, and Davis (2003) integrated constructs from eight

earlier information technology/information science (IT/IS) theories: theory of reasoned

action; technology acceptance model; motivational model; theory of planned behavior;

diffusion of innovation theory; social cognitive theory; model of personal computer use;

and a combined model of theory of planned behavior/technology acceptance model

(Khechine, Lakhal, & Ndjambou, 2016). UTAUT advances earlier models by integrating

constructs related to IT adoption from each of the eight theories. Like the earlier theories,

UTAUT is designed to gauge individuals’ intentions (behavioral intention) to use a

technology or system and subsequent technological use (use behavior) (Dwivedi, Rana,

Chen, & Williams, 2011). Researchers have found that UTAUT explains nearly 70% of

the variance related to behavioral intention and use behavior, whereas previous models

explained only 40% of the variance related to technology acceptance and utilization

(Kijsanayotin, Pannarunothai, & Speedie, 2009). For this reason, UTAUT is often

34
considered “the best predictive model in the [technology] acceptance literature”

(Alawadhi & Morris, 2008; Al-Shafi & Weerakkody, 2010; Khechine et al., 2016, p.

138).

UTAUT attributes behavioral intention and subsequent use of technology to four

primary constructs: 1) performance expectancy, 2) effort expectancy, 3) social influence,

and 4) facilitating conditions (Dwivedi et al., 2011). The original UTAUT model is

provided below (Figure 1). Performance expectancy refers to how individuals perceive

the ability of the technology to assist them in meeting goals related to job performance

(Venkatesh et al., 2003: 447; Khechine et al., 2016). Performance expectancy consists of

five components: perceived usefulness (Davis, 1989); extrinsic motivation (Davis,

Bagozzi, & Warshaw, 1992); job-fit (Thompson, Higgins, & Howell, 1994); relative

advantage (Venkatesh et al., 2003); and outcome expectations (Compeau, Higgins, &

Huff, 1999). Performance expectancy has been found to be the strongest predictor of

intention to use technology when considering both voluntary and mandatory adoption

(Toh, 2013; Venkatesh et al., 2003).

Effort expectancy examines the ease of use that is associated with a particular

technology. While its predictive power is not as strong as that of performance

expectancy, effort expectancy is a significant predictor of intention to use (Khechine et

al., 2016; Toh, 2013; Venkatesh et al., 2003). The research literature identifies three

components of effort expectancy: perceived ease of use (Davis et al., 1992; Toh, 2013);

complexity (Thompson et al., 1994; Toh, 2013); and ease of use (Moore & Benbasat,

1991; Toh, 2013). Social influence relates to an individual’s perception that important

figures (e.g., supervisors, colleagues) believe that he or she should accept and use

35
technology. Although it has been found to be a weak indicator, social influence can

predict behavioral intention with regard to IT adoption (Toh, 2013). Finally, facilitating

conditions relate to the idea that the necessary infrastructure is in place to support

technology use (Khechine et al., 2016; Venkatesh et al., 2003).

Figure 1: Original UTAUT model (Venkatesh et al., 2003)

Extensions of the UTAUT model examine trust and perceived risk as dimensions

of adoption. An extended UTAUT model is depicted in Figure 2. Trust is of particular

importance when electronic transactions are involved, as potential threats (e.g., lack of

control and uncertainty) are present (Bhattacherjee, 2002). Hertzum and colleagues

(2002) state that trust is a factor whenever information is shared (Hertzum, Andersen,

Andersen, & Hansen, 2002). Mayer and colleagues (1995) offer the following definition

of trust: “willingness of a party to be vulnerable to the actions of another party based on

the expectation that the other will perform a particular action important to the trustor,

irrespective of the ability to monitor or control that other party” (Mayer, Davis, &

36
Schoorman, 1995, p. 712). A recent study (Nguyen & Minh, 2018) defined trust as a

sense of security and willingness to rely on a provided service or information.

Historically, trust has received little attention in the research literature. However, trust is

increasingly important, especially as the Internet becomes a primary mechanism for

obtaining information (Kelton, Fleischmann, & Wallace, 2008).

The concept of trust has been examined on four levels in the extant literature: 1)

individual, in which trust is a personality trait; 2) interpersonal, in which trust acts as a

social tie between two actors; 3) relational, in which trust emerges as a result of repeated

interactions between actors over time; and 4) societal, in which trust is a functional

feature of a community (Kelton et al., 2008, 364, Table 1). These conceptualizations of

trust involve human actors. However, researchers suggest that trust can exist within

human-technology interactions (Kelton et al., 2008; Cassell & Bickmore, 2000; Friedman

& Millett, 1997; Kiesler & Sproull, 1997; Nass, Moon, Morkes, Kim & Fogg, 1997).

Klobas (1995) proposes that the user’s attitude toward the information (e.g., whether the

user trusts the source or not) moderates the relationship between information quality and

information use (Kelton et al., 2008).

Hertzum and colleagues (2002) find empirical evidence to support the importance

of trust in digital information. The researchers observed and analyzed project meetings

held by a team of software engineers. For the project (developing a system to facilitate

handling child support and alimony cases), the team would have to interact with several

internal and external stakeholders. Considering the diverse backgrounds of the

stakeholders (e.g., government employees, management, marketing), it can be expected

that trust would be essential to collaboration. In the context of online shopping, trust has

37
been shown to mediate online purchase intention (Chen and Barnes, 2007; Nguyen &

Minh, 2018).

Perceived risk emerges when individuals experience anxiety or uncertainty

surrounding the use of a new technology (Mandrik & Bao, 2005; Slade et al, 2015).

Perceived risk is frequently examined as an extension of the UTAUT model (Williams et

al., 2011; Slade et al., 2015). The findings regarding the impact of perceived risk on

behavioral intention have been mixed in the research. However, a recent study (Liebana-

Cabanillas et al., 2014) reported a statistically significant negative relationship between

perceived risk and subsequent behavioral intention.

UTAUT has been applied in the health services research literature to examine

physician acceptance of a clinical decision support system (Chang, Hwang, Hung, & Li,

2007); acceptance of EHRs among various healthcare professionals (Wills, El-Gayar, &

Bennett, 2008); and acceptance of health IT within community health centers in Thailand

(Kijsanayotin et al., 2009). The model has demonstrated its relevance to health IT: it

explained anywhere from 43% to 54% of behavioral intention (intention to use

technology) and anywhere from 27% to 28% of use behavior (Chang et al., 2007;

Kijsanayotin et al., 2009; Wills et al., 2008). UTAUT is selected for this study because it

integrates validated constructs from earlier theories to provide a comprehensive

examination of factors that can enhance or impede intention to use technology and

subsequent use behavior. As mentioned, this model explains almost 70% of the variation

in behavioral intention and use behavior, while its predecessors only explain 40% of the

variation. However, there are likely other factors that affect behavioral intention and use

behavior that UTAUT fails to capture. The facilitating conditions construct, for example,

38
is a broad, general category that likely will not generate meaningful findings for the

purposes of this particular study. However, earlier models might facilitate a closer

examination of factors that are not made apparent in UTAUT. Thus, the diffusion of

innovation theory was considered.

39
Figure 2: Extended UTAUT model (Venkatesh et al., 2003; Slade et al., 2015)

Diffusion of Innovation

Diffusion of innovation theory considers factors that influence the way

information is communicated to multiple stakeholders over time. Diffusion refers to the

process of communicating an innovation to members within a social system: it is a

particular way to develop and spread information to multiple parties in order to come to a

shared understanding (Rogers, 1995; Rogers, 2002). An innovation is defined as “an idea,

practice, or object perceived as new by an individual or other unit of adoption” (Rogers,

2002, p. 990). The literature identifies five determinants of rate of adoption for an

innovation: 1) relative advantage; 2) compatibility; 3) complexity; 4) trialability; and 5)

observability. For the purposes of this study, the researcher examined the five

determinants of integration and how they relate to innovation adoption and diffusion

(Figure 3).

40
 An innovation provides a relative advantage if individuals perceive it as a better

approach to a problem than its predecessor (Rogers, 2002). Relative advantage is a

subcomponent of the performance expectancy construct in UTAUT. Compatibility refers

to the degree to which the innovation aligns with various norms (Rogers, 2002).

Complexity encompasses individuals’ perceptions about how difficult the innovation is to

understand and use: this factor most closely relates to the effort expectancy component of

the UTAUT model. Trialability is defined as the degree to which individuals can

experiment with the innovation prior to adoption. Finally, observability refers to how

visible the results of the innovation are to others. Rogers (2002) proposes that innovations

believed to provide greater relative advantage, compatibility, trialability, observability,

and less complexity will be adopted more quickly than other innovations.

Like UTAUT, diffusion of innovation theory provides a framework to examine

factors that affect the adoption of a new technology. As stated earlier, UTAUT is the

strongest predictive model in the technology acceptance literature (Khechine et al.,

2016); as such, diffusion of innovation is not the primary framework for this study.

However, one of the advantages of diffusion of innovation theory is that it explicitly

considers the influence of trialability before adoption. This is an important consideration,

especially in the context of behavioral health data exchange. Sharing patients’ behavioral

health information via an HIE is in the nascent stages, and a pilot test of this kind of data

exchange might be beneficial to healthcare providers. Using an integrated conceptual

model will allow us to test the influence of trialability.

41
Figure 3: Diffusion of Innovation. Five determinants of integration that influence rate of
adoption (Rogers, 1983)

Reed’s Law of Group-Forming Networks

Merriam-Webster defines a network as “an interconnected or interrelated chain,

group, or system” (merriam-webster.com). A second definition is: “a usually informally

interconnected group or association of persons (such as friends or professional

colleagues)” (merriam-webster.com). Christine Heckart (2016) states the following

regarding the importance of networks: “Networks are now at the center of everything.

They are the foundation of our modern economy. They underlie every business, city,

government agency, covert organization, and teen social circle. Physical, virtual, and

42
social networks are central to how work gets done, information is communicated,

relationships are made and maintained, and funds are transferred.”

Reed’s Law of group-forming networks (GFN) proposes a way to determine

network value. According to Reed’s law, networks gain value when people are able to

form subgroups easily. These subgroups facilitate collaboration and information sharing

(Heckart, 2016). David P. Reed, who proposed the ideas behind GFN, argues that the

number of groups that can be formed via the Internet far surpasses the numbers proposed

by two earlier laws: Sarnoff’s Law (network value grows in proportion to the number of

users) and Metcalfe’s Law (network value grows in proportion to the square of the

number of users). Instead, Reed proposes that once all of the possible two- or three-party

groups have been taken into account, the value of the network grows in proportion to 2n

(Moore, 2006). A depiction of Reed’s Law is provided in Figure 4.

Reed suggests that while all three laws (Sarnoff’s, Metcalfe’s, and Reed’s) can be

applied to the Internet, Reed’s Law is most relevant to services that are established to

build communities, such as AOL. As such, the goal of Reed’s Law is to create

communities in which group-formation, collaboration, and information sharing are

possible (Jung & Lee, 2011). This idea has been applied specifically to the healthcare

context: the use of groups and teams and healthcare can facilitate the shift toward disease

management (Moore, 2006). Chronically ill patients are some of the most difficult and

costly to treat; behavioral health comorbidities further exacerbate this problem.

Collaborative networks, such as those described in Reed’s Law, could serve as a

mechanism to provide better, less expensive care to this demographic.

43
Figure 4. A depiction of Reed’s Law and the increase in network value.

Conceptual Model

As derived from the literature, the model in Figure 5 guided this study. The initial

quantitative phase tested the conceptual model to examine the factors that influence use

of behavioral health information from an HIE. The subsequent qualitative phase provided

an in-depth understanding of the facilitators and barriers identified in the conceptual

model and explored any additional factors that were not captured in the model.

UTAUT has been applied in the health services research literature, and it is a

useful framework for this study because it integrates multiple constructs from earlier

information technology theories to predict behavioral intention. The trialability construct

from the Rogers’ diffusion of innovation theory was added to the conceptual framework

to examine benefits (real or perceived) that could have come from participating in a pilot

test on behavioral health information exchange. Finally, Reed’s Law of group-forming

networks highlights the importance of creating of subgroups to facilitate collaboration

44
and information sharing, particularly in the context of chronic disease management. None

of the studies on behavioral health information exchange has applied a conceptual

framework considering all of these constructs, making this study the first to do so.

Figure 5: Conceptual model that was tested in this study. The constructs were derived
from the UTAUT and diffusion of innovation theories.

Summary

A review of the literature examines the prevalence of chronic medical illnesses

and behavioral health comorbidities, and it details the costs associated with 30-day

hospital readmissions for chronically ill patients with behavioral health comorbidities.

This chapter also examined health information technology (specifically, HIEs) as a

mechanism to facilitate information exchange between general medical and behavioral

health service providers and to reduce readmissions for this subset of patients. It also

45
considers the numerous barriers that make behavioral health information exchange

particularly difficult, including strict regulations and workflow disruptions. Although the

literature on behavioral health information exchange is sparse, there is evidence to

suggest that including behavioral health information in patients’ digital records could

lower readmission rates. However, there are no studies that integrate quantitative and

qualitative research approaches to consider factors that facilitate and impede the

exchange of behavioral health information from the providers’ perspectives.

46
 CHAPTER 3

METHODS

This chapter begins with an overview of the two study sites that were selected for

participation. Afterward, this chapter defines mixed methods research and provides

justification for using a mixed methods approach to collect and analyze data from the

study sites. The mixed methods design selected for the study is described in detail. Data

collection and analysis for the quantitative and qualitative phases of the study are

discussed, as well as the process for integrating the findings from the two phases.

Methods of quality assurance for the two phases of the study and the integration of the

results are addressed. Finally, ethical considerations for the study are discussed.

Study Sites: Overview

This study will examine the impact of behavioral health information exchange

using two HIEs: Patient Bridge (Alabama) and Coordinated Care Health Network, or

CCHN (Oklahoma). These sites were selected for participation in the study because they

have begun to make progress on using HIEs to exchange patients’ behavioral health

information in order to offer coordinated care. The following paragraphs provide

information about each of the study sites.

Study Site #1: Patient Bridge (Alabama)

Patient Bridge is an HIE that gives healthcare providers access to “an aggregated

patient care document complete with medication lists, lab results, and discharge

summaries” in an effort to ensure the provision of efficient, appropriate care for the

patient (Baptist Health). It was introduced as a hospital initiative in 2015, and it became

47
an independent organization on July 1, 2017. Approximately 350,000 patient records are

contained in Patient Bridge. All EHR users within the three-hospital Baptist Health

System (Baptist Medical Center South, Baptist Medical Center East, and Prattville

Baptist Hospital) have access to the HIE and exchange patient records via Patient Bridge.

Patient Bridge uses a query and retrieve model of data exchange, which enables

healthcare providers to request or search for specific pieces of health-related information

from other providers who treat the patient.

Study Site #2: Coordinated Care Health Network (CCHN), Oklahoma

CCHN is a private company that was established by Yeaman and Associates in

June 2016. CCHN serves as “a purpose-driven network offering health information

exchange and other population health management services to support the efficient and

secure sharing and delivery of patient information among diverse health care providers

for treatment at the point of care” (Coordinated Care Health Network). Approximately

6.8 million patient records are contained in the HIE, and 304 facilities access and utilize

CCHN, including St. Anthony Hospital and Duncan Regional Hospital. Similar to Patient

Bridge, CCHN uses a query and retrieve model of data exchange.

Research Approach

Defining Mixed Methods Research

Mixed methods research involves the integration of quantitative and qualitative

research approaches to answer a series of research questions (Plano Clark & Ivankova,

2016). Johnson and colleagues (2007) provide the following definition of mixed methods:

“Mixed methods research is the type of research in which a researcher or

team of researchers combines elements of qualitative and quantitative
research approaches (e.g., use of qualitative and quantitative viewpoints,

48
 data collection, analysis, inference techniques) for the broad purposes of
breadth and depth of understanding and corroboration.” (p. 108).

Mixed methods research approaches have several advantages. These approaches enable

the researcher to add meaning to numerical trends through the use of words, pictures, and

narratives (Caruth, 2013). Likewise, mixed methods approaches allow the researcher to

add precision to qualitative data through the use of numbers. Mixed methods approaches

also offer the opportunity to draw more robust conclusions; enhance the validity of the

findings; and add insight that could be missed when a single method is used (Caruth,

2013; Cronholm & Hjalmarsson, 2011; Hansen, O’Brien, Meckler, Chang, & Guise,

2016; Venkatesh, Brown, & Sullivan, 2016). However, there are also challenges

associated with mixed methods research approaches. These studies can be difficult for a

single researcher to conduct, as the researcher is required to be familiar with both

quantitative and qualitative methods. Furthermore, mixed methods studies are typically

more time-consuming and costly to conduct (Caruth, 2013; Cronholm & Hjalmarsson,

2011).

Despite these challenges, a mixed methods approach was deemed appropriate for

this study. Mixed methods approaches are appropriate to use when the researcher seeks to

answer questions that a single quantitative or qualitative approach cannot adequately

address (Shorten & Smith, 2017). Given the novelty and complexity of this research

topic, as well as the limited availability of quantitative data, incorporating a qualitative

component to the study serves to capture pertinent details that a quantitative study alone

might overlook. The conceptual framework that was developed for this study did not

capture all of the facilitators of and barriers to behavioral health information exchange

49
(e.g., legal and regulatory barriers). Furthermore, some of the facilitators and barriers that

are identified in the quantitative phase of the study benefited from further explanation,

which is provided through the use of qualitative methods.

Purposes of Mixed Methods Research

It is the responsibility of the researcher to justify why a mixed methods approach

is appropriate for a particular study (Plano Clark & Ivankova, 2016). A mixed methods

approach can serve a number of different purposes. The first purpose for mixed methods

is to allow the researcher to gain a better understanding of the research problem in

question by combining quantitative and qualitative approaches (Plano Clark & Ivankova,

2016; Bryman, 2006; Johnson & Onwuegbuzie, 2004; Reinhardt & Cook, 1979). Johnson

and Onwuegbuzie (2004) offer the following explanation for a mixed methods approach:

“The goal of mixed methods research is not to replace [quantitative or qualitative]

approaches but rather to draw from the strengths and minimize the weaknesses of both in

single research studies and across studies” (p. 14-15).

A second purpose of mixed methods research is to draw more valid conclusions

by comparing the results obtained from the quantitative and qualitative phases of the

study (Creswell, 2003; Halcomb & Hickman, 2016; Plano Clark & Ivankova, 2016).

When analyzing the two sets of results together, the researcher can look for convergence

(similarities in the qualitative and quantitative results) and divergence (differences in the

two sets of results) (Plano Clark & Ivankova, 2016; Venkatesh, Brown, & Sullivan,

2016). A third purpose of mixed methods is to draw more complete conclusions by using

both quantitative and qualitative methods to obtain complementary results about different

aspects of the research problem or question (Greene, Caracelli, & Graham, 1989; Plano

50
Clark & Ivankova, 2016). An example of using a mixed methods approach for this

purpose involves adopting quantitative methods to examine trends that emerge and

adopting qualitative methods to provide additional details about those trends (Plano Clark

& Ivankova, 2016; Venkatesh et al., 2016).

A fourth purpose of adopting a mixed methods approach is to use the results of

one method (either quantitative or qualitative) to guide the use of the other method,

thereby enabling the researcher to draw better, more refined conclusions (Greene et al.,

1989; Plano Clark & Ivankova, 2016). For example, the results of a quantitative survey

are used to develop interview questions for the qualitative strand of the study, and the

researcher selects a purposive sample of the survey respondents to complete the

secondary qualitative interview (Greene et al., 1989; Collins & O’Cathain, 2009;

Halcomb & Hickman, 2016). Finally, the social justice rationale is given when a mixed

methods approach is used to challenge unfair policies and practices (Plano Clark &

Ivankova, 2016). For this study, a mixed methods approach was selected: 1) to obtain a

better understanding of the research problem; 2) to draw more valid conclusions by

comparing quantitative and qualitative results; and 3) to achieve complementarity. The

qualitative phase of the current study enabled participants to elaborate on the trends that

emerged in the initial quantitative phase, and the quantitative and qualitative results were

compared via a joint display to look for convergence and divergence. Adopting a mixed

methods approach provided a richer, more complete understanding of the facilitators of

and barriers to behavioral health information exchange via an HIE.

51
Philosophical Assumptions

Scholars opine that empirical research should discuss the paradigm used to frame

the posed research questions (Shannon-Baker, 2016; Creswell & Plano Clark, 2018).

Paradigms are conceptualized as individual practices and beliefs that impact the manner

in which researchers choose their research questions and the methods they will employ to

answer them (Morgan, 2007). Postpositivism, constructivism, and pragmatism are some

of the primary research paradigms. Postpositivism and its predecessor, positivism, are

typically associated with quantitative research, while constructivism is often associated

with qualitative research (Hall, 2012). A third paradigm, pragmatism, places emphasis on

the research problem, and it promotes the use of mixed methods to answer the posed

research questions (Teddlie & Tashakkori, 2009; Halcomb & Hickman, 2016).

Additional paradigms that have been reported compatible with mixed methods research

include interpretivism, transformative, dialectical pluralism, and critical realism (Cohen

& Manion, 1994; Maxwell & Mittapalli, 2010; Hall, 2012; Thanh & Thanh, 2015; Plano

Clark & Ivankova, 2016; Johnson, 2017).

For the purposes of this research, a critical realism perspective was adopted

(Maxwell & Mittapalli, 2010; Johnson, 2017). The critical realism paradigm does not aim

to identify generalizable laws like positivism, nor does it aim to highlight the personal

experiences and beliefs of individuals like interpretivism (McEvoy & Richards, 2006).

Rather, under critical realism, the main objective of research is to learn about individuals’

perceptions of events that they have observed or experienced and to understand how

those events occur (Volkoff, Strong, & Elmes, 2007; Zachariadis, Scott, & Barrett, 2013).

From this perspective, the goal of the researcher is to better understand and explain the

52
phenomenon at hand (McEvoy & Richards, 2006). This study examines the phenomenon

of behavioral health information exchange via HIEs; identifies factors that facilitate and

impede the exchange of this kind of information; and explores additional factors that

could impact the exchange of this information. The aims of this study most closely align

with a critical realism perspective.

Mixed Methods Research Design

The primary aims of the study were: 1) to examine facilitators of and barriers to

the exchange of behavioral health information via an HIE; 2) to explore the identified

facilitators and barriers in greater detail. To accomplish these aims in the proposed order,

a sequential explanatory mixed methods study design was employed (Creswell & Plano

Clark, 2018; Schoonenboom & Johnson, 2017). The initial quantitative phase was

conducted to identify the facilitators and barriers that predict intention to use behavioral

health information obtained from the HIEs. The secondary aim of the study is to explore

those facilitators and barriers in greater depth. To achieve both of these aims, this study

adopted a sequential explanatory mixed methods design to identify factors that influence

the use of behavioral health information obtained from an HIE among healthcare

providers in Alabama and Oklahoma.

