A Unique Use of Regional Information Exchange by a Statewide Health System Serving Refugees: “Operation Allies Welcome”

Abstract

Background In September 2021, a military camp in the United States was identified for an initial relocation of over 6,600 Afghanistan refugees. This case report describes a novel use of existing health information exchange to expedite and provide health care for a large refugee population throughout the state during the duration of their entry into the United States.

Methods Medical teams of the health systems and military camp partnered to provide a scalable, reliable mechanism for clinical data exchange leveraging an existing regional health information exchange. Exchanges were evaluated for clinical type, originating source, and closed loop communication with the refugee camp and personnel military camp.

Results Approximately 50% of the camp residents were under the age of 18 years. Over 20 weeks, approximately 4.51% of the refugee camp residents were cared for in participating health systems. A total of 2,699 clinical data messages were exchanged, 62% of which were clinical documents.

Conclusion All health systems participating in care were offered support to utilize the tool and process set up using the regional health information exchange. The process and guiding principles may be applied to other refugee health care efforts to provide efficient, scalable, and reliable means of clinical data exchange to health care providers in similar situations.

Keywords

electronic health records - vulnerable populations - provider-provider communication - economic barriers - interoperability

Background and Significance

In September of 2021, Camp Atterbury, Edinburgh, Indiana, United States, was identified for initial relocation of over 7,000 Afghanistan refugees. According to Homeland Security, nearly 50% of the 6,600 refugees at the camp were children and 22% (roughly 1,450) were under the age of 9.[1] Therefore, the clinical needs of the camp were pediatric in nature. Given the patient population origins, the care for this group required knowledge aligned to global health and expanded infectious disease. The arrival of the refugees coincided with a surge in coronavirus disease 2019 patients due to the delta and omicron variants.[2]

Our health system assisted with the medical support of this population by leveraging special clinical services and targeted medical supplies, building on existing coalitions, and innovative use of existing technology. This study focuses specifically on the ability of our health system to leverage existing relationships throughout the state and regional health data exchange to enable clinical care.

Methods

Establish Point of Care Key Contacts

Chief Medical Officers at impacted hospitals and the health system quality and safety team served as primary contacts between Camp Atterbury and the medical health system. The Chief Medical Information Officer served as a primary information leader for the health system. Key contacts were established with the Indiana Hospital Association and the Indiana Health Information Exchange.

Utilization of Regional Health Information Exchange

Upon arrival at the Camp Atterbury location, refugees requiring medical care were transported to regional hospitals near the military camp and the children's hospital at our health system for acute care needs. Initial communication of the care between facilities in our health system to the medical team at the refugee camp occurred via daily phone calls and faxes.

Within a few days, the needs of the patients and the military medical and refugee operations identified attributes of a targeted and streamlined clinical data exchange. The process had the following key attributes:

• Efficient for patients, their families, medical, and military teams.

• Digital.

• Portable for the patient.

• Secure.

Refugee Patient Data Needs and Attributes

The patients from Afghanistan had a range of identification papers but were in a transient state as to location (address). They also did not have insurance identifiers and many children lacked certified identification documents.

The medical and military teams decided to utilize the camp as a primary address and a specific payer code unique to the group in our health system electronic health record (EHR). The patients originating from the refugee camp expected to have a several months' delay in determining their resettlement final location. It was determined that a primary care identifier linked to the camp could be utilized. If the camp itself served as a temporary but primary medical home, health systems throughout the state could leverage our existing regional health information exchange (HIE). The regional HIE also supports a Web-based, secure message email inbox for individual physicians and providers. Initiated formally in 2004, the regional HIE is one of the more established in the United States, facilitating the exchange of demographic data, clinical notes, laboratory data, radiology reports, and transfer of care documents for 123 hospitals (38 unique health systems), around 19,000 practices, and over 54,500 providers in the state of Indiana in a secure manner.[3]

The regional HIE created an inbox for “Dr. Camp Atterbury” and this provider name was assigned to the patients as their primary care doctor. The solution was tested on September 12, 2021 and implemented at our health system on September 13, 2021. Additional health systems were provided with the necessary data to leverage the process and refugee camp inbox. Documents and data were delivered in a personal inbox for providers. Establishing the account for refugee patients residing at the camp allowed key military medical leaders to access data from all camp patients attributed to “Dr. Camp Atterbury” ([Fig. 1]).

