Patient portal messaging for care coordination: a qualitative study of perspectives of experienced users with chronic conditions

BACKGROUND

Patient portal secure messaging (asynchronous electronic communication between physicians and their established patients) allows patients to manage their care through asynchronous, direct communication with their providers. This type of engagement with health information technology could have important benefits for patients with chronic conditions, and a more thorough understanding of the use and barriers of secure messaging among this population is needed. The objective of this study was to explore how experienced portal users engage with secure messaging to manage their chronic conditions.

METHODS

Three focus groups were conducted with 17 total patients who self-reported a cardiopulmonary condition. Participants were asked questions about their experience with patient portal secure messaging. Focus group transcripts were coded through inductive and deductive methods to reveal common themes.

RESULTS

Patients' motivation for using messaging included the speed and ease of such communication and direct access to a physician. Messaging was used by patients as an extension of the office visit and supported coordination of care among providers as well as patient collaboration with family members or caretakers. Patients identified challenges to using messaging, including technological barriers, worry about uncompensated physician time spent responding to messages, and confusion about what constitutes an appropriate 'non-urgent' message.

CONCLUSIONS

This study highlights the potential of patient portal messaging as a tool for care coordination to enhance chronic disease self-management. However, uncertainty about the appropriate use of portal messaging persists even among experienced users. Additional patient training in the proper use of secure messaging and its benefits for disease self-management may help to resolve these concerns.

Patient Engagement as Measured by Inpatient Portal Use: Methodology for Log File Analysis

Background

Inpatient portals (IPPs) have the potential to increase patient engagement and satisfaction with their health care. An IPP provides a hospitalized patient with similar functions to those found in outpatient portals, including the ability to view vital signs, laboratory results, and medication information; schedule appointments; and communicate with their providers. However, IPPs may offer additional functions such as meal planning, real-time messaging with the inpatient care team, daily schedules, and access to educational materials relevant to their specific condition. In practice, IPPs have been developed as websites and tablet apps, with hospitals providing the required technology as a component of care during the patient’s stay.

Objective

This study aimed to describe how inpatients are using IPPs at the first academic medical center to implement a system-wide IPP and document the challenges and choices associated with this analytic process.

Methods

We analyzed the audit log files of IPP users hospitalized between January 2014 and January 2016. Data regarding the date/time and duration of interactions with each of the MyChart Bedside modules (eg, view lab results or medications and patient schedule) and activities (eg, messaging the provider and viewing educational videos) were captured as part of the system audit logs. The development of a construct to describe the length of time associated with a single coherent use of the tool—which we call a session—provides a foundational unit of analysis. We defined frequency as the number of sessions a patient has during a given provision day. We defined comprehensiveness in terms of the percentage of functions that an individual uses during a given provision day.

Results

The analytic process presented data challenges such as length of stay and tablet-provisioning factors. This study presents data visualizations to illustrate a series of data-cleaning issues. In the presence of these robust approaches to data cleaning, we present the baseline usage patterns associated with our patient panel. In addition to frequency and comprehensiveness, we present considerations of median data to mitigate the effect of outliers.

Conclusions

Although other studies have published usage data associated with IPPs, most have not explicated the challenges and choices associated with the analytic approach deployed within each study. Our intent in this study was to be somewhat exhaustive in this area, in part, because replicability requires common metrics. Our hope is that future researchers in this area will avail themselves of these perspectives to engage in critical assessment moving forward.

Understanding Secure Messaging in the Inpatient Environment: A New Avenue for Communication and Patient Engagement

BACKGROUND

Patient portals, and the secure messaging feature in particular, have been studied in the outpatient setting, but research in the inpatient setting is relatively less mature.

OBJECTIVE

To understand the topics discussed in secure messaging in the inpatient environment, we analyzed and categorized messages sent within an inpatient portal.

MATERIALS AND METHODS

This observational study examined the content of all secure messages sent from December 2013 to June 2017 within an inpatient portal at a large Midwestern academic medical center (AMC). We analyzed a total of 2,598 messages, categorizing them by sender (patient, family, or care team member), type, and topic, and conducted a descriptive analysis of categories and an examination of code co-occurrence.