When a sequential explanatory mixed methods design is selected, the quantitative

and qualitative phases of the study are completed in a progressive manner. The order in

which each phase of the study is completed is determined by the overall research

objective and research questions (Teddlie & Tashakkori, 2009). To reiterate, the aims of

the current study were to examine facilitators of and barriers to behavioral health

information exchange via an HIE and to explore those factors in greater detail. In a

53
sequential explanatory mixed methods design, the first phase is comprised of quantitative

data collection and analysis. A validated survey instrument was used to collect data on

perceived facilitators of and barriers to the exchange of behavioral health information via

an HIE. The survey instrument is described in more detail later in Chapter 3.

Subsequently, qualitative data are collected and analyzed in order to provide an in-depth

explanation of the quantitative results (Plano Clark & Ivankova, 2016; Schoonenboom &

Johnson, 2017). As such, semi-structured interviews were employed to explore the

facilitators and barriers identified in the quantitative phase of the study, as well as to

uncover any additional factors that were not included in the conceptual model.

In a sequential explanatory mixed methods design, the subsequent qualitative

phase enables the researcher to provide a more thorough explanation of the quantitative

results through a closer exploration of subjects’ perspectives (Ivankova, Creswell, &

Stick,., 2006; Subedi, 2016). The initial quantitative phase provides a broad

understanding of the problem, as it allows the researcher to identify trends within the data

(Ivankova et al., 2006; Subedi, 2016). The sequential explanatory mixed methods design

is appropriate when the researcher is trying to explain unexpected findings from the

quantitative phase, such as outliers or exemplary cases (Creswell & Plano Clark, 2018).

The exchange of patients’ behavioral health information presents a different set of

challenges and obstacles than the exchange of general health information; as such,

unexpected results that were not captured in the conceptual model emerged in the

qualitative interviews. The sequential explanatory mixed methods design is considered a

more straightforward design, which makes it easier for a single researcher to implement

(Doyle, Brady, & Byrne, 2009; Plano Clark & Ivankova, 2016).

54
A diagram of the analytical process for this study is provided below (Figure 6).

55
56 Figure 6. Study procedural diagram. Adapted from Creswell (2015) and Akay (2017).
As shown in Figure 6, the initial quantitative phase of the study involved data collection

through the use of the modified UTAUT/Diffusion of Innovation survey instrument. This

survey was sent to a convenience sample of participants in Alabama and Oklahoma (n=

62). Next, the survey data were analyzed via partial least squares structural equation

modeling (PLS-SEM) in STATA 15. The trends that emerged from the quantitative phase

were used to develop the questions for the interview protocol, and convenience sampling

was used to select participants for the qualitative phase (n= 5). The semi-structured

interviews were conducted in-person and via conference call, and the interview

transcripts were analyzed in NVivo 12 using a combination of inductive and deductive

thematic analysis approaches. Finally, a joint display was employed to integrate the

findings from the quantitative and qualitative phases of the study and to generate meta-

inferences. More details about each phase of the study are provided in the following

sections.

Quantitative Phase

Sampling and data collection

Sampling. For the quantitative phase of the study, survey participants were

selected through convenience sampling. Convenience sampling is a form of non-random,

or non-probability sampling. Non-random sampling is appropriate when the goal of the

study is “not to generalize to a population but to obtain insights into a phenomenon,

individuals, or events” (Onwuegbuzie & Collins, 2007, p. 287). Under non-random

sampling, the researcher selects individuals and/or study sites that can provide a wealth of

information (Onwuegbuzie & Collins, 2007; Patton, 1990). Convenience sampling is

applied when members of the target population are easily accessible (e.g., because they

57
are located in the geographical area, are available at the requested time, or have expressed

willingness to participate in the study) (Etikan, Musa, & Alkassim, 2016). It is an

advantageous approach because it is affordable and easy to conduct (Etikan et al., 2016).

Given the constraints on resources for this project, convenience sampling was the most

logical approach.

Alabama and Oklahoma were selected to participate in this study because both

states have implemented initiatives to incorporate behavioral health information into the

patients’ electronic medical records, and there is ready access to the HIEs. Individuals

were identified as potential participants because their contact information was contained

in the HIE for their respective organizations. Because these participants utilize the HIEs,

it is possible that they have encountered behavioral health data in the system. Therefore,

they can offer the most insight on the factors that facilitate and impede the exchange of

behavioral health data.

Survey instrument. A validated UTAUT/diffusion of innovation survey instrument

was modified to fit the context of this study and adopted for data collection (see

Appendix B for the instrument). The survey was comprised of questions pertaining to the

following constructs that are hypothesized to influence behavioral intention: 1)

performance expectancy; 2) effort expectancy; 3) social influence; 4) perceived risk; 5)

trust; and 6) trialability. Each of these constructs was an independent variable in the

conceptual model, and they were operationalized as ordinal (categorical) variables. The

survey contained statements related to each of the constructs. Respondents expressed

their level of agreement with each statement using a 7-point Likert scale (1= “Strongly

58
agree”; 2= “Agree”; 3= “Somewhat agree”; 4= “Neutral”; 5= “Somewhat disagree”; 6=

“Disagree”; 7= “Strongly disagree”).

The first five constructs were derived from the extended UTAUT model (Slade et

al., 2015), and they have been found to have high reliability and validity: standardized

factor loadings and average variance extracted (AVE) values exceeded the recommended

threshold of 0.5 (Fornell & Larcker, 1981; Gefen et al., 2000; Slade et al., 2015, p. 33,

Table 2). Furthermore, the composite reliability values were above 0.90 for each of the

constructs, exceeding the minimum recommended value of 0.70 (Nunnally & Bernstein,

1994; Slade et al., 2015, p. 33, Table 2). Similar findings emerged for the behavioral

intention construct (Slade et al., 2015, p. 33, Table 2). Preliminary analysis of the survey

data collected for the current study also met the recommended thresholds for reliability

and validity. The standardized factor loadings are reported in Chapter 4 (see Figure 9 for

factor loadings).

Behavioral intention was the outcome of the combination of the independent

variables. It was also a predictor of use behavior. In this model, behavioral intention

acted as a mediating variable. Similar to the independent variables, behavioral intention

was operationalized as an ordinal (categorical) variable. Survey items related to

behavioral intention were answered using the same 7-point Likert scale adopted for the

independent variables.

Use behavior was operationalized as a dichotomous variable. Participants

answered “Yes” or “No” to the initial screening question: “Have you ever used

behavioral health information obtained from the HIE your organization uses?” Skip logic

was applied based on an individual participant’s response to the initial screening

59
question: those who responded “Yes” answered questions related to performance

expectancy; effort expectancy; social influence; perceived risk; and trust. Participants

who responded “No” to the screening question answered an additional set of questions

about trialability. Additionally, based on the response to the initial screening question,

subsequent questions were worded slightly differently to reflect actual experiences versus

perceptions of obtaining behavioral health information from the HIE.

Finally, the survey instrument included questions designed to collect demographic

information, which included data related to gender; education; job title; age;

race/ethnicity, and level of comfort and experience with technology. Gender, job title,

and race/ethnicity are categorical variables. Gender is classified as “Male,” “Female,” or

“Prefer not to state.” Job title is categorized as “Nurse;” “Physician;” “Physician’s

assistant;” and “Other (please specify).” Race/ethnicity is categorized as “American

Indian/Alaska Native;” “Asian;” “Native Hawaiian or Other Pacific Islander;”

“Black/African American;” “White;” “Other (please specify).” Level of education, age,

and level of computer skills are ordinal-level variables. Years of computer experience is

an interval-level variable: the participant reported the number of years he or she has used

computers. Next, the participants were asked if they believed that the use of computers

has been replaced by the use of smartphones and tablets. This question is coded as a

dichotomous variable (yes or no). The participants were then asked to quantify the

percentage of computer use that has been replaced by the use of smartphones and tablets:

this is reported as an interval-level variable (percentage of computer use replaced).

Survey administration. The survey was administered via SurveyMonkey. Prior to

distribution to the study sites, survey pilot testing was conducted amongst students from

60
various backgrounds. Minor wording changes and reordering of the questions were

suggested in an attempt to mitigate bias. All other questions were released in a

randomized order.

The survey instrument was sent to all healthcare providers (e.g., physicians,

nurses, nurse practitioners, physician assistants) who access the HIEs, as well as others

within the organizations who access the HIEs (e.g., directors, network administrators, and

patient experience representatives) in order to obtain a larger sample and to increase the

likelihood of gathering a variety of perspectives.

An initial prompt to participate in the survey was first sent via email to the chief

medical information officer (CMIO), who distributed the email to all potential

participants who have access to the two HIEs (Patient Bridge and CCHN). The prompt

gave a brief description of the study (study purpose, estimated duration of the study,

procedures, risks and benefits, alternatives to participation, confidentiality, and contact

information for the PI) and what participation in the study entails. Additionally, the

prompt contained a link to the online survey, as well as a consent form that provided

more detailed information about the study. This study was approved by the University of

Alabama at Birmingham Institutional Review Board (UAB IRB) on April 12, 2018 (IRB

Project Number IRB-300001017). The survey was made available to participants on June

4, 2018; it was officially closed at 11:59 PM (Central Standard Time) on August 14,

2018. Two reminder emails were sent to potential participants in an attempt to increase

survey completion. The first reminder was sent on July 5, 2018, and the final reminder

email was sent on July 30, 2018.

61
Data Management and Analysis

After the survey responses were collected, the data were exported from

SurveyMonkey into an Excel spreadsheet and were managed and formatted for analysis.

The data were then imported into STATA 15 for analysis. Preliminary data analysis

consisted of generating descriptive statistics (e.g., gender composition, age, role within

the organization, and level of expertise with technology) for the sample, as well as testing

for reliability. In addition, the survey responses were screened for outliers and to examine

the distribution of the data.

Structural Equation Modeling (Partial Least Squares)

Structural equation modeling, or SEM, was used to conduct the quantitative

analysis. SEM is a statistical modeling technique that often focuses on relationships

between theoretical constructs (Hox & Bechger, 2007). This technique is commonly used

in social sciences and is increasingly adopted in the information sciences arena

(Anderson & Gerbing, 1988; Chin, 1998). SEM is appropriate to use when several

relationships between variables are being considered simultaneously. Within SEM, a

dependent (outcome) variable in one equation can become an independent (predictor)

variable in another equation (Nachtigall, Kroehne, Funke, & Steyer, 2003). As depicted

in the conceptual model (Appendix A), behavioral intention is an outcome variable, but it

also acts as a predictor of use behavior. Additionally, SEM enables the researcher to

examine latent variables, consider measurement errors within observed variables, and

statistically test a priori theoretical models against empirical data (Chin, 1998). SEM has

been used in a previous health services study that employed UTAUT (Chang et al.,

62
2007), but it has not yet been used in the context of behavioral health information

exchange and integrated care.

Partial least squares structural equation modeling (PLS-SEM) is an alternative to

covariance-based SEM. PLS-SEM was originally developed by Wold (1966) as a soft-

modeling technique that has fewer restrictions and assumptions regarding the distribution

of the data, sample size, and level of measurement of the constructs of interest (Monecke

& Leisch, 2012). Like covariance-based SEM, PLS-SEM allows the researcher to test

hypotheses of existing theories and concepts (e.g., for confirmatory studies) or to develop

theories (e.g., for exploratory research). However, unlike covariance-based SEM, PLS-

SEM can be applied to studies that have small sample sizes (Haenlein & Kaplan, 2004;

Henseler et al., 2009; Hair et al., 2011; Kazar, 2014). PLS-SEM is primarily used for

predictive, or exploratory research, but it can also be applied in confirmatory studies

(Sarstedt et al., 2014). Because this study involves a small sample size, PLS-SEM was

deemed an appropriate covariance-based SEM alternative.

The number of studies that apply PLS-SEM has increased. However, some

researchers view this approach as less rigorous than a covariance-based SEM approach,

due in part to its application to small samples and non-normal data (Hair, Ringle, &

Sarstedt, 2011). In a later paper, Hair and colleagues (2012) acknowledged that in many

fields, including the social sciences, small sample sizes and developing theories are a

research reality; in the face of these restrictions, it is nearly impossible to meet the

assumptions of a covariance-based SEM approach (Hair, Ringle, Sarstedt, 2012).

Monecke & Leisch (2012) also argue in favor of PLS-SEM by stating “depending on the

researcher’s objectives and epistemic view of data to theory, properties of the data at

63
hand or level of theoretical knowledge and measurement development, PLS… is more

suitable” (p. 2). Finally, although a number of researchers have criticized the PLS-SEM

method, most of their criticisms lack support (Henseler et al., 2014).

Qualitative Phase

Sampling and data collection

The concluding question on the survey was used to recruit interviewees for the

subsequent qualitative phase of the study (“This survey is anonymous. However, if you

would like to be contacted for an interview, please provide your contact information

below.”). Convenience sampling was used for both the quantitative and qualitative phases

of the study. This method was appropriate for the quantitative phase because the survey

was anonymous; the survey was anonymous because of the sensitive nature of behavioral

health information and the possible contention surrounding the exchange of this

information. Even though there may be potential limitations associated with convenience

sampling in qualitative research, the convenience sampling method is justified in

qualitative research if generalizations are restricted to the context of the study (e.g., the

demographic and geographic location) (Robinson, 2014) or if the researcher is just

beginning to learn about the topic at hand (Morse, 2015). The topic of behavioral health

information exchange via an HIE is still a relatively new topic, and there is still much to

be uncovered about the facilitators and barriers of this kind of information exchange.

Furthermore, the findings from this study were restricted to the Alabama and Oklahoma

sites. For the purposes of this study, participants in Alabama and Oklahoma who were

willing to participate in a follow-up interview provided their contact information (emails

and telephone numbers) via the initial survey.

64
 Researchers are not in agreement with the appropriate sample size for qualitative

research. Some experts posit that there are no fixed rules and that depth, duration, and

feasibility should drive the sample size (Al-Busaidi, 2008), while others are more

prescriptive, saying that 15 participants is the smallest acceptable sample size (Bertaux,

1981). Some studies include as many as 60 participants (Morse, 1994).

Various factors can influence the number of participants required to reach

saturation (e.g., interview quality, number of interviews conducted per participant, and

researcher experience with qualitative methods) (Marshall, Cardon, Poddar, & Fontenot,

2013). The researcher has reached the point of data saturation when he or she gains no

new information from subsequent interviews (Marshall et al., 2013). However, because

there are few concrete guidelines regarding sample size for qualitative studies, it is up to

the researcher to determine when the point of saturation has been reached. For the

purposes of this study, 11 participants provided their contact information at the

conclusion of the survey. Upon follow-up, 5 of the 11 participants agreed to participate,

resulting in a total of 5 completed interviews. Over the course of the 5 participants,

several data points were reaching saturation. The 5th participant interview confirmed

saturation. The initial Request for Interview email was sent by the CMIO, and two

follow-up emails were sent by the PI to non-responders. The follow-up emails were sent

2 weeks and 4 weeks after the initial email. After 4 weeks (3 emails), it was determined

that the others were no longer able to provide an interview.

Procedure

After the analysis of the quantitative results, the qualitative phase was initiated. A

subsample of respondents from the quantitative phase of the study were contacted to

65
complete semi-structured interviews. Survey respondents who wanted to participate in a

follow-up interview provided email addresses and/or telephone numbers so that they

could be contacted to schedule an interview. The questions developed for the interviews

can be found in Appendix C. The interview questions were developed based on the trends

that emerged from the initial quantitative survey, and they were designed to allow study

participants to elaborate on some of the answers provided in the survey. Furthermore, the

interviews aided in gaining a better understanding of the factors that facilitate or impede

obtaining and using behavioral health information from an HIE. Participants were given

the opportunity to elaborate on how these factors, in conjunction, influenced their

intention to obtain and use behavioral health information from an HIE, as well as their

subsequent use behavior.

The questions were refined in order to capture the most accurate, useful

information from the interviews. The interview questions went through multiple rounds

of edits and were submitted to UAB IRB for approval. The interview protocol was then

pilot tested with three UAB faculty members with health informatics knowledge and with

one psychiatric nurse with behavioral health knowledge. Minor modifications were made

to the questions to improve both the flow of the protocol and the clarity of the questions.

Five interviews were conducted as a subsample of the survey participants. An

interview lasted anywhere from 26 minutes to 60 minutes, with a mean interview length

of 37 minutes. The participants worked in facilities located in Montgomery, Alabama and

in various cities in Oklahoma. The Montgomery interviews (with the exception of 1, due

to time constraints) were conducted in-person; the Oklahoma interviews and 1 of the

Montgomery interviews were conducted via Zoom, a teleconferencing tool that produces

66
audio recordings of the dialogue. All interviews were recorded and uploaded to Otter

Voice Notes for transcription.

Data Analysis

Thematic Analysis

Qualitative methods in healthcare are employed to explore complex phenomena

that healthcare providers, patients, and policymakers face (Denzin & Lincoln, 2000;

Sandelowski & Barroso, 2003; Tong et al., 2007; Vaismoradi, Turunen, & Bondas,

2013). These methodological approaches seek to gain understanding of the phenomenon

in question by gathering insights from the individuals who are experiencing it

(Vaismoradi et al., 2013).

Thematic analysis is described as a qualitative analysis approach that enables the

researcher to “identify, analyze, and report patterns (themes) within data” (Braun &

Clarke, 2006, p. 79; Barnett et al., 2011; Vaismoradi et al., 2013). The themes that

emerge from this analytical approach are essential for describing the research

phenomenon at hand (Daly, Kellehear, & Gliksman, 1997; Fereday & Muir-Cochrane,

2006). The use of thematic analysis is promoted because it can be conducted in a variety

of ways (Clarke & Braun, 2018).

Thematic analysis can be either inductive or deductive. Inductive thematic

analysis involves a close examination of raw qualitative data in order to generate various

concepts and/or themes from the researcher’s interpretation of the raw data; any patterns

or themes that emerge are driven by the data (Thomas, 2006; Fereday & Muir-Cochrane,

2006). When using inductive analysis, the researcher is not guided by a priori constructs.

Instead, themes emerge from the data that have been collected (e.g., interview transcripts)

67
(Strauss & Corbin, 1998). Deductive thematic analysis, on the other hand, is applied to

find evidence in the data to support theoretical perspectives or assumptions (Thomas,

2006). When a deductive analysis approach is selected, the researcher is guided by

constructs that are often derived from an existing theoretical framework (Crabtree &

Miller, 1992; Fereday & Muir-Cochrane, 2006).

For the purposes of this study, both inductive and deductive analysis approaches

were used. The interview questions were partially guided by the constructs in the

conceptual model. However, additional themes that emerged were derived from the

content within the interview transcripts (Clarke & Braun, 2018). The UTAUT and

diffusion of innovation theories have not yet been applied to the study of behavioral

health information exchange. Given the regulations that restrict the free exchange of

behavioral health-related data, additional factors that were not captured in the conceptual

framework emerged. Inductive analysis enables the researcher to account for additional

factors that are revealed in the qualitative interviews. Using qualitative data analysis

software (NVivo 12), this study adopted the four-stage process of analysis employed in

the Barnett et al. (2011) study, in which the researchers: 1) become familiar with the data;

2) develop themes and subthemes by aggregating coded segments of the data; 3) create

comparative categories; and 4) revise and refine the themes and subthemes. When both

the quantitative and qualitative data were analyzed, a discussion of the results was written

in order to provide a better understanding of the factors that facilitate and impede

obtaining and using behavioral health data from an HIE.

Integration and Meta-Inferences

68
Integration: Joint Displays

The following mixed methods research question guided the study: How do the

interview results help to explain the quantitative findings about factors that facilitate and

impede obtaining and using behavioral health information from an HIE? To answer this

question, the results of the quantitative and qualitative phases of the study were integrated

and interpreted together. Mixed methods researchers integrate quantitative and qualitative

data by first discussing the two sets of results separately, then creating a joint display

(Guetterman, Fetters, & Creswell, 2015). Joint displays are a mechanism to demonstrate

the findings from both phases of a mixed methods study; they help the researcher

integrate the findings from the two phases in order to generate meta-inferences

(Guetterman et al., 2015; Johnson, Grove, & Clarke, 2017). For the purposes of this

study, a joint display was created to facilitate comparison of the results. The display

contained details about the quantitative phase of the study: the names of the constructs

from the conceptual model were included, as well as the path coefficients and p-values

for each construct. Additionally, the display provided details about the themes that

emerged in the qualitative phase of the study; a description of each theme; and a pertinent

quote for each theme.

Quality Assurance

Validity for the Quantitative Phase

Validity helps researchers to assess the relevance of the quantitative data collected

for the purpose of answering quantitative research questions (Plano Clark & Ivankova,

2016). The survey instrument used in the quantitative arm of this study was developed

using modified questions from validated UTAUT and diffusion of innovation

69
instruments. The wording of the questions was modified to reflect the phenomenon of

interest. Because this study is the first to examine the facilitators of and barriers to

behavioral health information exchange via an HIE from a theoretical perspective, the

validity and reliability of the measures used in the study are not discussed in the extant

literature. However, as discussed in the section related to the survey instrument under the

Quantitative Phase heading, the measures have demonstrated both validity and reliability

in other contexts (Slade et al., 2015). Furthermore, preliminary analysis of the survey

data revealed that the measures used for this study met the criteria for reliability and

validity (see Figure 9). It is also important to note that these measures are self-reported

and could be subject to various biases. Taking these factors, as well as the small sample

size, into consideration, any associations that emerge from this study are not deemed

causal relationships. Furthermore, the findings are limited to this particular study and are

not generalized to other contexts.

Trustworthiness for the Qualitative Phase

Qualitative research has gained recognition as a valid research approach. As such,

there is greater emphasis on conducting rigorous qualitative research that will yield

credible results (Nowell, Norris, White, & Moules, 2017). The quality of these data is

determined based on “whether the findings are accurate from the standpoint of the

researcher, the participant, or the readers of an account” (Creswell, 2014, p. 201; Plano

Clark & Ivankova, 2016). There are several common procedures for establishing

trustworthiness in qualitative research, including member checking, peer debriefing, and

triangulation (Creswell & Miller, 2000; Nguyen, 2008; Hadi & Closs, 2016).

70
 This study employed member checking to establish trustworthiness. Through

member checking, the researcher obtains participants’ feedback about the data, how the

data were interpreted, and any conclusions that the researcher drew about the data

(Lincoln & Guba, 1985; Onwuegbuzie & Leech, 2007). Researchers can conduct member

checking by sending participants the following documents to review: an interview

transcript, emerging findings, or case summaries (Thomas, 2017). According to Lincoln

and Guba (1985), member checking is essential for establishing the trustworthiness of

qualitative data, as it allows participants to clarify their responses and reduces the

likelihood of “misrepresentation and misinterpretation of the ‘voice’” (Onwuegbuzie &

Leech, 2007, p. 241). Member checking can be useful when the aim of the research is to

provide a complete and accurate representation of individual experiences of a

phenomenon (Thomas, 2017).