Fig. 1 Sample design of the Web-based secure message inbox.

Deployment of Process Statewide

The process was designed and implemented over the course of 6 days from arrival of the first patient presenting for care at the children's hospital to use at the children's hospital (which served as a pilot site). After a 48-hour testing period, the system was offered to all health systems caring for patients from the refugee camp. The HIE team worked with the state hospital association to aid in the adoption of the information exchange. Outreach targeted the regional health systems receiving the most patients. The only required effort for health system was to select “Atterbury, Camp” as the provider within their EHR and the existing configuration with the regional HIE.

Education and Tracking

Medical personnel at the military camp were trained on the workflow by HIE support staff. The application is Web-based and access to the camp inbox was to be limited by military leadership to the primary medical team caring for patients. The process continued to be supported by routine phone call discussion between the hospital and military camp medical teams reviewing the existing discharges. Patients and data were tracked in two ways: the health system tracked the number of patients using the payer identifier, and the HIE tracked patients and types of data using the provider identifier.

Results

The mission of the teams involved in the resettlement effort was completion of the rigorous security and medical screenings required in United States for refugees. This mission was completed on January 25, 2022, approximately 20 weeks after the arrival of the first refugees.[4]

Patients Served, One Health System

In the first 30 days of supporting the refugees, the children's hospital cared for 172 unique patients, 96% of all patients referred to the health system. By the completion of the mission, the health system had cared for 325 unique patients in 692 unique encounters, or approximately 4.51% of the camp's estimated residents. Of these, most encounters occurred in the children's hospital ([Table 1]).

Table 1 Total patients by facility and encounter type in our health system

	ED	Observation	Inpatient	Outpatient	Clinic	Total patients
Adult hospitals, central	9	3	4	43	47	106
Adult hospitals, regional	3	1	1	7	11	23
Children's hospital	187	44	45	113	174	563
Total of encounter type	199	48	50	163	232	692

Abbreviation: ED, emergency department.

Clinical Data Exchanged, Statewide

In total, 2,699 total messages were exchanged via the refugee camp and health systems using the information exchange. Unique reports exchanged in the first month averaged between 9 and 58 each day ([Fig. 2]). Each “report” was a data element exchanged. For example, a patient may have a clinical note, a laboratory result, and a radiology report; this would result in three unique reports for a single patient. Most reports were related to emergency room visits and included transcribed records and laboratory results most frequently ([Fig. 3]). Transcribed records include all notes. The ADT (Admit, Discharge, Transfer data) items mostly included patient demographic information, including next of kin and billing information when available. The children's hospital accounted for 72.8% of all the messages exchanged ([Table 2]).

Fig. 2 Unique reports sent to the “Dr. Camp Atterbury” inbox.

Fig. 3 Unique report venues and types of data, all health systems.

Table 2 Unique reports by health system entity

Health system entity	Unique reports (%)
Regional health system 1	24 (1)
Systemwide health system, adult	381 (14)
Children's health system	1,965 (73)
Regional health system 2	329 (12)
Total	2,699 (100)

Use of Exchanged Data from the Refugee Camp and Military Medical Team

In the first week of the activated “Dr. Camp Atterbury” inbox, information exchange was confirmed via a daily handoff phone call and some paper faxing with the medical team at Camp Atterbury. The military medical team changed every few days, and the medical team at the children's hospital was able to validate the number of patients discharged back to the camp and clinical information received. The clinical data was housed in the Web-based docs4docs system. The training included downloading the information for patients per their request to aid in portability; however, due to security requirements our team did not further assist with any integration into the military medical records systems.