RESULTS

Patients were the most frequent message senders (63%); family members sent the fewest messages (10%). We identified five types of messages: Alert/Request; Thanks; Response; Question; and Other (typo/test message). Patient messages included Alerts/Requests (38%), Questions (31%), Statements of Thanks (24%), Response (1.2%), and Other (5%). We also identified 14 nonmutually exclusive message topics: Medication; Procedure/Treatment Plan; Schedule; Pain; Results; Diet; Discharge; Non-Medication Questions; Provider Requests; Symptoms; Custodial; Technical Issues; Potential Error; and Contact Information. Patient message topics most commonly discussed Symptoms (18%), Procedure/Treatment Plan (14%), or Pain (12%).

CONCLUSION

Our analysis of secure message content suggests certain message types and topics such as Alerts/Requests and Questions about symptoms and treatment plans are particularly important to patients. These findings demonstrate that both patients and family members utilize the secure messaging function to engage in the care process by posing questions, making requests, and alerting staff to problems. As this technology is implemented in additional facilities, future work should examine how use of secure messaging may be influenced by factors including patients' demographics, reasons for hospitalization, and length of stay.

Moving Organizational Culture from Volume to Value: A Qualitative Analysis of Private Sector Accountable Care Organization Development

OBJECTIVE

The concept of shifting from volume (i.e., billing for as many patients and services as possible) to value (i.e., reducing costs while improving quality) has been a key underpinning of the development of accountable care organizations (ACOs), yet the cultural change necessary to make this shift has been previously unexplored.

DATA SOURCES/STUDY SETTING

Primary data collected through site visits to four private sector ACOs.

STUDY DESIGN

Cross-sectional, semi-structured interview study with analysis done at the ACO level to learn about ACO development.

DATA COLLECTION

One hundred and forty-eight interviews recorded and transcribed verbatim followed by rigorous qualitative analysis using a grounded theory approach.

PRINCIPAL FINDINGS

The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost-benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided.

CONCLUSIONS

We found that moving from volume to value is central to the culture change required of an ACO. Our findings can inform future efforts that aim to create a more effective value-based health care system.

Training to Optimize Collaborative Use of an Inpatient Portal

BACKGROUND

Inpatient portals are an emerging technology that can facilitate collaborative interactions between patients and care teams, but little is known about how organizations attempt to implement and facilitate inpatient portal use for their providers.

METHODS

We held in-person, semistructured interviews with care team members and information technology (IT) staff and conducted rigorous thematic analysis of transcripts.

RESULTS

Interviews with 220 care team members and 4 IT staff identified 3 new areas of training needed to optimize inpatient portal implementation and use that extend beyond training to use other technologies: (1) teaching staff to train patients about tool use; (2) training about how to promote tool use to patients; and (3) training about optimal use of secure messaging.

DISCUSSION

Our findings show that inpatient portals are implemented within a collaborative multistakeholder context. Training efforts must consider the importance of this collaborative context to help providers learn to both incorporate the technology into their workflow and assist patients with portal use.

Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety

Objective

Agency for Healthcare Research and Quality (AHRQ) software applies standardized algorithms to hospital administrative data to identify patient safety indicators (PSIs). The objective of this study was to assess the validity of PSI flags and report reasons for invalid flagging.

Material and Methods

At a 6-hospital academic medical center, a retrospective analysis was conducted of all PSIs flagged in fiscal year 2014. A multidisciplinary PSI Quality Team reviewed each flagged PSI based on quarterly reports. The positive predictive value (PPV, the percent of clinically validated cases) was calculated for 12 PSI categories. The documentation for each reversed case was reviewed to determine the reasons for PSI reversal.

Results

Of 657 PSI flags, 185 were reversed. Seven PSI categories had a PPV below 75%. Four broad categories of reasons for reversal were AHRQ algorithm limitations (38%), coding misinterpretations (45%), present upon admission (10%), and documentation insufficiency (7%). AHRQ algorithm limitations included 2 subcategories: an "incident" was inherent to the procedure, or highly likely (eg, vascular tumor bleed), or an "incident" was nonsignificant, easily controlled, and/or no intervention was needed.