For this study, the researcher checked the transcripts of the audio files to ensure

that there were no errors. Afterward, the transcripts were summarized in a 1- to 2- page

document, in which a bulleted list of the points made in the interview was provided. At

the end of each interview, the researcher obtained permission to reach back out to the

interviewees in order to clarify points and to ask additional questions, if necessary. In the

follow-up, the researcher sent the summary of the interviews to the corresponding

participant and gave them the opportunity to correct any errors in interpretation. Two of

the 5 participants responded. One of the participants provided additional clarification for

one point of discussion; the other participant found no errors within the document.

To supplement member checking, this study also employed peer debriefing. Peer

debriefing provides an opportunity for the researcher to discuss the study procedures,

71
findings, and interpretations with another person (Onwuegbuzie & Leech, 2007). This

person asks questions about the research procedures, interpretation of the data, and

conclusions. The PI discussed the interview process and the themes that emerged from

the interviews with the committee chair, who asked clarifying questions and challenged

conclusions when necessary. The committee chair has expertise in the area of health

informatics and is familiar with various policies related to the electronic exchange of

personal health information. She was able to provide additional insight on the findings

from the interview findings when necessary.

Legitimation for the Integration Procedure

Onwuegbuzie and Johnson (2006) use the term “legitimation” to refer to matters

of quality in mixed methods research (Teddlie & Tashakkori, 2009, p. 308). Legitimation

is considered “a process of continuous evaluation… throughout a mixed research

project”, and it gauges the trustworthiness of the quantitative and qualitative data, as well

as the interpretations of these data (p. 310; Johnson & Onwuegbuzie, 2004).

Onwuegbuzie & Johnson (2006) developed a legitimation typology, in which they

identified nine types of legitimation (Teddlie & Tashakkori, 2009: 309, Table 12.7;

Onwuegbuzie, Johnson, & Collins, 2011). The nine types of legitimation are: 1) sample

integration; 2) inside-outside; 3) weakness minimization; 4) sequential; 5) conversion; 6)

paradigmatic mixing; 7) commensurability; 8) multiple validities; and 9) political

legitimation. Weakness minimization and inside-outside were used to legitimize the use

of mixed methods. Under weakness minimization, the researcher considers the extent to

which the limitations of one approach (qualitative or quantitative) are addressed by the

other approach (Onwuegbuzie et al., 2011). For example, the researcher might want to

72
determine if relationships that emerge in the quantitative phase of the study can be

explained more thoroughly in the qualitative phase (e.g., through in-depth or semi-

structured interviews) (Madey 1982; Onwuegbuzie et al., 2011). For this study, the

qualitative interviews were conducted in order to allow the interviewees to elaborate on

and/or clarify the trends that emerged from the initial quantitative phase. The inside-

outside legitimation type considers the extent to which the inferences from both the

quantitative and qualitative phases of the study are combined to generate a complete,

coherent understanding (Tashakkori & Teddlie, 2003; Onwuegbuzie et al., 2011). For this

study, the quantitative trends and qualitative themes were presented and interpreted using

a joint display, which facilitated the generation of meta-inferences.

Ethical Considerations

Research with human subjects requires adherence to ethical standards that have

been put in place to protect the rights of study participants (Plano Clark & Ivankova,

2016). For example, institutional review boards (IRBs) determine whether the researcher

provides adequate safeguards to protect participants’ right to privacy (Bromley, Mikesell,

Jones, & Khodyakov, 2015). For this study, IRB approval was obtained from the

University of Alabama at Birmingham (UAB) IRB (IRB-300001017), as well as from the

Alabama and Oklahoma study sites. Approval was obtained at both phases of the study.

The surveys for the quantitative phase of the study were anonymous unless the

participant agreed to participate in the subsequent qualitative (interview) phase. The

survey data were stored on an internal drive that only the PI could access. Any

identifying information that was revealed in the interviews was omitted in the final report

of the results. To ensure that the participants understood the details of the study, the

73
initial recruitment email contained information related to the study (e.g., research

purpose; expected duration of participation; study procedures; potential risks or

discomforts; benefits of the research; alternatives to participation; procedures used to

maintain confidentiality; and a statement regarding voluntary participation and

withdrawal). A statement was provided at the beginning of the survey: “By continuing

with this survey, you hereby grant consent for data collection, analysis, and use of your

answers in aggregate.” Similarly, verbal consent was obtained for the subsequent

qualitative phase of the study, and this consent is documented in the interview transcripts.

Summary

A definition for mixed methods research was provided in this chapter.

Additionally, justification for adopting an explanatory sequential mixed methods design

to examine the phenomenon of behavioral health information exchange via an HIE was

given. Each step of the quantitative and qualitative phases of the study was discussed.

Validity and legitimation concerns were addressed for both the quantitative and

qualitative phase of the study, as well as for the integration procedure. Finally, details

about addressing the ethical considerations around this study were provided.

74
 CHAPTER 4

RESULTS

This chapter begins by presenting the results of the quantitative phase of the

study. First, descriptive statistics of the sample are presented. Afterward, the results of

the PLS-SEM analysis are examined in order to test the conceptual model developed for

the study. The results of the follow-up qualitative study phase are presented. Finally, the

quantitative and qualitative results are compared in order to generate meta-inferences.

Quantitative Phase

Descriptive Statistics

A total of 80 participants initiated the survey, with 62 completing the survey in its

entirety. The descriptive statistics for this sample are displayed below in Table 1. All 62

surveys were usable for analysis. Of these 62 participants, only 9.68% (n= 6) actively

retrieved behavioral health data from their organization’s HIE; the remaining 90.32% (n=

56) did not actively engage in behavioral health data exchange.

75
Table 1: Descriptive statistics for behavioral health information exchange survey
participants.

(N=62)
n(%),
Variables M(SD)
Retrieved behavioral health data from their organization’s HIE
Yes 6 (9.68%)
No 56 (90.32%)
Gender
Female 49 (79.03%)
Male 12 (19.35%)
Prefer not to state 1 (1.61%)
Age Group
21-29 3 (4.84%)
30-39 18 (29.03%)
40-49 18 (29.03%)
50-59 16 (25.81%)
60-69 6 (9.68%)
70 and older 1 (1.61%)
Job Title
Nurses 27 (43.55%)
Physicians 10 (16.13%)
Physician's Assistants 2 (3.23%)
Others 23 (37.10%)
Education
High school diploma or GED 3 (4.84%)
Some College 8 (12.90%)
2 year Degree 20 (32.26%)
4 year college degree 10 (16.13%)
Master’s Degree 10 (16.13%)
Professional Degree 10 (16.13%)
Doctorate 1 (1.61%)
Ethnicity/Hispanic or Latino origin
Yes 3 (4.84%)
No 59 (95.16%)
Race
American Indian/Alaska Native 2 (3.23%)
Asian 5 (8.06%)
Black/African American 6 (9.68%)

76
White 47 (75.81%)
Other 2 (3.23%)
Level of computer experience
Novice 1 (1.61%)
Average 45 (72.58%)
Advanced 16 (25.81%)
Do you feel that some of your computer use has been replaced by the use
of a tablet or smartphone?
Yes 50 (80.65%)
No 12 (19.35%)
How much of their computer usage they believe had been replaced by 44.98
tablets and smartphones. (0% - 98%) (25.14%)

Of the 62 participants, 79.03% (n= 49) were female. The majority of the

participants (83.87%) were between the ages of 30 years and 59 years. With respect to

job title, 43.55% (n= 27) worked as nurses within their organization; 16.13% (n= 10)

were physicians; 3.23% (n= 2) were physician’s assistants; and 37.10% (n= 23) identified

their job role as “Other.” 4.84% of the participants (n= 3) obtained a high school diploma

or GED; 12.90% (n= 8) completed some college; 32.26% (n= 20) earned a 2-year degree;

16.13% (n= 10) earned a 4-year college degree; 16.13% (n= 10) earned a master’s

degree; 16.13% (n= 10) earned a professional degree; and 1.61% (n= 1) earned a

doctorate.

The racial/ethnic composition of the respondents is examined in this paragraph.

When asked whether the participants were of Hispanic or Latino origin, 4.84% (n= 3)

answered “yes”; the remaining 95.16% (n= 59) answered “no.” 3.23% of the respondents

(n= 2) identified as American Indian/Alaska Native; 8.06% (n= 5) identified as Asian;

9.68% (n= 6) identified as Black/African American; 75.81% (n= 47) identified as White;

and 3.23% (n= 2) identified as “Other.”

77
 Finally, level of computer experience and beliefs about computer usage are

outlined. The breakdown of level of computer experience among the participants is

depicted in Figure 7. Survey participants were asked, “Which best describes the level of

your computer skills?” 1.61% (n= 1) selected “Novice” (meaning that this person just

started using computers). 72.58% (n= 45) selected “Average” (meaning that these

participants are able to use word processors, spreadsheets, email, and surf the Web).

25.81% (n= 16) selected “Advanced” (meaning that these participants are able to install

software and set up configurations). On average, respondents reported having 20.08 years

of computer experience (SD= 7.74): the minimum was 4 years of experience, and the

maximum was 37 years. Next, participants were asked, “Do you feel that some of your

computer use has been replaced by the use of a tablet or smartphone?” 80.65% of the

respondents (n= 50) answered “yes,” while 19.35% (n= 12) answered “no.”

Subsequently, respondents were asked to report how much of their computer usage they

believe had been replaced by tablets and smartphones. On average, participants believed

that 44.98% of their computer usage had been replaced by the use of newer technology

(SD= 25.14): the minimum was 0%, and the maximum was 98%.

78
Figure 7: Level of computer experience among survey participants.

Participants who identified themselves as “Novice” just started using computers; those
who identified as “Average” are able to use word processors, spreadsheets, email, and
surf the Web; those who identified as “Advanced” are able to install software and set up
configurations. None of the participants in this sample identified as “Expert” (able to set
up operating systems and/or possess knowledge of computer programming languages).

Bivariate Statistics: Correlations

Bivariate statistics were generated for each of the independent variables

(performance expectancy; effort expectancy; social influence; perceived risk; trust;

trialability) and the dependent variables of interest: behavioral intention and use behavior.

The results are presented in Table 2. Spearman’s rank-order correlation coefficients were

generated to determine the strength and direction of the association between these

variables. Spearman’s rank correlation is a nonparametric test that is used when

examining the association between two ordinal-level variables; it is an appropriate

79
alternative when the traditional Pearson’s correlation cannot be applied due to non-

normality, a non-linear relationship, or the use of ordinal variables (Laerd Statistics).

Moderate to strong positive correlations exist between behavioral intention and

the following independent variables: performance expectancy (rs= 0.8008, p= 0.0000);

effort expectancy (rs= 0.8239, p= 0.0000); social influence (rs= 0.6641, p= 0.0000); trust

(rs= 0.8597, p= 0.0000); and trialability (rs= 0.6280, p= 0.0000). A moderate negative

correlation emerged between behavioral intention and perceived risk (rs= -0.4452, p=

0.0003).

Table 2: Spearman’s rank correlation between Behavioral Intention, Use Behavior, and
independent variables.
Independent variables Dependent Variables
Behavioral intention Use behavior
Performance expectancy 0.8008*** -0.1964
Effort expectancy 0.8239*** -0.2056
Social influence 0.6641*** -0.2436
Perceived risk -0.4452** 0.0582
Trust 0.8597*** -0.2939*
Trialability 0.6280*** ---
Behavioral Intention 1.000 -0.2703*
*p <0.05; **p < 0.01; ***p < 0.001

PLS-SEM: Factor Loadings

Next, the measurement model was examined (see Figure 8 for the measurement

model). Internal consistency of the items of each factor in the measurement model was

assessed. The measurement model is used to determine the reliability and validity of the

items included in each of the latent constructs; the Cronbach’s Alpha determines the

reliability of each factor (Elkaseh, Wong, & Fung, 2016). A Cronbach’s Alpha score of

0.7 or greater indicates an acceptable level of internal consistency (Hair et al., 1995;

Elkaseh et al., 2016). These values are contained in Figure 9. With the exception of item

80
4 on the performance expectancy factor (P4), all of the items meet the criteria for internal

consistency.

Figure 8: Measurement model for the study.

81
Figure 9: Factor loadings for the measurement model.

Results of Hypothesis Testing

For initial hypothesis testing, a series of regression models was run to examine the

relationships between the dependent and independent variables of interest. The results of

the regression models are presented in the following section. Subsequently, PLS-SEM

was conducted to test the conceptual model presented in Appendix A. The results of the

PLS-SEM are presented after the regression results.

82
 Predictors of behavioral intention: Linear regression. The results of the

unadjusted and adjusted linear regression models are presented in Table 3. The

unadjusted linear regression model tested the relationships between behavioral intention

(main dependent variable) and each of the independent variables identified in the

conceptual model: performance expectancy; effort expectancy; social influence;

perceived risk; trust; and trialability. Based on the regression model, performance

expectancy (b= 0.301, p= 0.030) and trust (b= 0.512, p= 0.000) are significant predictors

of behavioral intention. A subsequent adjusted linear regression model added the

following control variables: gender; job title; level of education; age category;

Hispanic/Latino classification; race/ethnicity; level of computer experience; years of

computer experience; computer replacement beliefs; and the percentage of computer use

being replaced by mobile phone or tablet. In this model, trust (b= 0.602, p= 0.013)

continued to be a significant predictor of behavioral intention. With regard to the control

variables, level of education was a predictor of behavioral intention. When compared to

participants who earned a high school diploma or GED (reference group), participants

who earned a doctorate scored lower on behavioral intention. However, it is worth noting

that both of these subgroups are small (3 participants earned a high school diploma or

GED, while only one participant earned a doctorate).

83
Table 3: Linear regression models examining the relationship between behavioral
intention and independent variables.
Unadjusted β P value

Performance expectancy 0.301* 0.030

Effort expectancy 0.171 0.16
Social influence -0.408 0.679
Perceived risk 0.936 0.251
Trust 0.512*** 0.000
Trialability 0.106 0.163
Adjusted
Performance expectancy 0.298 0.129
Effort expectancy 0.099 0.486
Social influence -0.032 0.813
Perceived risk 0.162 0.183
Trust 0.602* 0.013
Trialability 0.012 0.920
Gender
Male (reference)
Female -0.304 0.354
Prefer not to state 0.342 0.617
Age Group
21-29 (reference)
30-39 -0.343 0.436
40-49 0.069 0.869
50-59 -0.201 0.667
60-69 -0.050 0.918
70 and older 0.516 0.417
Job Title
Nurses (reference)
Physicians 0.625 0.403
Physician's Assistants 0.741 0.162
Others 0.005 0.984
Level of Education
High school diploma or GED (reference)
Some College 0.325 0.427
2 year Degree 0.576 0.128
4 year college degree 0.135 0.749
Master’s Degree 0.370 0.310

84
Professional Degree -0.229 0.722
Doctorate -2.030* 0.040
Ethnicity/Hispanic or Latino origin
Yes (reference)
No -0.492 0.418
Race
American Indian/Alaska Native (reference)
Asian -0.003 0.996
Black/African American -0.141 0.794
White 0.112 0.794
Other -1.265 0.222
Level of computer experience
Novice (reference)
Average -0.619 0.404
Advance -0.728 0.316
Years of computer experience -0.007 0.655
Computer replacement beliefs
Yes (reference)
No 0.325 0.186
Percentage of computer use being replaced by mobile phone
or tablet 0.0001 0.967
*p <0.05; **p < 0.01; ***p < 0.001
The unadjusted model accounted for the independent variables in the conceptual model.
The adjusted model incorporated demographic variables as controls.

Testing the conceptual model and hypotheses: PLS-SEM. Next, the results of the

partial least squares structural equation model (PLS-SEM) are examined. The

standardized path coefficients indicate the strength and direction of the relationship

between the constructs; statistical significance is also reported in the model. The results

of the analysis are presented in Table 4.

85
Table 4: Path analysis of constructs tested in the conceptual model.

Intention to use behavioral health information from the HIE

Β
Performance expectancy 0.382**
Effort expectancy 0.055
Social influence -0.043
Perceived risk 0.061
Trust 0.539***
Trialability 0.093
Use behavior 0.127
*p <0.05; **p < 0.01; ***p < 0.001

Performance expectancy predicted intention to use behavioral health information

obtained from the HIE (β= 0.382, p= 0.01). The first hypothesis (H1) was supported:

Performance expectancy has a positive impact on intention to use behavioral health

information obtained from the HIE. As hypothesized (H2), there was also a positive

association between effort expectancy (β= 0.055, p= 0.72) and behavioral intention, but

the association was not found to be statistically significant. Contrary to the hypotheses

(H3 and H4), there was a negative association between social influence (β= -0.043, p=

0.72) and behavioral intention and a positive association between perceived risk (β=

0.061, p= 0.47) and behavioral intention. However, neither of these associations was

statistically significant.

Like performance expectancy, trust was a significant predictor of intention to use

behavioral health information obtained from the HIE (β= 0.539, p= 0.00). The fifth

hypothesis (H5) was also supported: Trust has a positive impact on intention to use

behavioral health information obtained from the HIE. The direct positive relationship

between trust and behavioral intention has been supported in other studies (Lee & Song,

86
2013; Taiwo, Mahmood, & Downe, 2012). However, a relationship between trust and

perceived risk did not emerge in this study; therefore, H6 was not supported. Trialability

(β= 0.093, p= 0.34) also had a positive association with intention to use, but it was not

statistically significant (H7). Finally, the relationship between intention to use and use

behavior is examined. As hypothesized (H8), intention to use behavioral health

information obtained from the HIE had a positive impact on use behavior (β= 0.127, p=

0.68). However, the association was not statistically significant.

Summary of Quantitative Results. The PLS-SEM results revealed that

performance expectancy and trust are significant predictors of behavioral intention to

exchange behavioral health information via the HIEs, lending support to H1 and H5.

Higher scores on the performance expectancy measures were associated with higher

scores on the behavioral intention measures. Likewise, higher scores on the trust

measures were associated with higher scores on the behavioral intention measures. In the

context of this study, trust was the strongest predictor of behavioral intention. The

conceptual model with the path coefficients for each of the hypothesized relationships is

presented in Figure 10.

87
Figure 10: Conceptual model with path coefficients for the hypothesized relationships.

88
 Qualitative Phase

Information from in-depth analysis across five interviews was organized in NVivo

12 (see Table 5 for the final coding structure), resulting in the following themes: 1)

Usefulness of behavioral health information in care delivery; 2) Regulations restricting

the exchange of behavioral health information; 3) Behavioral health and stigma; 4)

Missing or difficult-to-locate behavioral health data; 5) Lack of mandatory training for

behavioral health information exchange; and 6) Future utilization of the HIEs. The

participants from Patient Bridge (AL HIE) included a local network director, a nurse

practitioner, a clinic/IT supervisor for a specialty clinic, and a director of operations for a

home health and hospice agency. There was only one participant from CCHN (OK HIE),

a patient experience representative. The lack of balance is noted in the limitations

(Chapter 5).

89
Table 5: Final coding structure for the qualitative phase.
Theme Description of Theme
Usefulness of Interviewees detail the ways in
behavioral health which BHIE can improve
information in delivery/provision of care in
care delivery healthcare settings. Likewise,
they talk about the ways in
which incorporating behavioral
health information into the
patient’s medical record can be
challenging.
Regulations Interviewees highlight some of
restricting the the regulatory barriers that
exchange of complicate the exchange of
behavioral health behavioral health information.
information
Behavioral health Interviewees discuss the stigma
information that continues to surround
exchange and behavioral health and how it
stigma complicates the exchange of
behavioral health information.
Missing or Interviewees discuss how much
difficult-to-locate effort they believe they’d have
behavioral health to put forward to learn how to
information exchange/identify behavioral
health information within a
patient record.
Lack of Interviewees discuss whether
mandatory they participated in a pilot test
training for and what they learned, or they
behavioral health discuss the ways in which they
information think they could have benefited
exchange from a pilot test.
90
Illustrative Quote
“A lot of patients come in and
don’t know exactly what all
their diagnoses are, what all
their medications are… That
information tends to be vitally
important to us… if for no
other reason, giving us a
historic perspective about
what the… patient’s baseline
presentation is and diagnoses
are… as well as… addressing
acute issues.” (Interviewee 4)
“The priority is making sure
that we are… in the clear
when it comes to [regulations
such as] 42 CFR Part 2, you
know? The priority is not
ensuring that behavioral and
mental health information is
able to make it to the next
provider on the HIE.”
(Interviewee 2)
“You know, behavioral health
stuff… there’s a lot of taboo
tied to what’s going on with
people… It’s a little bit more
challenging to access that
information.” (Interviewee 4)
“When I pull [Patient Bridge]
up, I look at the whole clinical
dashboard. I’m not even
recalling if I’ve seen, like, a
particular place where it’s
only talking about their
behavioral background.”
(Interviewee 3)
“I don’t know if there’s any
training or education… that
specifically had to do with
behavioral health
information…” (Interviewee
2)
 Future utilization Interviewees share concluding
of the HIEs thoughts about the use of the
HIEs for general medical and
behavioral health information
exchange.
“…I’m hopeful that in the
future… exchanging
behavioral and mental health
information will… as an
industry… that we’ll kind of
shift more to the… full
exchange of that
information.” (Interviewee 2)

Theme 1: Usefulness of behavioral health information in care delivery

Participants acknowledged that the exchange of behavioral health information via

the HIE could improve the delivery of care in various settings. In general, the exchange

of information via an HIE increases efficiency (e.g., within primary care and ambulatory

settings). More specifically, the exchange of behavioral health information is useful

within the emergency department:

I think the HIE, and HIEs in general, are very valuable in that use case because,
you know, an, an emergency department is kind of the front door of the hospital.
(…) The provider's able to query the HIE and get a picture on... because, you
know, they've, they've never seen this patient before probably. And they can view
the HIE and get a true... good broad look at a health history for this patient,
whether that's allergies and their immunization record, recent lab work, or mental
and behavioral health, uh, you know, diagnoses that may affect how they want to
treat that patient or interact with that patient, and kind of their bedside manner, I
suppose, within the emergency department. (Interviewee 2)

The use of behavioral health information exchange within an emergency department

could help the attending physician to become familiar with the patient’s medical history

and could prove useful in establishing post-discharge care:

(…) A lot of patients come in and don't know exactly what all their diagnoses are,
what all their medications are, even all the names of their physicians. That
information tends to be vitally important to us for knowing, you know...
I could, I could look at a person's medicines and tell what's going on with them.
Or at least have an idea of what's going on with them. And so, uh... If, if for no
other reason, giving us a historic perspective about what the (…) patient's baseline
presentation is and diagnoses are. Um, they can help us do a better job (…)
for continuity of care, as well as, uh, addressing acute issues. (Interviewee 4)

91
 One area in which behavioral health information exchange can be used to

establish continuity of care is in home health and hospice care. Home health aides are

often unfamiliar with all of the patients’ limitations (physical or mental). The exchange of

the full patient record, including any behavioral health diagnoses, can help aides prepare

to deliver high-quality care within the home:

(…) Knowing that history does help us because we are going into their homes,
and knowing what kind of environment we're going into, their learning abilities-
You know, (…) kind of where they are. That helps us know how to approach our
education of our plan of care. You know, sometimes we might need to get lock
boxes for medicine. You know, these types of things. So knowing these ahead of
time, it is helpful to know what we're stepping into. (Interviewee 3)

Being fully aware of the patients’ needs, including any behavioral challenges that they

may present, helps healthcare workers in various settings to deliver appropriate care.