From September 10, 2022, to May 10, 2022 (3 months after the last camp resident departed), 19 unique users accessed the “Dr. Camp Atterbury” inbox. They accessed anywhere from 1 to 917 data reports ([Fig. 4]).

Fig. 4 Use of data by military medical teams.

Discussion

In this report, we share the process of exchanging refugee health data in a region with an established HIE. The unique clinical health data needs of refugee population have been described with a special focus on identifiers and portability health data. In our health system, patients with a refugee status presented in September 2021 with a range of needs—some acute that could be resolved before discharge, others with more chronic diagnoses that required hand-off to the camp military medical team. To meet this need, it was quickly determined that a point of medical contact at the refugee camp base was critical to success.

Once this was established, it was clear that the most reliable identifier was establishing the patient's relationship with the camp as the provider identifier. Although acknowledged as a temporary identifier, the shared attributes of the patient status were widely accepted by all health systems contributing to care and allowing other health systems receiving patients from the camp to utilize the same “provider-location” to transmit their patient data. This also allowed a single collection site for the camp medical personnel. This did require the medical team to identify the patient's “provider” as the camp itself to ensure consistent transmission of data.

With 56% of the overall visits to all health systems being categorized as emergency room only, much of the clinical data included laboratory results and prescriptions. The 26% of inpatient admissions included more diagnostics (i.e., radiology results) and a comprehensive discharge summary. The children's hospital sent most of the messages, which is expected as most camp residents were under 18 years old and constituted the largest volume of off-base care.

Challenges in Clinical Records for Refugee Patients

Managing clinical data in the care of several thousand refugee patients had several challenges and opportunities. One of the first to address was identifying and serving patients with refugee status within the constructs of an EHR built for United States regulatory and revenue needs. Other demographic information—primary language, for example—did not highlight the patients' refugee status or needs. Even the location at the camp was challenging, as a certain barrack number was the most likely location that might change. EHRs are built systematically presuming certain social cultural assumptions, such as two-parent household, a household address, and a payer. Creating a single payer type for these patients allowed for tracking was the most effective aspect of our intervention.

Although U.S. standards of clinical interoperability were generally helpful in making clinical data exchangeable,[5] they did not support a patient whose home residence was in transition or not permanent. The EHR structures are also set up to prioritize exchange with other health systems and payers, not necessarily the social government agencies that were processing and assisting our patients.

There is a paucity of information regarding the practices of the exchange of refugee health data in the United States. Semere et al in 2016 provided analysis of U.S.-based data sets with publicly available documentation and found that few health data sets included refugee status, which limits the ability to understand and respond to their unique health care needs.[6] Ongoing attention and need for the creation of HIE is well documented.[7]

Globally, the challenges seen in the United States are shared. In 2019, Bozorgmehr et al reviewed the availability and integration of refugee and migrant workers and found that only 25 of the World Health Organization European region's 53 Region states had this information available.[8] In this study, the predominant data sources were medical and disease-specific records and data integration was limited. The identification of migration status in health records has also been described, but in extremely limited capacity. Norredam et al in 2011 described findings of integrating this information in the Danish national patient registration, which has an advantage of a national patient identifier.[9]

Lessons Learned for Clinical and Technology Leaders

Optimization of Digital Communication Tools and Direct Person Communication

The clinical data exchange was one part of successful communication. Our team continued to rely heavily on in-person huddles and verbal conversations (i.e., handoff) with military camp personnel to ensure the smooth transition between hospital care and the life of the patients moving back to camp. These unique challenges are not new to global health and refugee care[10]; however, they were new for many members of the medical teams working the children's hospital (which is a quaternary care level). Removing one barrier of communication was seen subjectively as a positive aid in this work. Of note, during the course of the camp and care provided, a total of 19 unique users from the military medical team utilized the exchange, with the top 5 users accounting for 75% of all the documents accessed. The ability to provide them access to a large amount of clinical information on demand improved efficiency, and therefore the military medical team's ability to receive and continue the care for patients returning to camp.