Discussion

These findings support previous research highlighting administrative data problems. Additionally, AHRQ algorithm limitations was an emergent category not considered in previous research. Herein we present potential solutions to address these issues.

Conclusions

If, despite poor validity, US policy continues to rely on PSIs for incentive and penalty programs, improvements are needed in the quality of administrative data and the standardized PSI algorithms. These solutions require national motivation, research attention, and dissemination support.

System-Wide Inpatient Portal Implementation: Survey of Health Care Team Perceptions

BACKGROUND

Inpatient portals, a new type of patient portal tailored specifically to the hospital setting, can allow patients to access up-to-date health information and exchange secure communications with their care team. As such, inpatient portals present an opportunity for patients to increase engagement in their care during a time of acute crisis that emphasizes focus on a patient's health. While there is a large body of research on patient portals in the outpatient setting, questions are being raised specifically about inpatient portals, such as how they will be incorporated into the flow of patient care in hectic, stressed, team-based hospital settings.

OBJECTIVE

Our aim is to improve understanding about hospital care team members' perceptions of the value of an interactive patient portal for admitted patients, as well as to ascertain staff orientation toward this new technology.

METHODS

Throughout the course of 2016, an inpatient portal, MyChart Bedside (MCB) was implemented across a five-hospital health system. The portal is a tablet-based app that includes a daily schedule, lab/test results, secure messaging with the care team, a place to take notes, and access to educational materials. Within a month of initial rollout, hospital care team members completed a 5-minute, anonymous online survey to assess attitudes and perceptions about MCB use and staff training for the new technology.

RESULTS

Throughout the health system, 686 staff members completed the survey: 193 physicians (23.6%), 439 nurses (53.7%), and 186 support staff (22.7%). Questions about the importance of MCB, self-efficacy in using MCB with patients, and feelings about sufficient training and resources showed that an average of 40-60% of respondents in each group reported a positive orientation toward the MCB technology and training received. This positive orientation was highest among support staff, lower among nurses, and lowest for physicians (all differences by staff role were statistically significant at P<.001). Additionally, 62.0% of respondents reported "not enough" training.

CONCLUSIONS

Despite the robust training effort, similar to that used in previous health information technology implementations at this health system, hospital care team members reported only a moderately positive orientation toward MCB and its potential, and the majority wanted more training. We propose that due to the unique elements of the inpatient portal-interactive features used by patients and providers requiring explanation and collaboration-traditional training approaches may be insufficient. Introduction of the inpatient portal as a new collaborative tool may thus require new methods of training to support enhanced engagement between patients and their care team.

Health Information Technology (HIT) Adaptation: Refocusing on the Journey to Successful HIT Implementation

In past years, policies and regulations required hospitals to implement advanced capabilities of certified electronic health records (EHRs) in order to receive financial incentives. This has led to accelerated implementation of health information technologies (HIT) in health care settings. However, measures commonly used to evaluate the success of HIT implementation, such as HIT adoption, technology acceptance, and clinical quality, fail to account for complex sociotechnical variability across contexts and the different trajectories within organizations because of different implementation plans and timelines. We propose a new focus, HIT adaptation, to illuminate factors that facilitate or hinder the connection between use of the EHR and improved quality of care as well as to explore the trajectory of changes in the HIT implementation journey as it is impacted by frequent system upgrades and optimizations. Future research should develop instruments to evaluate the progress of HIT adaptation in both its longitudinal design and its focus on adaptation progress rather than on one cross-sectional outcome, allowing for more generalizability and knowledge transfer.

The Rules of Engagement: Perspectives on Secure Messaging From Experienced Ambulatory Patient Portal Users

Background

Patient portals have shown promise in engaging individuals in self-management of chronic conditions by allowing patients to input and track health information and exchange secure electronic messages with their providers. Past studies have identified patient barriers to portal use including usability issues, low health literacy, and concerns about loss of personal contact as well as provider concerns such as increased time spent responding to messages. However, to date, studies of both patient and provider perspectives on portal use have focused on the pre-implementation or initial implementation phases and do not consider how these issues may change as patients and providers gain greater experience with portals.