Despite these perceived benefits, there are several barriers that prohibit the exchange of

behavioral health information.

Theme 2: Regulations restricting the exchange of behavioral health information

Participants discussed existing regulations and policies that make behavioral

health information exchange more difficult than general medical information exchange.

Perhaps the most significant perceived barrier to behavioral health information exchange

is 42 CFR Part 2, which is discussed in Chapter 2. 42 CFR Part 2 makes healthcare

workers (particularly those in administrative positions) hesitant to permit the exchange

behavioral health information via an HIE because this information is considered

sensitive.

So I don't know if you're familiar with 42 CFR Part 2 (…) When you start getting
into that sort of information being transmitted (…) There's some hesitancy from
kind of the stakeholders involved because you know that there is such sensitivity
around that sort of information, that sometimes, I think the mindset, if you are on

92
 the administration side, you know, of sending that health information exchange...
or of exchanging health information across partners, you know, I think a lot of
times your first thought goes to (…) I want to play it safe. You know, we got to
make sure we don't have any liability. We got to stay perfectly within the lines,
and we're not going to welcome any gray area here. (Interviewee 2)

As the quotation above suggests, 42 CFR Part 2 leaves room for interpretation with

regard to the exchange of behavioral health information, and it is not uncommon for

healthcare providers to come to different conclusions about what information can be

exchanged “for treatment and payment and operations purposes from within the HIE”

(Interviewee 2).

In an effort to permit behavioral health information exchange without

compromising the security of this sensitive information, CCHN (Oklahoma) implemented

roles-based access, which allows physicians to see information related to behavioral

health diagnoses and treatment within the patient record. On the other hand, the

registration and nursing groups may not access patients’ behavioral health information.

Behavioral health is (…) more secured. And so, you know, (…) only certain
people have access to look at those kind of records. Um, now on the general
health information, you can probably see the diagnosis, but you can't see, um, like
documentation of what's going on with that patient. (Interviewee 1)

Patient Bridge (Alabama) takes a more restrictive approach to behavioral health

information exchange:

(…) If a patient in the Baptist system receives care at the Crossbridge facility,
which is Baptist's (…) main facility for mental and behavioral health services,
then that, that information is pretty much suppressed from the HIE. It has a filter
that, that we shouldn't get any Crossbridge information across (…) when we do
get Crossbridge information across into the HIE, uh, that's actually part of my
day-to-day duty, is to opt out the entire patient record from exchange, if that
initial filter did not work. (…) it's such an imperfect system that we are opting out
hundreds of patients (…) because we don't have a better method to do it. So not
only are, you know, those hundreds of patients that have been to Crossbridge and
the mental and behavioral health not able to have their, that sort of data exchange,

93
 they're not able to have any of their data exchanged. They're opted out of general
exchange. They won't even show up if someone queries them in the HIE then.
(Interviewee 2)

The participants expressed some uncertainty that behavioral health information

exchange will be a widespread phenomenon within healthcare organizations in the near

future, given the influence of 42 CFR Part 2:

The way that our policy essentially works out is that's, that's not the priority.
The priority is making sure that we are, you know, in the clear when it comes to
42 CFR Part 2, you know? The priority is not ensuring that behavioral and mental
health information is able to make it to the next provider on the HIE. (Interviewee
2)

Based off the interviewees, the restrictions surrounding the exchange of behavioral health

information will most likely discourage the sharing of behavioral health information,

unless the information is essential to the provision of care. One interviewee contributed

this to the restrictions:

I mean, to me that's, that's more of a confidentiality could affect somebody's, um,

life. If everybody in healthcare knew what was going on with that person or what
they were thinking, maybe how they, um, treat them with medication may be a
little different, you know. (...) I mean, I don't see how any of an exchange for
behavioral health information would ever happen unless it was from, like, one
psychiatric to another psychiatric kind of thing. (Interviewee 1)

Regulations such as 42 CFR Part 2 were enacted in response to the stigma surrounding

sensitive diagnoses, including those related to behavioral health. That stigma persists

even today.

94
Theme 3: Behavioral health information exchange and stigma

Participants acknowledged the stigma that continues to surround behavioral health

disorders and contributes to the suppression of behavioral health information within

patients’ medical records. This issue is articulated by one interviewee:

You know, I think you could kind of make the case that the, the long-standing
stigma that our society has had against, you know, mental health issues or
behavioral health issues (…) kind of manifests itself in that, you know, 42 CFR or
other, you know, kind of regulatory captures. Because it is sensitive, it is private,
and you don't want it to be exchanged and be available to everyone (…)
(Interviewee 2)

As such, mental illness continues to be considered taboo, and because of this, information

related to a mental health diagnosis is often separated from the rest of a patient’s medical

record:

And so... but uh, I think the only challenge is that because of the, the taboo behind
it, (...) They make it a point to separate that from all other medical information,
because it's mental health. You know, but I think in order for that to happen, it
needs to be... I don't know, if the same transparency, but, you know, it's, it's kind
of hard to give it the same credence, when accessing information is not as easy.
(Interviewee 4)

Furthermore, the stigma surrounding mental illness may discourage patients from

revealing their diagnoses to a new healthcare provider. This hesitation to disclose hinders

the flow of health-related information, and it complicates the delivery of appropriate care,

especially if the provider is unfamiliar with the patient’s medical history. As one

interviewee noted:

And mental health is a very touchy subject for a lot of people, you know, and you
just can't get people to open up about stuff like that sometimes. And then, you
know, I'm grateful for people that can, you know, and actually go get help and be
treated for that. Really, you know, one of those iffy subjects for a lot of people.
(Interviewee 1)

95
Because patients are hesitant to share information related to behavioral health diagnoses

and/or treatment with practitioners who deliver general medical care, this information is

often missing from the patient record. This introduces yet another challenge for

healthcare providers in the area of behavioral health information exchange.

Theme 4: Missing or difficult-to-locate behavioral health information

One of the concerns raised about incorporating behavioral health into the

electronic medical record was centered on locating the information within the HIE. One

interviewee suggested that if behavioral health information is difficult to identify, it could

reduce efficiency in care provision. One interviewee summed up the thoughts of several:

Okay, the information may be there, but where does it appear for the doctor? (...)
Does this fit into their workflow? Does it... Not only is it, is it accessible, but is it
easy to access? You know, because, you know, an HIE is only as good as, you
know, its providers are at using it, so it can't have, you know, an, an impact on
patient care or patient outcomes unless, you know, the providers or nurses or front
office staff are actually utilizing and putting it to good use. (Interviewee 2)

As mentioned under Theme 2, Patient Bridge (Alabama) is designed such that it impedes

the exchange of behavioral health information across the HIE. The complete removal of

behavioral health patients’ records from the HIE further complicates the delivery of

appropriate care:

(…) you hope that a provider or group or something is always going to wait until
they have the best and the most complete information to make a treatment
decision or, or any healthcare decision like that, but just realistically,
(…)Sometimes people are rushed, and they feel like they have a complete picture
of care and, and they make a decision. (…) I think Patient Bridge being
inaccessible ensures that they might not have the fullest record, uh, that they
otherwise would. (Interviewee 2)

Based on the interview responses, it is not common practice for general medical

practitioners who access the HIE to look specifically for behavioral health information.

96
As such, the participants did not know where this information would be located within

the patient record:

I'm not even recalling if I've seen, like, a particular place where it's only talking
about their behavioral background. (…) We look more at the H&P, the discharge
summaries, the scans, the labs, you know, those types of things. But if there was a
tab like that, I don't even know if I've identified it. (…) Unless it's mixed in with
other notes, like progress notes and stuff, I would look at those. But as far as
going to a particular place to look just for behavioral stuff, I'm not sure that I've
ever done that. I just kind of look at the whole record as a whole. (Interviewee 3)

A participant (Interviewee 4) suggested that it might be beneficial to provide training to

assist healthcare providers in identifying behavioral health information in the patient

record. Adequate training could not only reduce the potential workflow issues associated

with behavioral health information exchange, but it could also facilitate the provision of

appropriate care.

Theme 5: Lack of mandatory training for behavioral health information exchange

The local network administrator for Patient Bridge (Alabama) trained participants

on proper use of the HIE. There was no component of the training that focused

exclusively on the exchange of behavioral health information via Patient Bridge:

(…) I don't know if there's any training or education that (…) specifically had to
do with behavioral health information, but (…) when a new member organization
joins the HIE, uh, that's part of my job, is, is the training and activation part of it,
is to go to that doctor's office or, or post-acute care site, or, you know, go visit,
uh, certain departments within the hospital and teach them about Patient Bridge.
Demonstrate how they can access it, let them know exactly what information they
can expect to find, whether that's behavioral health information or, in Patient
Bridge's case, a lot of times the lack of behavioral health information.
(Interviewee 2)

The training encompassed basic functions within Patient Bridge (e.g., how to log in; what

information can be found within the system; and where to locate it). One participant

97
encountered an issue with querying for non-behavioral health information via Patient

Bridge, but this issue has recently been resolved:

When we first signed up for it, (…) we did a test run. And then again, of course,
we had a problem with the query. So, uh, but we were still able to access the
system and you know, print the things, what we needed off. It... We just weren't
able to do (…) query until recently, apparently. I mean, it was simple. It was just
how to login and you know, um, you know, find the report you're looking for and
printing it off. Um, and it was, it was just simple, basic training. I mean, it's not
hard to maneuver through that system. (Interviewee 5)

The local network administrator provided details about how to access the information

contained within Patient Bridge:

(…) we have two ways people access the HIE. The first is, so like Baptist Health
System, the hospital, it's like integrated into their Cerner EMR. So the idea being
is, you know, you're, you're on a patient chart, a patient landing page. (…) And,
you know, whatever information is in Patient Bridge, they're going to be able to
view within their own EMR and, and right there at their fingertips. (…) And then
we also... so then, like, our home health agencies and post-acute care, they're our,
our view-only members. It's not integrated into their EMR software. So that, uh...
So they, they use it... It's like a web portal. It's just the URL address, and each
user has their own user credentials and login, everything like that. And that's the,
that's the position in which you can, uh, put roles on certain people. So like a
provider versus a nurse versus a registration or something like that, is, in theory,
you know, you could have, uh… So I think how we do it is, the provider... the
nurse... Pardon me, the nurse role is one below the provider, which is the highest
role access. The nurse role is able to retrieve virtually all of the medical record,
um, and then the provider role views virtually all of the record, and then it also is
able to view the family history section, which is where, you know, history of
alcoholism or, you know, something, you know, sensitive diagnoses or
information may appear, if we have it. (Interviewee 2)

The training was not mandatory. In fact, some participants learned about Patient

Bridge via word of mouth:

No, there wasn't [any training]. Basically the way it happened with me was, was
that, you know, I was working one day. And I was, um, doing my work-up on a
patient. Kind of getting the background information on their medical history. (…)
I was telling somebody, I... just kind of under my breath, "Yeah, man, I wish I...
This person has never been here. I wish we had more information on them." (…)
And then one of the, my coworker was like, "Hey, you know, look under Patient

98
 Bridge." And I was like, "What is that?" And then they showed me where it was
in the system. (Interviewee 4)

Similarly, there was no official training for participants to learn how to use CCHN

(Oklahoma). In fact, participants are reluctant to exchange sensitive information (e.g.,

behavioral health information) unless it is on a “need-to-know basis” (Interviewee 1).

However, one interviewee believed that training, particularly for the exchange and use of

behavioral health information, would prove beneficial because it would teach CCHN

participants to send this information to the providers so that they can be aware of

behavioral issues that could complicate the delivery of care:

But as a[n] individual that has not [gone] to schooling for anything like that, I
think definitely. Yeah, I think benefit for some training, you know, to understand,
you know, when a patient has schizophrenia or, um, bipolar or whatever, and
they're angry, you got to know how to calm them down and handle them, you
know. (…) Patients like that tend to be very, um, aggressive and because they
know you don't understand. And so they can be very aggravated very easily, you
know. (Interviewee 1)

Finally, a pilot test could enable healthcare providers to give input about specific

information that would be useful to have for treatment purposes:

(…) I think if we had a pilot test, you know, we could have provided some input
on some things that would have been helpful with regard to what we... What
things we would, like, like to be in there, or have access to. (…) we could
understand why [certain] things aren't accessible. For instance, I don't know, um...
I don't know why mental health is treated differently. You know, for me, in
particular, you know... I, I don't work in that area. So I don't know why the access
to it is so much different from, you know, any other health information on a
person. (Interviewee 4)

The lack of mandatory training for HIE use made it challenging for providers to figure

out how to integrate behavioral health information. However, the interviewees expressed

hope that they will be able to increase utilization of the HIEs in the future.

99
Theme 6: Future utilization of the HIEs

The interviews confirmed that Patient Bridge (Alabama) and CCHN (Oklahoma)

are relatively new initiatives, and knowledge about the existence of these systems is not

yet widespread. It is important to note that the interviewees see the value of exchanging

general health data across HIEs and hope to increase utilization in the near future:

I think now that I know that it's operational, we'll be able to use it more. (…) I
didn't even know it was working till about two weeks ago. (Interviewee 5)

Some participants also saw value in using the systems to exchange behavioral health

information between multiple providers, despite the numerous barriers that currently

exist:

(…) I'm hopeful that in the future, uh, you know, exchanging behavioral and
mental health information will, as, as an industry and everything, that we'll kind
of shift more to the... to the full exchange of that information. (…) I think it
should be just a part of a patient's whole medical record and, you know, when
you're holistically treating a patient, you need to know about any mental or
behavioral health diagnoses or issues they may have. (Interviewee 2)

Finally, a participant believes that these HIEs might be a necessary component to

providing appropriate care to these difficult-to-treat patients:

There's a lot of mental health patients walking around right now, who know or
don't know that they have mental health issues. Who we know or don't know have
mental health issues. And because they're not getting the care, eventually, you
know, something bad happens, and then (…) instead of addressing the mental
health issue, you know, they end up getting locked up and put in jail or
something. (…) I'm hopeful that with putting the systems in place in the, in the
hospitals, as well as a resurgence and then investing in opening facilities to keep
these patients to take care of them, providing the care they need. (Interviewee 4)

100
Summary of Qualitative Results. In summary, interviewees expressed that incorporating

behavioral health information into the patient record would assist in the delivery of

appropriate care, particularly when treating patients in the emergency department or

when handling patients who are in hospice and/or home care. However, there are barriers

to exchanging this information and including it in clinical decision making. These

barriers include regulations; the stigma that continues to surround behavioral health

disorders; and missing and/or difficult-to-locate information within the patient record.

Despite the numerous challenges and barriers, the interviewees are hopeful that the use of

the HIEs will increase and that over time, practitioners will be able to use the HIEs to

exchange both general medical and behavioral health information.

Integration

The mixed methods question for this study was: How do the interview results help

explain the quantitative findings about factors that facilitate and impede obtaining and

using behavioral health information from an HIE? To integrate the quantitative and

qualitative findings and address the mixed methods question, themes from the qualitative

phase were compared with the constructs that were tested in the conceptual model. A

joint display was developed to facilitate a comparison of quantitative and qualitative

results and to develop mixed methods inferences (Table 6).

101
 Table 6: Joint display of the quantitative constructs and qualitative themes related to factors that facilitate or impede behavioral
health information exchange via an HIE.

Quantitative Qualitative Meta-Inferences

Construct Path Theme Illustrative quotes Relationship between
coefficient quantitative constructs and
(P-value) qualitative themes
Performance 0.382 (0.01)* Usefulness of “…if you don’t know The “usefulness” theme provides
Expectancy behavioral health somebody… and you’re having further insight into the
information in to see another provider… that significance of performance
care delivery can help them understand expectancy. Having patients’ full
too… Maybe there’s medical history (including
something… mental status that behavioral health diagnoses and
says, ‘This is why’.” treatment) is helpful, particularly
in the emergency department,
“I think the HIE… [is] very where the physician may be
102

valuable in [the emergency encountering the patient for the

department]… they’ve never first time.
seen this patient before
probably. And they can view
the HIE and get a… broad look
at a health history for this
patient… mental and
behavioral health… diagnoses
that may affect how they want
to treat… or interact with that
patient, and kind of their
bedside manner… within the
emergency department.”

102
 “If I have a patient that comes
in with either altered level of
consciousness, or they come in
with a drug overdose, or…
some kind of acute confusion
going on… it would be helpful
to know if there was any pre-
existing… mental health issue
that required medications that
could have instigated that
situation.”
Effort Expectancy 0.055 (0.72) Missing or “Okay, the information may be Effort expectancy did not predict
difficult-to- there, but where does it appear intention to exchange behavioral
locate behavioral for the doctor? …Does this fit health information via the HIEs.
health into their workflow? …an HIE However, interviewees expressed
information is only as good as, you know, concern that behavioral health
103

its providers are at using it, so information would be difficult to

it can’t have… an impact on
patient care or patient
outcomes unless… the
providers or nurses or front
office staff are actually
utilizing and putting to good
use.”
locate in the HIE, thus
suggesting that learning to
identify and exchange this
information would require
additional effort from the
provider.

“Patient Bridge, I think…

accesses some general
discharge information,
admission and discharge
information… I don’t recall
seeing anywhere where there
was… listings of medications
there. Again, we have that

103
 separate somewhere else in our
system.”

“When I pull [Patient Bridge]

up, I look at the whole clinical
dashboard. I’m not even
recalling if I’ve seen, like, a
particular place where it’s only
talking about their behavioral
background.”
Social Influence -0.043 (0.72) No themes No quotes related to social Social influence did not predict
related to social influence emerged from the intention to exchange behavioral
influence interviews. health information via the HIEs.
emerged from The interviewees did not discuss
the interviews. efforts from supervisors to
encourage behavioral health
104

information exchange. Therefore,

no themes or quotes related to
social influence emerged.
Perceived Risk 0.061 (0.47) Regulations “The priority is making sure Perceived risk did not predict
restricting the that we are… in the clear when intention to exchange behavioral
exchange of it comes to [regulations such health information via the HIEs,
behavioral health as] 42 CFR Part 2, you know? but the interviewees
information The priority is not ensuring that acknowledged regulations (e.g.,
behavioral and mental health 42 CFR Part 2) that restrict the
information is able to make it exchange of this information.
to the next provider on the The organization could risk
HIE.” facing fines if these regulations
are violated.

104
 Behavioral “You know, behavioral health
health stuff… there’s a lot of taboo
information tied to what’s going on with
exchange and people… It’s a little bit more
stigma challenging to access that
information. People are a lot
less likely to just release that
information.”
“I think you could kind of
make the case that… the long-
standing stigma that our society
has had against, you know,
mental health issues or
behavioral health issues… kind
of manifests itself in… 42 CFR
or other… regulatory
captures.”
105
Trust 0.539 No themes No quotes related to trust
(0.00)** related to trust emerged from the interviews.
emerged from
the interviews.
Trialability 0.093 (0.34) Lack of “No, there wasn’t [any
mandatory training]… I think if we had a
training for pilot test, you know, we could
behavioral health have provided some input on
things that would have been
105
The interviewees identified a
second level of risk: risk to the
patient. Because behavioral
health disorders are highly
stigmatized, patients fear the
possibility of persecution and/or
loss of employment if this
information is released.
Trust predicted intention to
exchange behavioral health
information via the HIEs. The
interviewees did not express
beliefs that behavioral health
information is less trustworthy
than general medical
information, so it did not emerge
as a theme in the qualitative
phase of the study.
Trialability did not predict
intention to exchange behavioral
health information via the HIEs.
The training that was provided
focused on basic information
 information helpful with regard to what
exchange we… would like to be in there,
or have access to… we could
understand why [certain] things
aren’t accessible.”
related to the HIEs, and it was
not mandatory. No aspect of the
training focused on exchanging
and obtaining behavioral health
information from the HIEs.

“I don’t know if there’s any

training or education… that
specifically had to do with
behavioral health information,
but… when a new member
organization joins the HIE…
that’s part of my job… is the
106

training and activation part of

it.”

“…he did a training for us… I

mean, mostly, it was just
knowledge of how to get [the
information] we needed to
get… It was more of a
physically using the website
kind of training.”

Behavioral 0.127 (0.68) Future utilization “…I’m hopeful that in the
Intention of the HIEs future… exchanging behavioral
and mental health information
will… as an industry… that
we’ll kind of shift more to
the… full exchange of that
information. …I think it should
be just a part of the patient’s
Behavioral intention did not
predict actual use of the HIEs to
exchange behavioral health
information. This finding is
likely due to the fact that
participation in behavioral health
exchange efforts is low.
However, the interviewees

106
 whole medical record and, you
know, when you’re holistically
treating a patient, you need to
know about any mental or
behavioral health diagnoses or
issues they may have.”
expressed some hope that in the
future, it will become standard
practice to share patients’
behavioral health records.

“…I’m hopeful that with

putting systems in place… in
the hospitals, as well as a
resurgence and then investing
in open facilities to keep these
patients, to take care of them,
providing the care they need.”

“…I think now that I know

[Patient Bridge is] operational,
we’ll be able to use it more…
like I said, I didn’t even know
107

it was working ‘til about two

weeks ago.”
The far right column examines the quantitative constructs and qualitative themes in conjunction to highlight concordance and
discordance in the findings.

107
As Table 6 demonstrates, there were 7 constructs tested in the conceptual model that was

developed for the quantitative phase of the study: 1) performance expectancy; 2) effort

expectancy; 3) social influence; 4) perceived risk; 5) trust; 6) trialability; and 7)

behavioral intention. Six themes emerged from the qualitative interviews: 1) Usefulness

of behavioral health information in care delivery; 2) Missing or difficult-to-locate

behavioral health data; 3) Regulations restricting the exchange of behavioral health

information; 4) Behavioral health information exchange and stigma; 5) Lack of

mandatory training for behavioral health information exchange; and 6) Future utilization

of the HIEs.