One additional need, particularly for a small number of patients with complex diagnosis, was a handoff to a physician or medical care team at a quaternary care pediatric center. This took the form of a cover letter and care conference to augment the clinical data; it occurred in a very small number of cases for families settled in other states and did not utilize the regional network.

Use of Existing Health Information Exchange Networks

Our experience highlights to use of a regional HIE for an urgent public health situation. Although this scenario does not specifically align to the traditional disaster response or global health programs, similar needs related to speed and organization collaboration were identified and those clinicians with such experience provided much needed leadership.

Prior to the HIE, other means for sharing of clinical data were utilized. Clinicians facing a similar challenge may have to facilitate collaboration using other, nonautomated means of secure communication to provide medical handoff. The patients and their support (i.e., families and loved ones) can also be provided portable, secure records to aid in medical handoff.

Using our existing HIE for automated clinical data exchange between health systems and the military camp was effective, efficient and secure. Nonhealth system players in the health information space (such as the military) can be connected to HIEs to achieve specific goals for populations.

Advocacy Opportunities

Finally, our experience highlighted an opportunity to help shape the standards for information exchange that may enable more solutions for medical care teams taking care of refugee and displaced persons. The United Nations estimates that in 2022, the number of refugees reached 32.5 million, with an average of 400,000 children born in refugee status annually.[11] Health information technology leaders have called for inclusion of social determinants of health in data standards to enable easier data exchange and portability.[12] In light of the growing need to support refugees and displaced persons, a more comprehensive health data model particularly for social determinants is needed. Health and technology leaders should advocate for broad and inclusive definitions of social determinants of health, to promote improved clinical care and health for refugees and other displaced persons.

Conclusion

Our statewide health system inclusive of a comprehensive children's health service was able to leverage established relationships and technical infrastructure to provide cohesive communication with the military camp serving Afghanistan refugees. A key to success was the augmentation of preexisting collaboration between different health systems and hospitals, as well as building on the existing infrastructure for a provider-attribution health exchange. The situation of refugees requires an approach for acute medical need; however, our process represents a scalable and sustainable model for future patient matching as the refugees transition into the next step of resettlement.

Clinical Relevance

This case study illustrates the utility for a temporary, large scale exchange of clinical data using existing partnerships and information exchange. This should provide insight for other health care professionals and systems who require this service for a transient or temporary population. This case study suggests innovative use of patient identifiers to facilitate the use of existing exchanges, which may benefit other use cases in population health and value-based care.

Multiple-Choice Questions

1. Refugee health system has unique clinical data needs. These include:

   • Identifier as refugee status.

   • Other identifiers as refugee status, such as temporary address.

   • Ease of access to land of birth or recent habitation.

   • All of the above.

   Correct Answer: The correct answer is option d. Electronic health records demographics do not routinely capture or provider standard fields for refugee status, land of birth, or other appropriate identifiers for refuge status. All of these data points are necessary to provide clinical care as well as interoperable and longitudinal records.

2. Regional health information exchanges are frequently used for all the following except:

   • Patient level data between individual providers.

   • Large batch data for populations for a specific public health need.

   • Vaccine status data from other locations.

   • Secure messages between patients and their doctors.

   Correct Answer: The correct answer is option d. Secure messages between patients and their doctors are not routinely included functionality in the health information exchanges, but usually in the primary EHR.

Conflict of Interest

None declared.

Acknowledgments

The authors would like to thank the staff and leadership of the Indiana Health Information Exchange (IHIE), specifically Maggie Hilt, Jane McKendree, and Becky Learn.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by Indiana University Institutional Review Board. It was deemed a non-human subjects research.

• References

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• 2 Indiana Department of Health. Indiana COVID-19 Home Dashboard. Published March 2020. Accessed May 9, 2023 at: https://www.coronavirus.in.gov/indiana-covid-19-dashboard-and-map/ 2022
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Publication History

Received: 02 January 2023

Accepted: 11 April 2023

Accepted Manuscript online:
13 April 2023

Article published online:
28 June 2023