Performance Expectancy

Performance expectancy was a significant predictor of intention to use behavioral

health information obtained from an HIE. Interviewees elucidated that behavioral health

information would be useful in care delivery, particularly in the emergency department,

where physicians and other care providers may be encountering the patient for the first

time. Having access to a patient’s full medical history, including behavioral health

diagnoses, can be useful in developing an appropriate plan of care, as well as for

coordinating post-discharge care.

Effort Expectancy

Effort expectancy did not emerge as a significant predictor of intention to use

behavioral health information obtained from an HIE. However, the interviewees shared

concerns about locating behavioral health information in the system and the potential

impacts on workflow. Interviewees stated that they were uncertain about how behavioral

health information would appear within the HIE (e.g., is there a separate tab for them to

108
click in order to access a patient’s behavioral health information, or is it combined with

the general medical history?). Contrary to the initial quantitative results, these statements

suggest that the participants believe that it would require effort on their part to learn to

identify and exchange behavioral health information via the HIE. This is an interesting

finding that warrants further research.

Perceived Risk

Perceived risk did not emerge as a significant predictor of intention to use

behavioral health information obtained from an HIE. However, the interviewees

discussed two barriers to behavioral health information exchange that, if ignored, could

place healthcare organizations and patients at risk. The first barrier is the existing

regulations that restrict the sharing of patients’ behavioral health history. One interviewee

specifically mentioned 42 CFR Part 2, which pertains to treatment for substance use

disorders. Other interviewees did not name particular regulations and policies, but they

indicated an awareness of these policies. Overall, the participants agreed that behavioral

health information would be useful in the delivery of care, but the priority of the health

system is to ensure that they are not placing the organization at risk by violating

regulations that protect patient privacy and confidentiality.

A second barrier is the stigma that continues to surround behavioral health

disorders. One interviewee suggested that this stigma precipitated the creation of the

regulations discussed in the previous paragraph. Because behavioral health disorders are

still considered taboo, there is still a fear of persecution and loss of employment if

information disclosing a patient’s diagnosis and/or treatment is leaked. These potential

outcomes put behavioral health patients at a high level of risk. Given that behavioral

109
health information exchange via HIEs could place both patients and healthcare

organizations at risk, it is interesting to note that perceived risk did not emerge as a

significant predictor of intention to use behavioral health information obtained from an

HIE. Further research is warranted.

Trust

Trust was a significant predictor of behavioral intention to use behavioral health

information obtained from an HIE. However, no themes related to trust emerged in the

subsequent qualitative interviews. A potential explanation for this finding is that the

survey and interview questions were related to trust in the information that is being

received through the HIE. The trends from the initial quantitative survey indicated that

the participants believe that behavioral health information is trustworthy and reliable. The

subsequent qualitative phase of included interview questions that explored whether the

interviewees believed that behavioral health information was less trustworthy or less

reliable than general medical information. The interviewees did not express any concerns

related to the trustworthiness or reliability of behavioral health information, compared to

general medical information.

Trialability

Trialability did not emerge as a significant predictor of intention to use behavioral

health information obtained from an HIE. Some of the interviewees stated that they

participated in training for the use of the systems, in which they learned basic information

(e.g., how to log in to the HIE, what information could be found within the system, and

where to find the information). However, other interviewees did not participate in the

training, which indicates that the training was not mandatory. Furthermore, there was no

110
aspect of the training that focused specifically on behavioral health information (e.g.,

how to identify behavioral health information or where to locate it within the system).

The lack of mandatory training could partially explain why the trailability construct did

not significantly predict intention to use behavioral health information from the HIE.

Behavioral Intention

Behavioral intention did not emerge as a significant predictor of actual use of

behavioral health information obtained from the HIE. This finding was likely due to the

fact that only a few participants (6 total, or 9.68% of the sample) reported that they obtain

and use behavioral health information from their organization’s HIE. However, the

interviewees acknowledged that there is value in obtaining behavioral health information

from the HIE so that the care team can have a more complete understanding of patients’

needs. Although the interviewees expressed doubt that incorporating behavioral health

information into patients’ electronic medical records (EMRs) will become standard

practice in the near future, they expressed hope that hospitals and health systems will

eventually shift to the full exchange of patient information so that they can deliver

appropriate care to chronically ill patients with a behavioral health comorbidity.

In conclusion, only two constructs (performance expectancy and trust) emerged as

significant predictors in the initial quantitative phase of the study. One theme (Usefulness

of behavioral health information in care delivery) emerged from the subsequent

qualitative phase that provided further insight into the significance of the performance

expectancy construct. However, there were a number of divergent findings. Perceived

risk did not emerge as a significant predictor in the quantitative phase, but the

interviewees identified existing regulations and stigma as barriers to behavioral health

111
information exchange. While trust was found to be a significant predictor of behavioral

intention in the quantitative phase, it did not emerge as a theme in the subsequent

qualitative phase. Trialability did not emerge as a significant predictor of behavioral

intention in the quantitative phase, but the interviewees discussed a lack of training

(specifically for behavioral health information exchange) in the subsequent qualitative

phase. Finally, behavioral intention was not a significant predictor of actual use of the

HIEs for the purposes of behavioral health information exchange. This is likely due to the

fact that participation in behavioral health information exchange efforts at these two

study sites is low. However, interviewees expressed hope that in the future, the HIEs will

be used to exchange the full patient record, including any behavioral health diagnoses or

treatment.

Summary

The results of the quantitative phase of the study were presented first.

Performance expectancy and trust were found to be significant predictors of intention to

use behavioral health information obtained from the HIE. However, behavioral intention

was not a significant predictor of actual use, but this could be partially explained by the

low number of participants who exchange and use behavioral health information from the

HIE.

Next, the results of the qualitative phase were presented. Six themes emerged

from the interview transcripts. Finally, the quantitative and qualitative findings were

integrated using a joint display to offer more in-depth explanations of the trends that

emerged from the initial quantitative phase.

112
 CHAPTER 5

DISCUSSION, IMPLICATIONS, AND FUTURE RESEARCH

The purpose of this sequential explanatory mixed methods study was to identify

and explain factors that facilitate and impede the use of behavioral health information

from an HIE. This chapter provides a discussion of the findings from the quantitative and

qualitative phases of the study, as well as a discussion of the integrated findings. Next,

the limitations of the current study are examined. Finally, the implications of the study

are outlined, and directions for future research are provided.

This chapter discusses the findings and future research opportunities to answer the

following research questions:

• QUAN-RQ1: What factors influence intention to use behavioral health

information obtained from HIEs in hospitals?

• QUAL-RQ1: From the healthcare providers’ perspective, what are the facilitators
of and barriers to obtaining and using behavioral health information from an HIE?

• MM-RQ1: How do the interview results help explain the quantitative findings
about factors that facilitate and impede obtaining and using behavioral health
information from an HIE?

Discussion of the Findings

Findings from the Quantitative Phase

The quantitative phase of this study tested the following hypotheses that were

derived from the conceptual model:

• H1: Performance expectancy has a positive (+) impact on intention to use

behavioral health information obtained from a health information exchange (HIE)
system.

113
 • H2: Effort expectancy has a positive (+) impact on intention to use behavioral
health information obtained from an HIE.

• H3: Social influence has a positive (+) impact on intention to use behavioral
health information obtained from an HIE.

• H4: Perceived risk has a negative (-) impact on intention to use behavioral health
information obtained from an HIE.

• H5: Trust has a positive (+) impact on intention to use behavioral health
information obtained from an HIE.

• H6: Trust has a negative (-) impact on perceived risk of using behavioral health
information obtained from an HIE.

• H7: Trialability has a (+) impact on intention to use behavioral health information
obtained from an HIE.

• H8: Intention to use has a positive (+) impact on use behavior of behavioral health
information obtained from an HIE.

The conceptual model was tested using PLS-SEM, and two paths were revealed to have

statistically significant coefficients, lending support for H1 and H5. The relationship

between performance expectancy and behavioral intention was statistically significant, as

was the relationship between trust and behavioral intention.

Findings from the Qualitative Phase

The interviews were conducted in order to gain additional insights about the

trends that emerged from the quantitative surveys. Six themes emerged from the

interviews: (a) Usefulness of behavioral health information in care delivery; (b)

Regulations restricting the exchange of behavioral health information; (c) Behavioral

health information exchange and stigma; (d) Missing or difficult-to-locate behavioral

health information; (e) Lack of mandatory training for behavioral health information

exchange; and (f) Future utilization of the HIEs. These themes not only offer further

114
explanation for the trends that emerged from the initial quantitative phase of the study,

but they also reveal additional factors that could facilitate or impede the exchange of

behavioral health information via an HIE.

Integration of the Quantitative and Qualitative Findings

A joint display was created in order to demonstrate the findings of the quantitative

and qualitative phases of the study together and to generate meta-inferences (see Table

6). The first theme from the qualitative phase of the study (Usefulness of behavioral

health information in care delivery) further explains the significance of the performance

expectancy construct from the quantitative phase. It is necessary for healthcare providers

have access to a patient’s full medical history, including any behavioral health issues, so

that they can develop an appropriate plan of care.

Performance Expectancy and Behavioral Intention. The influence of performance

expectancy on behavioral intention is supported in the literature. As mentioned in

Chapter 2, performance expectancy has been found to be the strongest predictor of

behavioral intention to use technology in numerous studies, including within the context

of healthcare (Davis, 1989; Davis et al., 1989; Moore & Benbasat, 1991; Thompson et

al., 1994; Venkatesh et al., 2003; Chang et al., 2007; Kijsanayotin et al., 2009; Toh,

2013).

While performance expectancy is often found to have the strongest impact on

behavioral intention, in some contexts, other factors are more influential (e.g., effort

expectancy and social influence) (Cimperman, Brencic, & Trkman, 2015; Wills et al.,

2008; Venkatesh & Morris, 2000). Performance expectancy has also been found not to

predict intention (Schaper & Pervan, 2007; Ifinedo, 2012). It is possible that having

115
knowledge about the potential benefits of using technology might not provide adequate

motivation for healthcare professionals to adopt the technology, particularly if other

contextual factors are at play (Ifinedo, 2012). This explanation aligns with the findings

that emerged from the current study. Although the survey participants believed that

exchanging behavioral health information through an HIE would improve job

performance, the majority of the participants (90.32%) reported that they do not currently

participate in behavioral health information exchange.

Usefulness of behavioral health information in care delivery. The interviewees

elaborated on the influence of performance expectancy on behavioral intention by stating

that having access to patients’ full medical record would assist in the delivery of better

care. This idea is present in the literature. Patients with a behavioral health diagnosis are

frequent users of emergency department services. Not only are these patients admitted for

health issues, but they often come to the emergency department for last-minute refills

without knowing necessary information about the prescription (Greene, 2013). It is an

established premise that patients with behavioral health diagnoses may not be reliable

historians of their health (Frith, 1979; Frith, 2014; Bedford & David, 2014).

To further complicate matters, EHRs frequently fail to capture behavioral health

data: information related to diagnoses, hospitalization for acute psychiatric services, and

total outpatient care days are eliminated from the patients’ medical record at alarming

rates (Madden et al., 2016). Similarly, in the current study, interviewees recognized the

potential pitfalls of relying on patient recall, particularly when working with behavioral

health patients.

116
 Trust and Behavioral Intention. The extended UTAUT model examines the

influence of trust on behavioral intention. Trust was found to be a predictor of behavioral

intention in the context of mobile payments across multiple studies (Chandra et al., 2010;

Shin, 2010; Lu et al., 2011; Shaw, 2014), and in some cases (Chandra et al., 2010; Shin,

2010), trust emerged as the most significant predictor of behavioral intention (Slade et al.,

2015). In the context of healthcare, trust has been found to predict intention to use

technology among both patients and physicians (Alaiad & Zhou, 2013; Hsieh, 2015).

The current study is not consistent with the Hsieh (2015) study with regard to the

relationships between perceived risk and intention to use and trust and perceived risk.

Given the heightened restrictions surrounding the exchange of behavioral health

information, further research is warranted to understand why perceived risk was not a

predictor of intention to use behavioral health information obtained from an HIE in the

quantitative phase.

Trust did not emerge as a theme in the subsequent qualitative interviews. This is

likely due to the fact that the interviewees, on the whole, did not believe that behavioral

health information is somehow less reliable in clinical decision making than general

medical information. In fact, only one participant (Interviewee 4) expressed concerns

about the reliability of behavioral health information, and these concerns would only

arise if the participant were unable to verify the source of the information. Based on the

interview responses, the other participants did not feel that behavioral health data are any

less reliable than general medical data.

Regulations restricting the exchange of behavioral health information. The

interviewees acknowledged the existence of regulations that limit their ability to

117
exchange behavioral health information via their organization’s HIE, regardless of the

potential benefits that could come from having the full patient record. Specifically, one of

the interviewees mentioned 42 CFR Part 2. This finding is consistent with the extant

literature. 42 CFR Part 2 restricts the exchange of information related to a substance use

disorder (e.g., receiving treatment for such a disorder) unless the patient provides written

consent (Awad, 2013). However, 42 CFR Part 2 is not always applicable. Some facilities

have HIEs that are designed to properly identify and manage substance abuse

information, and these systems enable compliance with existing regulations (SAMHSA,

2014), but many systems are not programmed to comply with the additional

confidentiality requirements established by 42 CFR Part 2 (Lardiere, 2013; McGregor et

al., 2015). To reduce the risk of violating 42 CFR Part 2, healthcare facilities whose

systems are not designed to identify and manage substance abuse data opt out of

integrating this information into the patient record (SAMHSA, 2014). The literature

supports the low participation rates in behavioral health information exchange (9.68%)

that emerged from the current study. Furthermore, as one interviewee stated explicitly, it

is important to note that one of the first priorities of a health system is to ensure that it is

compliant with existing regulations and policies. While improving the quality of patient

care is essential to health systems, it must be done within the bounds of regulations like

42 CFR Part 2.

Behavioral health information exchange and stigma. In addition to regulations

that restrict behavioral health information exchange, the interviewees also acknowledged

that behavioral health disorders continue to be stigmatized. This idea is consistent with

the literature: the stigma surrounding behavioral health contributed substantially to the

118
policies and regulations (e.g., 42 CFR Part 2) that make this information more secure

(McGregor et al., 2015; Wakeman & Freidmann, 2017). These policies, however well-

intentioned at the time of their creation, pose substantial barriers to the delivery of quality

care (Wakeman & Friedmann, 2017).

Potential violations of existing regulations and the stigma surrounding behavioral

health would put patients, healthcare providers, and healthcare organizations at risk if

behavioral health records were leaked as a result of a data breach. If the regulations are

violated, the healthcare organizations could face financial penalties. Likewise, if a

patient’s behavioral health records are compromised as a result of a data breach, the

patient could face persecution, job loss, and loss of job-related benefits. However,

perceived risk was not found to be a significant predictor of intention to use behavioral

health information obtained from the HIEs. This was an unexpected finding, given the

sensitivity of behavioral health information. Further research is warranted.

Missing or difficult-to-locate behavioral health information. The interviewees

stated that they do not know how to access behavioral health information within the HIE.

More specifically, they expressed uncertainty about whether this information is kept

separate from the rest of a patient’s medical history. These reports are consistent with the

literature. In fact, hospitals often keep psychiatric treatment information separate from

the rest of the patient record, which presents several challenges (Greene, 2013; Kozubal

et al., 2013).

One of the concerns about incorporating behavioral health information into the

patients’ medical records was related to workflow. Based on the interviews, providers of

general medical care have been unable to locate this information; this issue could reduce

119
efficiency in the process of care delivery. This concern was also voiced in a study that

examined behavioral health care providers’ beliefs about using HIEs in their work

(Shank, 2011). The results of the current study suggest that general medical care

providers share this sentiment.

Interestingly, effort expectancy was not a significant predictor of intention to use

behavioral health information obtained from the HIE, despite the concerns the

interviewees expressed. However, it is necessary to reiterate that 90.32% of the

participants did not exchange behavioral health information through the HIE. The

interview provided an opportunity for the participants to expand on their perceptions, as

well as to discuss their experience (or lack thereof) with exchanging behavioral health

information electronically. It is possible that the quantitative findings would have been

different if more of the participants had actual experience with behavioral health

information exchange.

Lack of mandatory training for behavioral health information exchange.

Interviewees stated that the training provided focused primarily on basic functions of the

organizations’ HIEs (e.g., how to log in to the system, how to access information within

the patient record). Similarly, Bruns and colleagues (2018) stated that the resources

required for implementation and training are numerous, and this frequently acts as a

barrier to the adoption and implementation of EHRs in behavioral health settings.

Furthermore, the information that is captured and managed by behavioral health care

providers is more qualitative in nature (e.g., psychotherapy notes), while general medical

information is more structured (Bruns et al., 2018). Applying these points to the context

of the current study, it is unlikely that general medical practitioners would be able to

120
make use of behavioral health information exchanged via the HIE without proper

training.

It is important to note that trialability did not emerge as a significant predictor of

intention to use behavioral health information obtained from the HIE. The qualitative

interviews revealed that the training that was provided did not focus specifically on

behavioral health information exchange. The interviews could offer a partial explanation

for the findings from the initial quantitative phase of the study.

Behavioral intention and future utilization of the HIEs. Behavioral intention was

not found to be a significant predictor of actual use of behavioral health information

obtained from an HIE. This finding likely emerged because the participation in

behavioral health information exchange efforts at the two study sites is low. However, in

the qualitative phase of the study, interviewees expressed hope that in the future, the

HIEs will be used to exchange the full patient record, including any behavioral health

diagnoses or treatment.

Contribution to Theory

Chapter 2 outlined two primary theoretical frameworks that were used to study

the facilitators of and barriers to behavioral health information exchange via an HIE:

UTAUT and diffusion of innovation theory. The results of the study and the ways in

which they connect to these theoretical frameworks are discussed in the following

sections.

UTAUT Framework

UTAUT gauges technology acceptance within organizations by examining the

following factors that are proposed to influence intention to use technology: performance

121
expectancy, effort expectancy, and social influence. Extensions of the UTAUT model

have also considered the influence of additional factors, such as perceived risk and trust.

In the context of the current study, performance expectancy and trust were significant

predictors of intention to use behavioral health information obtained via the

organizations’ HIEs. The study revealed that a positive association exists between both

performance expectancy and intention to use and trust and intention to use. In other

words, healthcare providers who perceived that using behavioral health information

obtained from the HIEs in would improve their job performance (e.g., enable them to

make more appropriate treatment recommendations) more frequently reported that they

would send and receive behavioral health information via the HIEs. On the other hand,

providers who had less favorable perceptions of the usefulness of behavioral health

information in performing their jobs less frequently reported that they would use the

systems to send and receive behavioral health information. Similarly, providers who

agreed that they would find behavioral health information that they received through the

HIEs reliable more frequently reported that they would engage in behavioral health

information exchange. Those who doubted the reliability of behavioral health information

received through the HIEs less frequently reported that they would participate in

behavioral health information exchange.

Effort expectancy and perceived risk were not found to be significant predictors

of intention to use behavioral health information from the HIE in the quantitative phase

of this study. However, themes related to effort and perceived risk emerged in the

subsequent qualitative phase. The emergence of these themes suggests that to some

122
extent, effort expectancy and perceived risk could influence intention to participate in

behavioral health information exchange.

Diffusion of Innovation

Diffusion of innovation theory examines five determinants of the rate of adoption

of an innovation: 1) relative advantage; 2) compatibility; 3) complexity; 4) trialability;

and 5) observability. Four of the determinants (relative advantage, compatibility,

complexity, and observability) are closely related to the constructs that were presented in

UTAUT, so they were not included in the conceptual model to be tested. However,

trialability is not captured in UTAUT. The trialability determinant considers the degree to

which employees can experiment with the innovation before it is implemented. In the

context of the current study, trialability was not a significant predictor of intention to use

behavioral health information obtained from the HIEs in the quantitative phase. However,

lack of formal training in behavioral health information exchange did emerge as a theme

in the subsequent qualitative phase. This theme suggests that the lack of formal training

in behavioral health information exchange is likely a deterrent to sharing this information

via the HIEs.

Contribution to Practice

Healthcare providers have traditionally limited the practice of health information

exchange to general medical data (ONC for Health Information Technology, 2014).

However, behavioral health conditions have become a public health concern, and the

connection between physical health and behavioral health is becoming an accepted

premise in the healthcare field (Ranallo, Kilbourne, Whatley, & Pincus, 2016; Grando et

al., 2017). Early clinical trials that have integrated behavioral health into general medical

123
care (e.g., within primary care settings) have demonstrated better physical and mental

health among patients (Druss, Rohrbaugh, Levinson, & Rosenheck, 2001; Unutzer et al.,

2002; Alexopoulos et al., 2009; Grando et al., 2017). Furthermore, some healthcare

providers have expressed concerns about omitting behavioral health data from the patient

record. For example, not having access to a patient’s full medical history could hinder a

physician’s ability to make an appropriate treatment recommendation for a medical

illness (Grando et al., 2017, p. 248, Table 6). The findings of the current study lend

support to the notion that behavioral health information exchange could help healthcare

providers deliver better care to patients.

Contribution to Policy

In order to deliver integrated care, different types of providers in various

treatment settings must have access patients’ full medical history (SAMHSA-HRSA

Center for Integrated Health Solutions). As of 2014, 11 states allowed both primary care

and behavioral health care providers to participate in the practice of health information

exchange; the states were all at different stages of implementation (SAMHSA-HRSA

Center for Integrated Health Solutions). The states who have undertaken efforts to

facilitate the exchange of behavioral health information via HIEs agree on the following:

• It is important to educate 1) patients on their rights to privacy; 2) stakeholders

about existing policies that impede behavioral health information exchange and

potential strategies to facilitate compliance; 3) stakeholders about the benefits of

behavioral health information exchange and why it is important to start

incorporating this into practice sooner rather than later;

124
 • It is necessary to encourage the integration of behavioral health information into

the HIEs by including behavioral health care providers and technology vendors

in decision-making and standards development activities;

• It is prudent to consider existing regulations (e.g., relaxing or reinterpreting 42

CFR Part 2), as well as to establish guidelines and standards for best practices

when handling sensitive information (SAMHSA-HRSA Center for Integrated

Health Solutions).

Currently, SAMHSA is proposing to revise the 42 CFR Part 2 regulation in an

effort to coordinate care for patients with substance use disorders; the proposed changes

are primarily in response to the opioid epidemic (hhs.gov). This effort is the first of four

regulations that aim to increase the value of care delivered to patients by addressing

barriers to coordinated care (hhs.gov). Elinore McCance-Katz, the first Assistant

Secretary for Mental Health and Substance Use, stated the following regarding the

omission of behavioral health information: “The lack of critical substance use history in a

patient’s medical record can lead to potentially damaging consequences for a person with

a substance use disorder and can further stigmatize these conditions” (hhs.gov).

Limitations of the Current Study

There are some limitations to the current study. The first is the small sample size

for both the quantitative and qualitative phases of the study. A nonparametric method of

analysis (PLS-SEM) was selected for the quantitative phase to address the sample size

issue. Although the findings that emerged are valid in the context of the current study

(specifically, at the Alabama and Oklahoma study sites), the results are not widely

generalizable. Furthermore, the relationships between various constructs that were found

125
in the quantitative phase of the study cannot be deemed causal. Similarly, because there

were few participants who exchange behavioral health information via the HIEs, there

was not enough variation in the responses to compare participants to non-participants

(e.g., it was not possible to determine whether the predictors varied between the two

groups). The use of convenience sampling might have contributed to the lack of variation

in the responses. However, the lack of active participants in the behavioral health

information exchange initiatives could also be partially explained by the novelty of both

Patient Bridge (Alabama) and CCHN (Oklahoma).

Likewise, the qualitative phase of the study has some limitations. The first is the

small number of participants from Oklahoma (CCHN) in the interviews: only 1

participant was associated with CCHN, and the remaining 4 were associated with

Alabama (Patient Bridge). With regard to Patient Bridge, the results of the qualitative

interviews revealed that not all of the participants are using the system to exchange

patients’ medical records (whether they contain behavioral health information or not). In

fact, some of the participants reported that they only learned about Patient Bridge within

the past few months, even though it has been in existence for nearly 2 years.

Another limitation of the study is the lack of medical care providers (e.g.,

physicians, nurse practitioners) represented in the qualitative interviews. 62.91% of the

participants self-identified as a physician, nurse, nurse practitioner, or physician assistant.

However, only 1 of the 5 interviewees (a nurse practitioner) actually delivered care to

patients. Similarly, only 10 physicians completed the initial quantitative survey; the

results of the qualitative interviews indicated that Oklahoma (CCHN) has built roles-

126
based access into its HIE. Roles-based access restricts viewing of sensitive information

(such as a behavioral health diagnosis) to physicians.

Recommendations for Future Research

There are several recommendations to contribute further to this area of research.

One contribution is to identify behavioral health patients whose information has been

exchanged via the HIEs for interview participation in order to understand their

perspectives on the benefits and challenges of exchanging their behavioral health records

via the HIEs. Another recommendation is to replicate the study in other states.

Specifically, Maryland has begun to experiment with the practice of exchanging

behavioral health information via its statewide HIE. Chesapeake Regional Information

System for our Patients (CRISP) developed plans to implement open source software,

Consent2Share, which will enable healthcare providers to access behavioral health

information via the CRISP interface if the names of those providers are contained in the

patients’ written consent (Maryland Behavioral Health Coalition, 2017). In a letter to

former Secretary of the Maryland Department of Health Dennis Schrader, the coalition

emphasized:

“Integration [of care] would be substantially enhanced with this progressive HIE
that can provide both behavioral and somatic health data to both behavioral and
somatic health providers. We urge the Department to continue supporting the
implementation of this new initiative.” (Maryland Behavioral Health Coalition,
2017)

A recent conversation between the researcher and a colleague revealed that Maryland has

begun to allow the exchange of behavioral health information using Consent2Share. One

future research direction would be to replicate the current study in the state of Maryland

in order to determine if there are any additional factors that influence healthcare

127
providers’ intentions to participate in behavioral health information exchange. To

increase response rates, incentives could be provided in the Maryland study. A final

avenue of future research is to conduct a longitudinal study. The longitudinal study will

serve to determine whether participation in the behavioral health exchange initiatives in

the two states have increased over time and to gauge whether the factors that predict

intention to participate have changed.

Conclusion

Hospital readmissions are common occurrences among patients with behavioral

health disorders. A number of factors contribute to this pattern, including poverty, weak

networks of social support, and the existence of physical comorbidities. To make matters

worse, regulations have traditionally impeded the exchange of behavioral health

information (e.g., substance abuse and mental health diagnoses) unless the patient has

given consent. 42 CFR Part 2, one of the primary barriers to the exchange of substance

abuse information, is in the process of being relaxed in an effort to facilitate the exchange

of this information. However, many healthcare providers are uncertain about what is and

is not permitted with regard to information exchange, and they err on the side of caution.

For these and other reasons, research that focuses on the potential of HIEs to integrate the

behavioral and general health services arenas is limited. However, the prevalence of

suboptimal treatment outcomes for behavioral health patients with chronic illnesses

indicates that it is necessary to commit more efforts to providing higher quality care to

some of the most vulnerable patients.

The results of the current study indicate that healthcare providers believe that

having patients’ complete patient record, including any information related to behavioral

128
health, would be useful in delivering better care to patients. Furthermore, having the

complete patient record would be particularly helpful in emergency situations. The

providers also indicated that trusting the behavioral health information that they receive

from the HIEs would influence their willingness to incorporate this information into the

patients’ medical records and into clinical decision-making. However, there are a number

of barriers that complicate the exchange of behavioral health information via HIEs. These

barriers include existing regulations (namely 42 CFR Part 2); the stigma surrounding

behavioral health disorders; lack of training in using the systems to exchange behavioral

health information; and missing and/or difficult-to-locate behavioral health information.

The current study contributes to our understanding of the potential role of HIEs in

integrating the traditionally fragmented behavioral and general health service arenas.

Healthcare providers are becoming increasingly aware that integrating behavioral health

services into the care continuum is a necessary step to improving health outcomes

(Chapman, Chung, & Pincus, 2017). The results of the study could encourage reluctant

healthcare providers to invest in the technology that will help to achieve those goals:

better experience of care, improved population health, and lower healthcare costs.

Furthermore, the study highlights the regulatory, cultural, and technical barriers to the

exchange of behavioral health information. Addressing these barriers will be crucial to

the future success of behavioral health information exchange initiatives.

129
 REFERENCES

Abdeljalil, A.-B., Arbus, C., Montastruc, F., de Souto Barreto, P., André, L., Vellas, B.,
& Rolland, Y. (2019). Antidepressants in nursing homes for dependent older
patients: the cross-sectional associations of institutional factors with prescription
conformance. European Geriatric Medicine, 1-10.

Adler-Milstein, J., Bates, D. W., & Jha, A. K. J. (2011). A survey of health information
exchange organizations in the United States: implications for meaningful use.
Annals of Internal Medicine, 154(10), 666-671.

Ahmad, F., S., Metlay, J. P., Barg, F. K., Henderson, R. R., & Werner, R. M. (2013).
Identifying hospital organizational strategies to reduce readmissions. American
Journal of Medical Quality, 28(4), 278-285.

Ahmedani, B. K., Solberg, L. I., Copeland, L. A., Fang-Hollingsworth, Y., Stewart, C.,
Hu, J., … & Lu, C. Y. (2015). Psychiatric comorbidity and 30-day readmissions
after hospitalization for heart failure, AMI, and pneumonia. Psychiatric Services,
66(2), 134-140.

Akay, C. (2017). Turkish high school students’ English demotivation and their seeking
for remotivation: A mixed method research. English Language Teaching, 10(8),
107-122.

Alaiad, A., & Zhou, L. (2013). Patients’ behavioral intention toward using healthcare
robots. Proceedings of the 19th Americas Conference on Information Systems.
Chicago, IL. Retrieved from
https://www.researchgate.net/profile/Ahmad_Alaiad/publication/2699877
41_Patient_Behavioural_Intention_toward_Adopting_Healthcare_Robots/link
s/5597be0f08ae793d137cd893/Patient-Behavioural-Intention-toward-
Adopting-Healthcare-Robots.pdf.

Alakeson, V., Frank, R. G., & Katz, R. E. (2010). Specialty care medical homes for
people with severe, persistent mental disorders. Health Affairs, 29(5), 867-873.

AlAwadhi, S., & Morris, A. (2008). The Use of the UTAUT Model in the Adoption of E-
government Services in Kuwait. Paper presented at the Hawaii International
Conference on System Sciences, Proceedings of the 41st Annual.

Al-Busaidi, Z. Q. (2008). Qualitative research and its uses in health care. Sultan Qaboos
University Medical Journal, 8(1), 11.

Alexander, E. C., de Silva, D., Clarke, R., Peachey, M., & Manikam, L. (2018). A before
and after study of integrated training sessions for children's health and care

130
 services. Health & Social Care in the Community, 26(6), 801-809.

Alexopoulos, G. S., Reynolds IIIm MD, C. F., Bruce, M. L., Katz, I. R., Raue, P. J.,
Muslant, B. H., … & PROSPECT Group. (2009). Reducing suicidal ideation and
depression in older primary care patients: 24-month outcomes of the PROSPECT
study. American Journal of Psychiatry, 166(8), 882-890.

Al-Shafi, S., & Weerakkody, V. (2010). Factors Affecting E-government Adoption in the
State of Qatar. European and Mediterranean Conference on Information Systems.

American Hospital Association (2012). Bringing behavioral health into the care
continuum: Opportunities to improve quality, costs and outcomes.

Anderson, J. C., & Gerbing, D. W. (1988). Structural equation modeling in practice: A

review and recommended two-step approach. Psychological Bulletin, 103(3), 411.

Annamalai, A., Staeheli, M., Cole, R. A., & Steiner, J. L. (2018). Establishing an
integrated health care clinic in a community mental health center: Lessons
learned. Psychiatric Quarterly, 89(1), 169-181.

Ashton, C. M. & Wray, N. P. (1996). A conceptual framework for the study of early
readmission as an indicator of quality of care. Social Science & Medicine, 43(11),
1533-1541.

Awad, S. (2013). Confused by confidentiality? A primer on 42 CFR Part 2. Retrieved

from
https://www.asam.org/resources/publications/magazine/read/article/2013/08/15/co
nfused-by-confidentiality-a-primer-on-42-cfr-part-2.

Barnett, J., Vasileiou, K., Djemil, F., Brooks, L., & Young, T. (2011). Understanding
innovators' experiences of barriers and facilitators in implementation and
diffusion of healthcare service innovations: a qualitative study. BMC Health
Services Research, 11(1), 342-354.

Bates, D. W., & Bitton, A. (2010). The future of health information technology in the
patient-centered medical home. Health Affairs, 29(4), 614-621.

Baptist Health. (2018). Patient Bridge. Retrieved from

https://www.baptistfirst.org/patients-and-visitors/patient-and-visitor-
information/patient-bridge

Battersby, M., Kidd, M. R., Licinio, J., Aylward, P., Baker, A., Ratcliffe, J., . . .
Fairweather-Schmidt, A. K. (2018). Improving cardiovascular health and quality
of life in people with severe mental illness: study protocol for a randomised
controlled trial. Trials, 19(1), 366.

131
Bedford, N. J., & David, A. S. (2014). Denial of illness in schizophrenia as a disturbance
of self-reflection, self-perception and insight. Schizophrenia Research, 152(1),
89-96.

Belfort, R., Bernstein, W., Ingargiola, S. (2014). Integrating Physical and Behavioral
Health: Strategies for Overcoming Legal Barriers to Health Information
Exchange. Retrieved from https://www.shvs.org/wp-
content/uploads/2014/11/RWJF_SHVS_IntegratingPhysicalBehavioralHealt
h.pdf.

Ben-Assuli, O., Shabtai, I., Leshno, M., & Hill, S. (2014). EHR in emergency rooms:
exploring the effect of key information components on main complaints. Journal
of Medical Systems, 38(4), 36.

Benjenk, I., & Chen, J. (2018). Effective mental health interventions to reduce hospital
readmission rates: a systematic review. Journal of Hospital Management and
Health Policy, 2(45), 1-13.

Benzer, J. K., Sullivan, J. L., Williams, S., & Burgess, J. F. (2012). One-year cost
implications of using mental health care after discharge from a general medical
hospitalization. Psychiatric Services, 63(7), 672-678.

Berryman, R., Yost, N., Dunn, N., & Edwards, C. (2013). Data interoperability and
information security in healthcare.

Bertaux, D. (1981). From the life-history approach to the transformation of sociological

practice. Biography and society: The life history approach in the social sciences,
29-45.

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: care, health, and
cost. Health Affairs, 27(3), 759-769.

Bhattacherjee, A. (2002). Individual trust in online firms: Scale development and initial
test. Journal of Management Information Systems, 19(1), 211-241.

Blount, A., Schoenbaum, M., Kathol, R., Rollman, B. L., Thomas, M., O'donohue, W., &
Peek, C.J. (2007). The economics of behavioral health services in medical
settings: A summary of the evidence. Professional Psychology: Research and
Practice, 38(3), 290-297.

Blumenthal, D. (2009). Stimulating the adoption of health information technology. New

England Journal of Medicine, 360(15), 1477-1479.

Blumenthal, D. (2010). Launching HITECH. New England Journal of Medicine, 362(5),

382-385.

132
Bradford, D. W., Cunningham, N. T., Slubicki, M. N., McDuffie, J. R., Kilbourne, A. M.,
Nagi, A., & Williams, J. J. (2013). An evidence synthesis of care models to
improve general medical outcomes for individuals with serious mental illness: a
systematic review. The Journal of Clinical Psychiatry, 74(8), e754-764.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative
Research in Psychology, 3(2), 77-101.

Bresnick, J. (2013). Rhode Island HIE begins exchange of behavioral health data.
Retrieved from https://ehrintelligence.com/news/rhode-island-hie-begins-
exchange-of-behavioral-health-data.

Bromley, E., Mikesell, L., Jones, F., & Khodyakov, D. (2015). From subject to
participant: Ethics and the evolving role of community in health research.
American Journal of Public Health, 105(5), 900-908.

Bruns, E. J., Hook, A. N., Parker, E. M., Esposito, I., Sather, A., Parigoris, R. M., . . .
Hyde, K. L. (2018). Impact of a Web-Based Electronic Health Record on
Behavioral Health Service Delivery for Children and Adolescents: Randomized
Controlled Trial. Journal of Medical Internet Research, 20(6), e10197.

Bryman, A. (2006). Integrating quantitative and qualitative research: how is it done?

Qualitative Research, 6(1), 97-113.

Buja, A., Claus, M., Perin, L., Rivera, M., Corti, M. C., Avossa, F., Schievano, E., Rigon,
S., Toffanin, R., Baldo, V., & Boccuzzo, G. (2018). Multimorbidity patterns in
high-need, high-cost elderly patients. PloS One, 13(12), e0208875.

Burgess, J. F., Hockenberry, J. M. (2014). Can all cause readmission policy improve
quality or lower expenditures? A historical perspective on current initiatives.
Health Economics, Policy and Law, 9(2), 193-213.

Callan, K. F. J., Galterio, L.; Just, B.; Reich, K.; Steigerwald, C.; Turner-Combs, M. L.;
Wolf, S. H..; Dooling, J.; Kirby, A.; Rhodes, H. (2014). "Making Health
Information Exchange Work: HIOs Currently Not Ready to Support the
Information Needs of a Reformed Healthcare System—But Small Changes Offer
Big Outcomes" Journal of AHIMA, 85(11), 32-36.

Campbell, A. N. C., McCarty, D., Rieckmann, T., McNeely, J., Rotrosen, J., Wu, L. T., &
Bart, G. (2019). Interpretation and integration of the federal substance use privacy
protection rule in integrated health systems: a qualitative analysis. Journal of
Substance Abuse Treatment, 97, 41-46.

Caruth, G. D. (2013). Demystifying Mixed Methods Research Design: A Review of the

133
 Literature. Online Submission, 3(2), 112-122.

Cassell, J., & Bickmore, T. (2000). External manifestations of trustworthiness in the

interface. Communication of the ACM, 43(12), 50-56.

Centers for Disease Control and Prevention. Public Health and Promoting
Interoperability Programs (formerly, known as Electronic Health Records
Meaningful Use). Retrieved from
https://www.cdc.gov/ehrmeaningfuluse/introduction.html.

Chandra, S., Srivastava, S., & Theng, Y-L. (2010). Evaluating the role of trust in
consumer adoption of mobile payments systems: An empirical analysis.
Communications of the Association for Information Systems, 27(29), 561-588.

Chang, E. T., Vinzon, M., Cohen, A. N., & Young, A. S. (2019). Effective models
urgently needed to improve physical care for people with serious mental illnesses.
Health Services Insights, 12, 1178632919837628.

Chang, I.-C., Hwang, H.-G., Hung, W.-F., & Li, Y. (2007). Physicians’ acceptance of
pharmacokinetics-based clinical decision support systems. Expert Systems with
Applications, 33(2), 296-303.

Chapman, E., Chung, H., & Pincus, H. A. (2017). Using a continuum-based framework
for behavioral health integration into primary care in New York State. Psychiatric
Services, 68(8), 756-758.

Chen, J., Novak, P., Barath, D., Goldman, H., & Mortensen, K. (2018). Local health
departments’ promotion of mental health care and reductions in 30-day all-cause
readmission rates in Maryland. Medical Care, 56(2), 153-161.

Chen, Y.-H., & Barnes, S. (2007). Initial trust and online buyer behaviour. Industrial
Management & Data Systems, 107(1), 21-36.

Chin, W. W. (1998). Commentary: Issues and opinion on structural equation modeling:

JSTOR.

Cifuentes, M., Davis, M., Fernald, D., Gunn, R., Dickinson, P., & Cohen, D. J. (2015).
Electronic health record challenges, workarounds, and solutions observed in
practices integrating behavioral health and primary care. Journal of the American
Board of Family Medicine, 28(Supplement 1), S63-S72.

Cimperman, M., Brencic, M. M., & Trkman, P. (2015). Analyzing older users’ home
telehealth services acceptance behavior- applying an Extended UTAUT model.
International Journal of Medical Informatics, 90, 22-31.

Clark, V. L. P., & Ivankova, N. V. (2015). Mixed methods research: A guide to the field

134
 (Vol. 3): Sage Publications.

Clarke, V., & Braun, V. (2018). Using thematic analysis in counselling and
psychotherapy research: A critical reflection. Counselling and Psychotherapy
Research, 18(2), 107-110.

Cohen, L., & Manion, L. (Eds.). (1994). Research methods in education (L. Cohen, &
Manion, L. (Eds.) Ed. 4th ed. ed.). London: Longman.

Collins, K. M., & O’Cathain, A. (2009). Introduction: Ten points about mixed methods
research to be considered by the novice researcher. International Journal of
Multiple Research Approaches, 3(1), 2-7.

Compeau, D., Higgins, C. A., & Huff, S. (1999). Social cognitive theory and individual
reactions to computing technology: A longitudinal study. MIS Quarterly, 145-
158.

Coordinated Care Health Network. CCHN: Closing the Information Gap to Improve
Care. Retrieved from http://coordinatedcarehn.com/.

Cothren, R. M. (2017). Breaking HIE Barriers. Paper presented at the HIMSS Annual
Conference & Exhibition, Orlando- Orange County Convention Center.

Crabtree, B. F., & Miller, W. F. (1992). A template approach to text analysis: developing
and using codebooks.

Creswell, J. W. (2015). A concise introduction to mixed methods research. Thousand

Oaks, CA: Sage Publications.

Creswell, J. W., & Clark, V. L. P. (2018). Designing and conducting mixed methods
research: Sage Publications.

Creswell, J. W., & Miller, D. L. (2000). Determining validity in qualitative inquiry.

Theory into Practice, 39(3), 124-130.

Cronholm, S., & Hjalmarsson, A. (2011). Experiences from sequential use of mixed
methods. The Electronic Journal of Business Research Methods, 9(2), 87-95.

Crowley, R. A., & Kirschner, N. (2015). The integration of care for mental health,
substance abuse, and other behavioral health conditions into primary care:
executive summary of an American College of Physicians position paper. Annals
of Internal Medicine, 163(4), 298-299.

Daly, J., Kellehear, A., Gliksman, M., & Daly, K. G. (1997). The public health
researcher: A methodological guide: Oxford University Press Melbourne.

135
Davis, F. D., Bagozzi, R. P., & Warshaw, P. R. (1989). User acceptance of computer
technology: A comparison of two theoretical models. Management Science, 35(8),
982-1003.

Davis, F. D., Bagozzi, R. P., & Warshaw, P. R. (1992). Extrinsic and intrinsic motivation
to use computers in the workplace. Journal of Applied Social Psychology, 22(14),
1111-1132.

Davis, F. D. (1989). Perceived usefulness, perceived ease of use, and user

acceptance of information technology. MIS Quarterly, 13(3), 319-340.

Davis, M., Balasubramanian, B. A., Waller, E., Miller, B. F., Green, L. A., & Cohen, D.
J. (2013). Integrating behavioral and physical health care in the real world: early
lessons from advancing care together. Journal of the American Board of Family
Medicine, 26(5), 588-602.

Delaney, K. R., Naegle, M. A., Valentine, N. M., Antai-Otong, D., Groh, C. J., &
Brennaman, L. (2018). The effective use of psychiatric mental health nurses in
integrated care: Policy implications for increasing quality and access to care. The
Journal of Behavioral Health Services & Research, 45(2), 300-309.

Demetriades, J. E. (2005). Laying the foundations: Information architecture for

HealthePeople Person-Centered Health Records (p. 73-88): Springer.

Denzin, N. K. (2010). Moments, mixed methods, and paradigm dialogs. Qualitative

Inquiry, 16(6), 419-427.

Denzin, N. K., & Lincoln, Y. S. (2000). Handbook of qualitative research. 2nd ed.
London: Sage.

DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is a risk factor for
noncompliance with medical treatment: meta-analysis of the effects of anxiety
and depression on patient adherence. Archives of Internal Medicine, 160(14),
2101-2107.

Distel, E., Casey, M., & Prasad, S. (2016). Reducing Potentially-Preventable

Readmissions in Critical Access Hospitals.

Donmoyer, R. (2006). Take my paradigm… please! The legacy of Kuhn’s construct in

educational research. International Journal of Qualitative Studies in Education,
19(1), 11-34.

Downing, N. L., Adler-Milstein, J., Palma, J. P., Lane, S., Eisenberg, M., Sharp, C., . . .
Longhurst, C. A. (2016). Health information exchange policies of 11 diverse
health systems and the associated impact on volume of exchange. Journal of the
American Medical Informatics Association, 24(1), 113-122.

136
Doyle, L., Brady, A.-M., & Byrne, G. (2009). An overview of mixed methods research.
Journal of Research in Nursing, 14(2), 175-185.

Draper, D., Rogers, W. H., Kahn, K. L., Keeler, E. B., Reinisch, E. J. … Kamberg, C.
(2006). Effects of Medicare’s Prospective Payment System on the Quality of
Hospital Care. Santa Monica, CA: RAND Corporation. Retrieved from:
https://www.rand.org/pubs/research_briefs/RB4519-1.html.

Druss, B. G., & Mauer, B. J. (2010). Health care reform and care at the behavioral
health—primary care interface. Psychiatric Services, 61(11), 1087-1092.

Druss, B. G., Rohrbaugh, R. M., Levinson, C. M., & Rosenheck, R. A. (2001). Integrated
medical care for patients with serious psychiatric illness: A randomized trial.
Archives of General Psychiatry, 58(9), 861-868.

Dwivedi, Y. K., Rana, N. P., Chen, H., & Williams, M. D. (2011). A Meta-analysis of the
Unified Theory of Acceptance and Use of Technology (UTAUT). Paper presented
at the IFIP international working conference on governance and sustainability in
information systems-managing the transfer and diffusion of it.

Elkaseh, A. M., Wong, K. W., & Fung, C. C. (2016). Perceived ease of use and perceived
usefulness of social media for e-learning in Libyan higher education: A structural
equation modeling analysis. International Journal of Information and Education
Technology, 6(3), 192.

Etikan, I., Musa, S. A., & Alkassim, R. S. (2016). Comparison of convenience sampling
and purposive sampling. American Journal of Theoretical and Applied Statistics,
5(1), 1-4.

Falconer, E., Kho, D., & Docherty, J. P. (2018). Use of technology for care coordination
initiatives for patients with mental health issues: a systematic literature review.
Neuropsychiatric Disease and Treatment, 14, 2337.

Farmanova, E., Baker, G. R., & Cohen, D. (2019). Combining Integration of Care and a
Population Health Approach: A Scoping Review of Redesign Strategies and
Interventions, and their Impact. International Journal of Integrated Care, 19(2).

Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: A
hybrid approach of inductive and deductive coding and theme development.
International Journal of Qualitative Methods, 5(1), 80-92.

Fontanarosa, P. B., & McNutt, R. A. (2013). Revisiting hospital readmissions. JAMA,

309(4), 398-400.

Fornell, C., & Larcker, D. F. (1981). Evaluating structural equation models with

137
 unobservable variables and measurement error. Journal of Marketing Research,
18(1), 39-50.

Friedman, B., & Millett, L. I. (1997). Reasoning about computers as moral agents: A
research note: Stanford: CSLI Publications.

Frith, C. D. (1979). Consciousness, information processing and schizophrenia. The

British Journal of Psychiatry, 134(3), 225-235.

Frith, C. D. (2014). The cognitive neuropsychology of schizophrenia: Psychology press.

Furukawa, M. F., Raghu, T., Spaulding, T. J., & Vinze, A. (2008). Adoption of health
information technology for medication safety in US hospitals, 2006. Health
Affairs, 27(3), 865-875.

Gandhi, T. K., Kaplan, G. S., Leape, L., Berwick, D. M., Edgman-Levitan, S.,
Edmondson, A., . . . Vincent, C., & Wachter, R. (2018). Transforming concepts in
patient safety: a progress report. BMJ Qual Saf, 27(12), 1019-1026.

Gefen, D., Straub, D., & Boudreau, M-C. (2000). Structural equation modelling and
regression: Guidelines for research practice. Communications of the Association
for Information Systems, 4(7).

Ghitza, U. E., Sparenborg, S., Tai, B. (2011). Improving drug abuse treatment delivery
through adoption of harmonized electronic health record systems. Substance
Abuse and Rehabilitation, 2, 125-131.

Ghitza, U. E., Wu, L.-T., Tai, B. (2013). Integrating substance abuse care with
community diabetes care: implications for research and clinical practice.
Substance Abuse and Rehabilitation, 4, 3-10.

Golden, R. L., Emery-Tiburcio, E., Post, S., Ewald, B., & Newman, M. (2018).
Connecting social, clinical, and home care services for persons with serious
illness in the community. Journal of the American Geriatrics Society, 67, S412-
S418.

Goldschmidt, P. G. (2005). HIT and MIS: implications of health information technology

and medical information systems. Communications of the ACM, 48(10), 68-74.

Goodell, S., Druss, B. G., & Walker, E. R. (2011). Mental disorders and medical
comorbidity. Robert Wood Johnson Foundation, 2.

Gordon, W. J., & Catalini, C. (2018). Blockchain technology for healthcare: facilitating
the transition to patient-driven interoperability. Computational and Structural
Biotechnology Journal, 16, 224-230.

138
Grando, M. A., Murcko, A., Mahankali, S., Saks, M., Zent, M., Chern, D., … &
Hiestand, M. (2017). A study to elicit behavioral health patients’ and providers’
opinions on health records consent. The Journal of Law, Medicine, & Ethics,
45(2), 238-259.

Greene, J. (2013). Behavioral health data in the electronic health record: Privacy
concerns slow sharing. Annals of Emergency Medicine, 62(4), A19-A21.

Greene, J. C., Caracelli, V. J., & Graham, W. F. (1989). Toward a conceptual framework
for mixed-method evaluation designs. Educational Evaluation and Policy
Analysis, 11(3), 255-274.

Guetterman, T. C., Fetters, M. D., & Creswell, J. W. (2015). Integrating quantitative and
qualitative results in health science mixed methods research through joint
displays. The Annals of Family Medicine, 13(6), 554-561.

Hadi, M. A., & Closs, S. J. (2016). Ensuring rigour and trustworthiness of qualitative
research in clinical pharmacy. International Journal of Clinical Pharmacy, 38(3),
641-646.

Haenlein, M., & Kaplan, A. M. (2004). A beginner's guide to partial least squares
analysis. Understanding Statistics, 3(4), 283-297.

Hair, J., Ringle, C., & Sarstedt, M. (2011). PLS-SEM: Indeed a silver bullet. The Journal
of Marketing Theory and Practice, 19.

Hair, J. F., Henseler, J., Dijkstra, T. K., & Sarstedt, M. (2014). Common beliefs and
reality about partial least squares: comments on Rönkkö and Evermann.

Hair, J. F., Ringle, C. M., & Sarstedt, M. (2012). Partial least squares: the better approach
to structural equation modeling? Long Range Planning, 45(5-6), 312-319.

Hair Jr, J., Anderson, R., Tatham, R., & Black, W. (1995). Multivariate Data Analysis
with Reading, New Jersey, Englewood Cliffs: Prentice-Hall: Inc.

Hair Jr, J. F., Matthews, L. M., Matthews, R. L., & Sarstedt, M. (2017). PLS-SEM or
CB-SEM: updated guidelines on which method to use. International Journal of
Multivariate Data Analysis, 1(2), 107-123.

Halcomb, E., & Hickman, L. (2016). Attitudes and immunisation practices of Australian
general practice nurses. Contemporary Nurse, 52(4), 440-446.

Hall, R. (2012). Mixed methods: In search of a paradigm. Retrieved from Vortrag.

Download (am 10.01. 2013) unter: http://www. auamii.
com/proceedings_Phuket_2012/Hall. pdf.

139
Hansen, M., O’Brien, K., Meckler, G., Chang, A. M., & Guise, J. M. (2016).
Understanding the value of mixed methods research: the Children’s Safety
Initiative- Emergency Medical Services. Emerg Med J, 33(7), 489-494.

Health Information & the Law. (2018). 42 CFR Part 2: An Overview. Retrieved from
http://www.healthinfolaw.org/federal-law/42-cfr-part-2.

Healthcare Information and Management Systems Society. “HIMSS Redefines

Interoperability.” Retrieved from https://www.himss.org/resource-
news/himss-redefines-interoperability.

HealthIT.gov. What are the different types of health information exchange? Retrieved
from https://www.healthit.gov/faq/what-are-different-types-health-information-
exchange

Heckart, C. (2016). The network effect on wealth creation. Retrieved from

https://www.networkworld.com/article/3128366/the-network-effect-on-wealth-
creation.html

Henseler, J., Christian, M.R., Sinkovics, R.R. (2009). The use of partial least squares path
modeling in international marketing. Advances in International Marketing, 20,
277-319.

Henseler, J., Dijkstra, T. K., Sarstedt, M., Ringle, C. M., Diamantopoulos, A., Straub, D.
W., … & Calantone, R. J. (2014). Common beliefs and reality about PLS:
Comments on Ronkko and Evermann (2013). Organizational Research Methods,
17(2), 182-209.

Hertzum, M., Andersen, H. H., Andersen, V., & Hansen, C. B. (2002). Trust in
information sources: seeking information from people, documents, and virtual
agents. Interacting with Computers, 14(5), 575-599.

Heslin, K. C., & Weiss, A. J. (2015). Hospital readmissions involving psychiatric

disorders, 2012: Statistical brief #189. Retrieved from
https://hcup-us.ahrq.gov/reports/statbriefs/sb189-Hospital-Readmissions-
Psychiatric-Disorders-2012.pdf.

Hesselink, G., Zegers, M., Vernooij-Dassen, M., Barach, P., Kalkman, C., Flink, M., . . .
& Wollersheim, H. (2014). Improving patient discharge and reducing hospital
readmissions by using Intervention Mapping. BMC Health Services Research,
14(1), 389-399.

HIMSS. What is Interoperability? Retrieved from

https://www.himss.org/library/interoperability-standards/what-is-interoperability.

Hines, A., Barrett, M., Jiang, H., & Steiner, C. (2014). Conditions with the largest

140
 number of adult hospital readmissions by payer, 2011. HCUP Statistical Brief
#172. Rockville, MD: Agency for Healthcare Research and Quality.

Holmgren, A. J., Patel, V., & Adler-Milstein, J. (2017). Progress in interoperability:

measuring US hospitals’ engagement in sharing patient data. Health Affairs,
36(10), 1820-1827.

Houben, N., Janssen, E. P., Hendriks, M. R., van der Kellen, D., van Alphen, B. P., &
van Meijel, B. (2019). Physical health status of older adults with severe mental
illness: The PH i SMI‐E cohort study. International Journal of Mental Health
Nursing, 28(2), 457-467.

Hox, J., & Bechger, T. (2007). An introduction to structural equation modeling.

Hsieh, P. J. (2015). Physicians’ acceptance of electronic medical records exchange: An

extension of the decomposed TPB model with institutional trust and perceived
risk. International Journal of Medical Informatics, 84(1), 1-14.

Hu, L. L., Sparenborg, S., Tai, B. (2011). Privacy protection for patients with substance
use problems. Substance Abuse and Rehabilitation, 2, 227-233.

Hussey, P. S., Wertheimer, S., & Mehrotra, A. (2013). The association between health
care quality and cost. Annals of Internal Medicine, 158(1), 27-34.

Ifinedo, P. (2012). Understanding information systems security policy compliance: An

integration of the theory of planned behavior and the protection motivation
theory. Computers & Security, 31(1), 83-95.

Imboden, A. D., & Fehr, K. K. (2018). Collaborative care of attention deficit

hyperactivity disorder: An innovative partnership to serve rural pediatric patients.
Journal of Pediatric Health Care, 32(6), 584-590.

Institute for Healthcare Improvement. The IHI Triple Aim. Retrieved from
http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx.

Institute of Medicine. (1999). To Err is Human: Building a Safer Health System.

Retrieved from
http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1
999/To-Err-is-
Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf.

Ivankova, N. V., Creswell, J. W., & Stick, S. L. (2006). Using mixed-methods sequential
explanatory design: From theory to practice. Field Methods, 18(1), 3-20.

Jha, A. K., DesRoches, C. M., Campbell, E. G., Donelan, K., Rao, S. R., Ferris, T. G., . . .
& Blumenthal, D. (2009). Use of electronic health records in US hospitals. New

141
 England Journal of Medicine, 360(16), 1628-1638.

Johnson, R. B. (2017). Dialectical pluralism: A metaparadigm whose time has come.

Journal of Mixed Methods Research, 11, 156-173.

Johnson, R. E., Grove, A. L., & Clarke, A. (2017). Pillar integration process: A joint
display technique to integrate data in mixed methods research. Journal of Mixed
Methods Research, 1558689817743108.

Johnson, R. B., & Onwuegbuzie, A. J. (2004). Mixed methods research: A research

paradigm whose time has come. Educational Researcher, 33(7), 14-26.

Johnson, R. B., Onwuegbuzie, A. J., & Turner, L. A. (2007). Toward a definition of

mixed methods research. Journal of Mixed Methods Research, 1(2), 112-133.

Jung, G., & Lee, B. (2011). How Did Facebook Outspace Myspace With Open
Innovation? An Analysis Of Network Competition With Changes Of Network
Topology. Paper presented at the PACIS.

Kaelber, D. C., & Bates, D. W. (2007). Health information exchange and patient safety.
Journal of Biomedical Informatics, 40(6), S40-S45.

Kane, J. M., Kishimoto, T., & Correll, C. U. (2013). Non‐adherence to medication in

patients with psychotic disorders: epidemiology, contributing factors and
management strategies. World Psychiatry, 12(3), 216-226.

Kartha, A., Anthony, D., Manasseh, C. S., Greenwald, J. L., Chetty, V. K., Burgess Jr, J.
F., . . . Jack, B. W. (2007). Depression is a risk factor for rehospitalization in
medical inpatients. Primary Care Companion to the Journal of Clinical
Psychiatry, 9(4), 256-262.

Kash, B. A., Baek, J., Cheon, O., Manzano, J.-G. M., Jones, S. L., Paranilam, J., &
Phillips, R. A. (2019). How Leading Hospitals Operationalize Evidence-Based
Readmission Reduction Strategies: A Mixed-Methods Comparative Study Using
Systematic Review and Survey Design. American Journal of Medical Quality,
1062860618824410.

Kash, B. A., Baek, J., Davis, E., Champagne-Langabeer, T., & Langabeer II, J. R. (2017).
Review of successful hospital readmission reduction strategies and the role of
health information exchange. International Journal of Medical Informatics, 104,
97-104.

Katon, W., Lin, E. H., & Kroenke, K. (2007). The association of depression and anxiety
with medical symptom burden in patients with chronic medical illness. General
Hospital Psychiatry, 29(2), 147-155.

142
Kazár, K. (2014). PLS Path analysis and its application for the examination of the
psychological sense of a brand community. Procedia Economics and Finance, 17,
183-191.

Kelton, K., Fleischmann, K. R., Wallace, W. A. (2008). Trust in digital information.

Journal of the American Society for Information Science, 59(3), 363-374.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., . . .
Wang, P. S. (2003). The epidemiology of major depressive disorder: Results from
the National Comorbidity Survey Replication (NCS-R). JAMA, 289(23), 3095-
3105.

Khechine, H., Lakhal, S., & Ndjambou, P. (2016). A meta‐analysis of the UTAUT
model: Eleven years later. Canadian Journal of Administrative Sciences, 33(2),
138-152.

Kiesler, S., & Sproull, L. (1997). “Social” human-computer interaction. Paper presented
at the Human values and the design of computer technology.

Kijsanayotin, B., Pannarunothai, S., & Speedie, S. M. (2009). Factors influencing health
information technology adoption in Thailand's community health centers:
Applying the UTAUT model. International Journal of Medical Informatics,
78(6), 404-416.

Klobas, J. E. (1995). Beyond information quality: Fitness for purpose and electronic
information resource use. Journal of Information Science, 21(2), 95-114.

Knopf, A. (2018). As 42 CFR Part 2 faces possible demise, methadone patients panic,
taper. Alcoholism & Drug Abuse Weekly, 30(26), 1-4.

Kozubal, D. E., Samus, Q. M., Bakare, A. A., Trecker, C. C., Wong, H.-W., Guo, H., . . .
Jamison, K. R. (2013). Separate may not be equal: A preliminary investigation of
clinical correlates of electronic psychiatric record accessibility in academic
medical centers. International Journal of Medical Informatics, 82(4), 260-267.

Kuperman, G. J. (2011). Health-information exchange: why are we doing it, and what are
we doing? Journal of the American Medical Informatics Association, 18(5), 678-
682.

Kutlubaev, M. A., & Hackett, M. L. (2014). Part II: predictors of depression after stroke
and impact of depression on stroke outcome: an updated systematic review of
observational studies. International Journal of Stroke, 9(8), 1026-1036.

Laerd Statistics. Spearman's rank-order correlation using SPSS Statistics. Retrieved from
https://statistics.laerd.com/spss-tutorials/spearmans-rank-order-correlation-using-
spss-statistics.php.

143
Lardiere, M. R. (2013). Unlocking and sharing behavioral health records: movement
emerges to exchange sensitive records through HIEs. Journal of AHIMA, 84(4),
36-40.

Lee, J.-H., & Song, C.-H. (2013). Effects of trust and perceived risk on user acceptance
of a new technology service. Social Behavior and Personality: An International
Journal, 41(4), 587-597.

Liébana-Cabanillas, F., Sánchez-Fernández, J., & Muñoz-Leiva, F. (2014). The

moderating effect of experience in the adoption of mobile payment tools in
Virtual Social Networks: The m-Payment Acceptance Model in Virtual Social
Networks (MPAM-VSN). International Journal of Information Management,
34(2), 151-166.

Lincoln, Y. S., & Denzin, N. K. (2000). The handbook of qualitative research: Sage.

Lincoln, Y. S., & Guba, E. G. (1985). Effective evaluation. New York: Jassey-Bass.

Lincoln, Y. S., & Guba, E. G. (1985). Establishing trustworthiness. Naturalistic Inquiry,

289, 331.

Lu, Y., Yang, S., Chau, P., & Cao, Y. (2011). Dynamics between the trust transfer
process and intention to use mobile payment services: A cross-environment
perspective. Information & Management, 48(8), 393-403.

Madden, J. M., Lakoma, M. D., Rusinak, D., Lu, C. Y., & Soumerai, S. B. (2016).
Missing clinical and behavioral health data in a large electronic health record
(EHR) system. Journal of the American Medical Informatics Association, 23(6),
1143-1149.

Madey, D. L. (1982). Some benefits of integrating qualitative and quantitative methods in

program evaluation, with illustrations. Educational Evaluation and Policy
Analysis, 4(2), 223-236.

Mandrik, C. A., & Bao, Y. (2005). Exploring the concept and measurement of general
risk aversion. ACR North American Advances.

Mangurian, C., Keenan, W., Newcomer, J. W., Vittinghoff, E., Creasman, J. M., &
Schillinger, D. (2017). Diabetes prevalence among racial-ethnic minority group
members with severe mental illness taking antipsychotics: double jeopardy?
Psychiatric Services, 68(8), 843-846.

Manton, K. G., Woodbury, M. A., Vertrees, J. C., & Stallard, E. (1993). Use of Medicare
services before and after introduction of the prospective payment system. Health

144
 Services Research, 28(3), 269-292.

Marshall, B., Cardon, P., Poddar, A., & Fontenot, R. (2013). Does sample size matter in
qualitative research?: A review of qualitative interviews in IS research. Journal of
Computer Information Systems, 54(1), 11-22.

Maryland Behavioral Health Coalition. (2017). Strategy to Improve Behavioral and

Somatic Health Integration in the Maryland Medicaid Program. Retrieved from
https://mdpsych.org/wp-content/uploads/2015/04/BH-Coalition-LTR-
Schrader-Re-Integration-100217.pdf.

Maryland Department of Health. (2012). The benefits of a behavioral health carve-out

program.

Maxwell, J. A., & Mittapalli, K. (2010). Realism as a stance for mixed methods research.
Handbook of mixed methods in social & behavioral research, 145-168.

Mayer, R. C., Davis, J. H., & Schoorman, F. D. (1995). An integrative model of

organizational trust. Academy of Management Review, 20(3), 709-734.

McEvoy, P., & Richards, D. (2006). A critical realist rationale for using a combination of
quantitative and qualitative methods. Journal of Research in Nursing, 11(1), 66-
78.

McGovern, M., Dent, K., & Kessler, R. (2018). A unified model of behavioral health
integration in primary care. Academic Psychiatry, 42(2), 265-268.

Mechanic, D. (2012). Seizing opportunities under the Affordable Care Act for
transforming the mental and behavioral health system. Health Affairs, 31(2), 376-
382.

Merriam-Webster. Retrieved from https://www.merriam-

webster.com/dictionary/network.

Miller, J. E., Glover, R., & Gordon, S. (2014). Crossing the behavioral health digital
divide: the role of health information technology in improving care for people
with behavioral health conditions in state behavioral health systems. National
Association of State Mental Health Program Directors.

Monecke, A., & Leisch, F. (2012). semPLS: structural equation modeling using partial
least squares.

Monica, K. (2017). Healthcare's growing focus on behavioral health data exchange.

Retrieved from EHR Intelligence website:
https://ehrintelligence.com/news/healthcares-growing-focus-on-behavioral-health-
data-exchange.

145
Moore, A. (2006). The economics of group forming network theory. Retrieved from
https://communities-dominate.blogs.com/brands/2006/02/the_economics_o.html.

Moore, G. C., & Benbasat, I. (1991). Development of an instrument to measure the

perceptions of adopting an information technology innovation. Information
Systems Tesearch, 2(3), 192-222.

Morgan, D. L. (2007). Paradigms lost and pragmatism regained: Methodological

implications of combining qualitative and quantitative methods. Journal of Mixed
Methods Research, 1(1), 48-76.

Morisky, D. E., Green, L. W., & Levine, D. M. (1986). Concurrent and predictive
validity of a self-reported measure of medication adherence. Medical Care, 24(1),
67-74.

Morse, J. M. (1991). Approaches to qualitative-quantitative methodological triangulation.

Nursing Research, 40(2), 120-123.

Morse, J. M. (1994). Designing funded qualitative research.

Morse, J. M. (2015). Critical analysis of strategies for determining rigor in qualitative

inquiry. Qualitative Health Research, 25(9), 1212-1222.

Nachtigall, C., Kroehne, U., Funke, F., & Steyer, R. (2003). Pros and cons of structural
equation modeling. Methods Psychological Research Online, 8(2), 1-22.

Narrow, W. E., Rae, D. S., Robins, L. N., & Regier, D. A. (2002). Revised prevalence
estimates of mental disorders in the United States: using a clinical significance
criterion to reconcile 2 surveys' estimates. Archives of General Psychiatry, 59(2),
115-123.

Nass, C., Moon, Y., Morkes, J., Kim, E.-Y., & Fogg, B. (1997). Computers are social
actors: A review of current research. Human Values and the Design of Computer
Technology, 72, 137-162.

Nguyen, T. S. T. (2008). Peer debriefing. The Sage encyclopedia of qualitative research

methods. Retrieved from http://srmo.sagepub.com/view/ sage-encyc-qualitative-
research-methods/n312.xml.

Nguyen, H. M., & Le Minh, H. (2018). Examining the effect of emotion to the online
shopping stores' service recovery: A meta-analysis. Journal of Environmental
Accounting and Management, 6(1), 59-70.

Nies, H., & Berman, P. C. (2004). Integrating services for older people: a resource book
for managers. European Health Management Association.

146
North Carolina Department of Information Technology. Frequently Asked Questions.
Retrieved from https://hiea.nc.gov/frequently-asked-questions#are-there-
restrictions-on-submitting-substance-abuse-data-to-nc-healthconnex?.

Nowell, L. S., Norris, J. M, White, D. E., & Moules, N. J. (2017). Thematic analysis:
Striving to meet the trustworthiness criteria. International Journal of Qualitative
Methods, 16(1), 1609406917733847.

Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory, New York: McGraw-
Hill.

Office of the Federal Register. Confidentiality of Substance Use Disorder Patient

Records: A Proposed Rule by the Health and Human Services Department.
Retrieved from
https://www.federalregister.gov/documents/2019/08/26/2019-
17817/confidentiality-of-substance-use-disorder-patient-records.

Office of the National Coordinator for Health Information Technology. Retrieved from
https://www.healthit.gov/.

Onwuegbuzie, A. J., & Collins, K. M. (2007). A typology of mixed methods sampling

designs in social science research. The Qualitative Report, 12(2), 281-316.

Onwuegbuzie, A. J., & Johnson, R. B. (2006). The validity issue in mixed research.
Research in the Schools, 13(1), 48-63.

Onwuegbuzie, A. J., Johnson, R. B., & Collins, K. M. (2011). Assessing legitimation in

mixed research: A new framework. Quality & Quantity, 45(6), 1253-1271.

Onwuegbuzie, A. J., & Leech, N. L. (2007). Validity and qualitative research: An

oxymoron? Quality & Quantity, 41(2), 233-249.

Ouwens, M., Wollersheim, H., Hermens, R., Hulscher, M., & Grol, R. (2005). Integrated
care programmes for chronically ill patients: A review of systematic reviews.
International Journal for Quality in Health Care, 17(2), 141-146.

Patton, M. Q. (1990). Qualitative evaluation and research methods: SAGE Publications,

Inc.

Pederson, J. L., Warkentin, L. M., Majumdar, S. R., & McAlister, F. A. (2016).

Depressive symptoms are associated with higher rates of readmission or mortality
after medical hospitalization: a systematic review and meta-analysis. Journal of
Hospital Medicine, 11(5), 373-380.

Perrin, J., Reimann, B., Capobianco, J., Wahrenberger, J. T., Sheitman, B. B., & Steiner,

147
 B. D. (2018). A model of enhanced primary care for patients with severe mental
illness. North Carolina Medical Journal, 79(4), 240-244.

Phichitchaisopa, N., & Naenna, T. (2013). Factors affecting the adoption of healthcare
information technology. EXCLI Journal, 12, 413.

Plano Clark, V.L., & Ivankova, N.V. (2016). Mixed methods research: A guide to the
field. Los Angeles, CA: Sage.

Ranallo, P. A., Kilbourne, A. M., Whatley, A. S., & Pincus, H. A. (2016). Behavioral
health information technology: From chaos to clarity. Health Affairs, 35(6), 1106-
1113.

Raths, D. (2018). House passes bill to align HIPAA, 42 CFR Part 2. Retrieved from
https://www.hcinnovationgroup.com/cybersecurity/hipaa/news/13030458/house-
passes-bill-to-align-hipaa-42-cfr-part-2.

Reinhardt, C., & Cook, T. D. (1979). Beyond qualitative versus quantitative methods
Qualitative and quantitative methods in evaluation research (pp. 7-32): Sage
Publications.

Reisman, M. (2017). EHRs: the challenge of making electronic data usable and
interoperable. Pharmacy and Therapeutics, 42(9), 572.

Robinson, O. C. (2014). Sampling in interview-based qualitative research: A theoretical

and practical guide. Qualitative Research in Psychology, 11(1), 25-41.

Rogers, E. (1995). Diffusion of Innovations (4th Eds.) ACM The Free Press (Sept. 2001).
New York, 15-23.

Rogers, E. M. (1983). Diffusion of innovations. The Free Press.

Rogers, E. M. (2002). Diffusion of preventive innovations. Addictive behaviors, 27(6),

989-993.

Rogers, E.M. 2003. Diffusion of innovations. 5th ed. New York:

The Free Press/Simon & Schuster, Inc.

Rosenthal, R. N. (2018). Managing the opiod use disorder crisis. Supplement to Current
Psychiatry, 17(4).

Ross, K. M., Klein, B., Ferro, K., McQueeney, D. A., Gernon, R., & Miller, B. F. (2019).
The cost effectiveness of embedding a behavioral health clinician into an existing
primary care practice to facilitate the integration of care: a prospective, case-
control program evaluation. Journal of Clinical Psychology in Medical Settings,
26(1), 59-67.

148
Saks, M. J., Grando, A., Murcko, A., & Millea, C. (2018). Granular patient control of
personal health information: Federal and state law considerations. Jurimetrics,
58(4), 411-435.

SAMHSA. Behavioral Health Integration. Retrieved from

https://www.samhsa.gov/sites/default/files/samhsa-behavioral-health-
integration.pdf.

SAMHSA-HRSA Center for Integrated Health Care Solutions. (2016). What is Integrated
Care? Retrieved from https://www.integration.samhsa.gov/about-us/what-is-
integrated-care.

Sandelowski, M., & Barroso, J. (2003). Writing the proposal for a qualitative research
methodology project. Qualitative Health Research, 13(6), 781-820.

Sarstedt, M., Ringle, C. M., Henseler, J., & Hair, J. F. (2014). On the emancipation of
PLS-SEM: A commentary on Rigdon (2012). Long Range Planning, 47(3), 154-
160.

Schaper, L. K., & Pervan, G. P. (2007). ICT and OTs: a model of information and
communication technology acceptance and utilisation by occupational therapists.
International Journal of Medical Informatics, 76, S212-221.

Schiefelbein, E. L., Olson, J. A., & Moxham, J. D. (2014). Patterns of health care
utilization among vulnerable populations in Central Texas using data from a
regional health information exchange. Journal of Health Care for the Poor and
Underserved, 25(1), 37-51.

Schmidt, E. M., Behar, S., Barrera, A., Cordova, M., & Beckum, L. (2018). Potentially
preventable medical hospitalizations and emergency department visits by the
behavioral health population. The Journal of Behavioral Health Services &
Research, 45(3), 370-388.

Schoonenboom, J., & Johnson, R. B. (2017). How to construct a mixed methods research
design. KZfSS Kölner Zeitschrift für Soziologie und Sozialpsychologie, 69(2),
107-131.

Shank, N. (2011). Behavioral health providers' beliefs about health information

exchange: A statewide survey. Journal of the American Medical Informatics
Association, 19(4), 562-569.

Shannon-Baker, P. (2016). Making paradigms meaningful in mixed methods research.

Journal of Mixed Methods Research, 10(4), 319-334.

Shi, Y., Yang, D., Zeng, Y., & Wu, W. (2017). Risk factors for post-stroke depression: A

149
 meta-analysis. Frontiers in Aging Neuroscience, 9, 218.

Shin, D-H. (2010). Modelling the interaction of users and mobile payment system:
Conceptual framework. International Journal of Human-Computer Interaction,
26(10), 917-940.

Shorten, A., & Smith, J. (2017). Mixed methods research: expanding the evidence base.
Retrieved from
http://eprints.whiterose.ac.uk/118744/3/RMS%20EBN%20Mixed%20meth
od%20research%20FINAL%204-25-17.pdf.

Slade, E. L., Dwivedi, Y. K., Piercy, N. C., & Williams, M. D. (2015). Modeling
consumers’ adoption intentions of remote mobile payments in the United
Kingdom: Extending UTAUT with innovativeness, risk, and trust. Psychology &
Marketing, 32(8), 860-873.

Snell, E. (2018). HHS Final Rule Differs from HIPAA Regulations on Data Sharing.
Retrieved from https://healthitsecurity.com/news/hhs-final-rule-differs-
from-hipaa-regulations-on-data-sharing.

Strauss, A., & Corbin, J. (1998). Basics of qualitative research techniques: Sage
publications Thousand Oaks, CA.

Subedi, D. (2016). Explanatory sequential mixed method design as the third research
community of knowledge claim. Am J Educ Res, 4(7), 570-577.

Szajna, B. (1996). Empirical evaluation of the revised technology acceptance model.

Management Science, 42(1), 85-92.

Tai, B., Boyle, M., Ghitza, U., Kaplan, R. M., Clark, H. W., & Gersing, K. (2012).
Meaningful use of electronic behavioral health data in primary health care.
Science Translation Medicine, 4(119), 119.

Taiwo, A. A., Mahmood, A. K., & Downe, A. G. (2012). User acceptance of

eGovernment: Integrating risk and trust dimensions with UTAUT model. Paper
presented at the 2012 International Conference on Computer & Information
Science (ICCIS).

Tamasi, R. (2015). Behavioral-health organizations can partner with hospitals to reduce

readmissions. Modern Healthcare, 45(50), 25.

Teddlie, C., & Tashakkori, A. (2003). Major issues and controversies in the use of mixed
methods in the social and behavioral sciences. Handbook of mixed methods in
social & behavioral research, 3-50.

Teddlie, C., & Tashakkori, A. (2009). Foundations of mixed methods research:

150
 Integrating quantitative and qualitative approaches in the social and behavioral
sciences: Sage.

Thalmayer, A. G., Harwood, J. M., Friedman, S., Azocar, F., Watson, L. A., Xu, H., &
Ettner, S. L. (2018). The Mental Health Parity and Addiction Equity Act
Evaluation Study: impact on nonquantitative treatment limits for specialty
behavioral health care. Health Services Research, 53(6), 4584-4608.

Thanh, N. C., & Thanh, T. (2015). The interconnection between interpretivist paradigm
and qualitative methods in education. American Journal of Educational Science,
1(2), 24-27.

Thayabaranathan, T., Andrew, N. E., Kilkenny, M. F., Stolwyk, R., Thrift, A. G.,
Grimley, R., Johnston, T., Sundararajan, V., Lannin, N. A., & Cadilhac, D. A.
(2018). Factors influencing self-reported anxiety or depression following stroke or
TIA using linked registry and hospital data. Quality of Life Research, 27(12),
3145-3155.

Thomas, D. R. (2006). A general inductive approach for analyzing qualitative evaluation

data. American Journal of Evaluation, 27(2), 237-246.

Thomas, D. R. (2017). Feedback from research participants: Are member checks useful
in qualitative research? Qualitative Research in Psychology, 14(1), 23-41.

Thompson, R. L., Higgins, C. A., & Howell, J. M. (1994). Influence of experience on

personal computer utilization: Testing a conceptual model. Journal of
Management Information Systems, 11(1), 167-187.

Thompson, T. G., & Brailer, D. J. (2004). The decade of health information technology:
Delivering consumer-centric and information-rich health care: Framework for
strategic action. Washington, DC: US Department of Health and Human
Services.

Toh, C. H. (2013). Assessing adoption of wikis in a Singapore secondary school: Using

the UTAUT model. Paper presented at the 2013 IEEE 63rd Annual Conference
International Council for Education Media (ICEM).

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative
research (COREQ): a 32-item checklist for interviews and focus groups.
International Journal for Quality in Health Care, 19(6), 349-357.

Treku, D. N., & Xiao, N. (2018). Motivating health information exchange use as a
formative construct for measuring quality of IT-enabled healthcare delivery.

Tzeel, A., Lawnicki, V., & Pemble, K. R. (2011). The business case for payer support of
a community-based health information exchange: A Humana pilot evaluating its

151
 effectiveness in cost control for plan members seeking emergency department
care. American Health & Drug Benefits, 4(4), 207-216.

Unutzer, J., Katon. W., Callahan, C. M., Williams Jr., J. W., Hunkeler, E., Harpole, L., …
& Arean, P. A. (2002). Collaborative care management of late-life depression in
the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-
2845.

U.S. Department of Health & Human Services. HITECH Act Enforcement Interim Final
Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/special-
topics/hitech-act-enforcement-interim-final-rule/index.html.

Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic
analysis: Implications for conducting a qualitative descriptive study. Nursing &
Health Sciences, 15(3), 398-405.

Venkatesh, V., Brown, S. A., & Sullivan, Y. W. (2016). Guidelines for conducting
mixed-methods research: An extension and illustration. Journal of the Association
for Information Systems, 17(7), 2.

Venkatesh, V., & Morris, M. G. (2000). Why don’t men ever stop to ask for directions?
Gender, social influence, and their role in technology acceptance and usage
behavior. MIS Quarterly, 115-139.

Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User acceptance of
information technology: Toward a unified view. MIS Quarterly, 27(3), 425-478.

Vest, J. R., & Gamm, L. D. (2010). Health information exchange: persistent challenges
and new strategies. Journal of the American Medical Informatics Association,
17(3), 288-294.

Vest, J. R., Kern, L. M., Silver, M. D., Kaushal, R., & investigators, H. (2014). The
potential for community-based health information exchange systems to reduce
hospital readmissions. Journal of the American Medical Informatics Association,
22(2), 435-442.

Vestjens, L., Cramm, J. M., Birnie, E., & Nieboer, A. P. (2018). Evaluating an integrated
primary care approach to improve well-being among frail community-living older
people: A theory-guided study protocol. BMC Geriatrics, 18(1), 173.

Volkoff, O., Strong, D. M., & Elmes, M. B. (2007). Technological embeddedness and
organizational change. Organization Science, 18(5), 832-848.

Wakeman, S. E., & Friedmann, P. (2017). Outdated Privacy Law Limits Effective
Substance Use Disorder Treatment: The Case Against 42 CFR Part 2. Health

152
 Affairs Blog. DOI: 10.1377/hblog20170301.058969

West, V. L., Borland, D., & Hammond, W. E. (2014). Innovative information

visualization of electronic health record data: a systematic review. Journal of the
American Medical Informatics Association, 22(2), 330-339.

Williams, M., Rana, N., Dwivedi, Y., & Lal, B. (2011). Is UTAUT really used or just
cited for the sake of it? A systematic review of citations of UTAUT’s originating
article.

Wills, M. J., El-Gayar, O. F., & Bennett, D. (2008). Examining healthcare professionals’
acceptance of electronic medical records using UTAUT. Issues in Information
Systems, 9(2), 396-401.

Wilson, K., & Khansa, L. (2018). Migrating to electronic health record systems: A
comparative study between the United States and the United Kingdom. Health
Policy.

Wisdom, J., & Creswell, J. W. (2013). Mixed methods: Integrating quantitative and
qualitative data collection and analysis while studying patient-centered medical
home models. Rockville: Agency for Healthcare Research and Quality.

Wold, H. (1966). Estimation of principal components and related models by iterative

least squares. Multivariate Analysis, 391-420.

Woods, J. (2018). It’s not 42 CFR Part 2 that hurts the care of patients- it’s ignorance.
Alcoholism & Drug Abuse Weekly, 30(28), 5-6.

Wu, L. T., Ghitza, U. E., Zhu, H., Spratt, S., Swartz, M., & Mannelli, P. (2018).
Substance use disorders and medical comorbidities among high-need, high-risk
patients with diabetes. Drug and Alcohol Dependence, 186, 86-93.

Zachariadis, M., Scott, S., & Barrett, M. (2013). Methodological implications of critical
realism for mixed-methods research. MIS Quarterly, 855-879.

153
Appendix A: Conceptual Model

154
 Appendix B: Survey Prompt and Questionnaire Items

Hello, and thank you for taking time to complete this survey. The survey will be used to
determine factors that influence the intention to use behavioral health information
obtained from a health information exchange. The survey is to be completed by
physicians, nurse practitioners, and other healthcare providers who obtain and use health
information from the organization’s HIE.

Have you ever used behavioral health information obtained from the HIE your
organization uses? __ Yes __ No

(If “yes”, have the participant answer the questions pertaining to PE, EE, SI, perceived
risk, and trust. If “no”, have the physicians answer these questions, in addition to
questions related to trialability.)

Performance Expectancy
PU= Perceived Usefulness (Davis, 1989)
RA= Relative Advantage (Rogers, 1983)
OE= Outcome Expectations (Compeau & Higgins, 1995)
• P1. I would find the use of behavioral health information obtained from HIE
useful in my job (PU).
• P2. Using behavioral health information obtained from HIE enables me to
accomplish tasks more quickly (RA).
• P3. Using behavioral health information obtained from HIE increases my
productivity (RA).
• P4. If I use behavioral health information obtained from HIE, I will increase my
chances of timely reimbursement (OE).

Effort Expectancy
PEU= Perceived Ease of Use (Davis, 1989)
EU= Ease of Use (Moore & Benbassat, 1991)
C/S= Complexity/Simplicity (Rogers, 1983)
• E1. My interaction with behavioral health information obtained from HIE would
be clear and understandable (PEU).
• E2. It would be easy for me to become skillful at using behavioral health
information obtained from HIE (PEU).
• E3. I would find it easy to use behavioral health information obtained from HIE
(PEU).
• E4. Learning to obtain behavioral health information from HIE is easy for me
(EU).
• E5. I have no difficulty finding behavioral health information within the
information obtained from the HIE (C/S).

155
 • E6. I have no difficulty understanding the behavioral health information that I
obtained from the HIE (C/S).

Social Influence
SN= Subjective Norm (Azjen, 1991)
SF= Social Factors (Thompson, Higgins, & Howell, 1994)
• S1. People who influence my behavior think I should use behavioral health
information obtained from HIE (SN).
• S2. People who are important to me think that I should use behavioral health
information obtained from HIE (SN).
• S3. The senior management of this organization has been helpful in the use of
behavioral health information obtained from HIE (SF).
• S4. In general, the organization has supported the use of behavioral health
information obtained from HIE (SF).

Perceived Risk
Lu et al., 2011
• PR1. I do not feel totally safe providing patients’ behavioral health information
through HIE.
• PR2. I am worried about using behavioral health information obtained from HIE
because other people may be able to access patient information.
• PR3. I do not feel secure sending patients’ behavioral health information through
HIE.

Trust
Schneider, 1998; Jarvenpaa, 1999; Gefen, 2000; Chandra, Srivastava, & Theng, 2010

• TRU1. I trust the behavioral health information received through HIE.

• TRU2. I trust the behavioral health information received through HIE to be
reliable.
• TRU3. I trust the behavioral health information received through HIE to be
secure.
• TRU4. I believe the behavioral health information received through HIE is
trustworthy.

Trialability
Rogers, 1983
• TRI1. I would be more likely to want to obtain and use behavioral health
information from HIE if I were able to participate in a pilot test.
• TRI2. I really won’t lose much by trying to obtain and use behavioral health
information from HIE, even if I don’t like it.
Behavioral Intention to Use the Information

156
B= Behavioral Intention (consistent with the underlying theory for all the intention
models)
• B1. I intend to use behavioral health information obtained from HIE.
• B2. I predict that I will use behavioral health information obtained from HIE.
• B3. I plan to use behavioral health information obtained HIE.
Demographic Information
1. What is your gender? __Male __Female
2. What is the highest level of education you have completed?
__High school/GED
__Some college
__2-year college degree (Associate)
__4-year college degree (BA, BS, BSN, etc.)
__Master’s degree (MA, MS)
__Professional degree (MD, PharmD)
__Doctoral degree (PhD, DNP, etc.)
3. How old are you?
__21-29
__30-39
__40-49
__50-59
__60-69
__70+
4. Are you of Hispanic or Latino origin? __Yes __No
5. What is your racial background? (Check all that apply)
__American Indian/Alaska Native
__Asian
__Native Hawaiian or Other Pacific Islander
__Black/African American
__White
__Other (please specify): __________
6. Which best describes the level of your computer skills?
__Novice user (You just started using computers)
__Average user (You use word processors, spreadsheets, e-mail, surf the
Web, etc.)
__Advanced user (You can install software, setup configurations, etc.)
__Expert user (You can setup operating systems; know some computer
programming languages, etc.)
7. How many years of computer experience do you have? ___ years
8. Do you feel that some of your computer use has been replaced by use of a tablet
or smartphone? __Yes __No
9. By what percentage would you estimate that your computer use has been replaced
by the use of a tablet or smartphone?

157
10. Please write any additional comments that you may want to share.
11. This survey is anonymous. However, if you would like to be contacted for an
interview, please provide your contact information below.

158
 Appendix C: Interview Questions

Section 1: Introductory Questions

1. Please tell me about yourself and your role in the organization.
2. Please describe your role/interaction with the HIE in your organization.
3. Please describe how HIEHIEs are used within your organization.
4. Could you describe for me under what conditions you have or would use the HIE
to retrieve behavioral health information?

Section 2: Behavioral Health Information Exchange Initiative

1. The survey suggests that the query and use of behavioral health information via
the HIE is low. What are your thoughts on this finding?
2. What do you think your organization can do to increase the query and use of
behavioral health information through the HIE?

Section 3: Performance Expectancy

1. In your opinion, how can behavioral health information query and use be utilized
in delivering care to patients?
2. In your opinion, what challenges might arise for healthcare providers as a result of
querying and using behavioral health information through the HIE?

Section 4: Trust
1. How has the exchange of general health information been useful to you in treating
patients?
2. In your opinion, what would make general health information more useful in
treating patients?
3. Now, let’s think about behavioral health information. What are your thoughts
about the usefulness of behavioral health information specifically in treating
patients?

Section 5: Trialability
1. Please describe any opportunities the organization provided to learn about
exchanging behavioral health information.
2. If your organization did not provide the opportunity to participate in a pilot test, in
what ways do you think a pilot test could facilitate behavioral health information
exchange?

Section 6: Effort Expectancy

1. Please describe the process of querying and using behavioral health information
from the HIE, as you currently understand it.
2. What challenges, if any, do you think you would face in querying and using
behavioral health information from the HIE?
3. How would these challenges impact your ability to treat patients?

Section 7: Perceived Risk

1. What are your perceptions of behavioral health information?

159
 2. What are some of the potential risks of sharing behavioral health information
electronically?

Section 8: Additional Factors/Concluding Thoughts

1. What else would you like to discuss regarding the query and use of behavioral
health information via the HIE?
2. May I have your permission to reach back out to you to follow up on any of the
points that you made today, if necessary?

160
 Appendix D: Projected Timeline

Phase Month Task Deliverable

I 1-3 • Develop survey and • Survey and
interview questions interview
• Submit to IRB questions
• Identify participants • First 2-3
for quantitative chapters of
phase of study dissertation
• Write dissertation
II 3-6 • Data collection: • Data
obtain readmissions (readmissions
data from HIE and and surveys)
send out links for • Preliminary
survey via email analysis
• Preliminary data
analysis
• Report writing
phase (quant.)
III 6-9 • Identify • Data
interviewees from (transcribed
quantitative strand interviews)
(purposive • Analysis of
sampling) qual. data
• Conduct interviews
• Transcribe/coding
• Report writing
IV 9-12 • Final dissertation • Dissertation
writing drafts
• Final
dissertation
• Final defense

161
Appendix E: UAB IRB Approval Form (IRB-300001017)

162
Response to IRB Feedback

163
Appendix F: Baptist Health IRC Approval Form

164
165