Objective

Our study examined the following research question: Within primary care offices with high rates of patient-portal use, what do experienced physician and patient users of the ambulatory portal perceive as the benefits and challenges of portal use in general and secure messaging in particular?

Methods

This qualitative study involved 42 interviews with experienced physician and patient users of an ambulatory patient portal, Epic’s MyChart. Participants were recruited from the Department of Family Medicine at a large Academic Medical Center (AMC) and included providers and their patients, who had been diagnosed with at least one chronic condition. A total of 29 patients and 13 primary care physicians participated in the interviews. All interviews were conducted by telephone and followed a semistructured interview guide. Interviews were transcribed verbatim to permit rigorous qualitative analysis. Both inductive and deductive methods were used to code and analyze the data iteratively, paying particular attention to themes involving secure messaging.

Results

Experienced portal users discussed several emergent themes related to a need for greater clarity on when and how to use the secure messaging feature. Patient concerns included worry about imposing on their physician’s time, the lack of provider compensation for responding to secure messages, and uncertainty about when to use secure messaging to communicate with their providers. Similarly, providers articulated a lack of clarity as to the appropriate way to communicate via MyChart and suggested that additional training for both patients and providers might be important. Patient training could include orienting patients to the “rules of engagement” at portal sign-up, either in the office or through an online tutorial.

Conclusions

As secure messaging through patient portals is increasingly being used as a method of physician-patient communication, both patients and providers are looking for guidance on how to appropriately engage with each other using this tool. Patients worry about whether their use is appropriate, and providers are concerned about the content of messages, which allow them to effectively manage patient questions. Our findings suggest that additional training may help address the concerns of both patients and providers, by providing “rules of engagement” for communication via patient portals.

Searching for management approaches to reduce HAI transmission (SMART): a study protocol

BACKGROUND

Healthcare-associated infections (HAIs) impact patients' lives through prolonged hospitalization, morbidity, and death, resulting in significant costs to both health systems and society. Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are two of the most preventable HAIs. As a result, these HAIs have been the focus of significant efforts to identify evidence-based clinical strategies to reduce infection rates. The Comprehensive Unit-based Safety Program (CUSP) provides a formal model for translating CLABSI-reduction evidence into practice. Yet, a national demonstration project found organizations experienced variable levels of success using CUSP to reduce CLABSIs. In addition, in Fiscal year 2019, Medicare will expand use of CLABSI and CAUTI metrics beyond ICUs to the entire hospital for reimbursement purposes. As a result, hospitals need guidance about how to successfully translate HAI-reduction efforts such as CUSP to non-ICU settings (clinical practice), and how to shape context (management practice)-including culture and management strategies-to proactively support clinical teams.

METHODS

Using a mixed-methods approach to evaluate the contribution of management factors to successful HAI-reduction efforts, our study aims to: (1) Develop valid and reliable measures of structural management practices associated with the recommended CLABSI Management Strategies for use as a survey (HAI Management Practice Guideline Survey) to support HAI-reduction efforts in both medical/surgical units and ICUs; (2) Develop, validate, and then deploy the HAI Management Practice Guideline Survey, first across Ohio hospitals, then nationwide, to determine the positive predictive value of the measurement instrument as it relates to CLABSI- and CAUTI-prevention; and (3) Integrate findings into a Management Practices Toolkit for HAI reduction that includes an organization-specific data dashboard for monitoring progress and an implementation program for toolkit use, and disseminate that Toolkit nationwide.

DISCUSSION

Providing hospitals with the tools they need to successfully measure management structures that support clinical care provides a powerful approach that can be leveraged to reduce the incidence of HAIs experienced by patients. This study is critical to providing the information necessary to successfully "make health care safer" by providing guidance on how contextual factors within a healthcare setting can improve patient safety across hospitals.

Working with an Electronic Medical Record in Ambulatory Care: A Study of Patient Perceptions of Intrusiveness

OBJECTIVE

To assess patient perceptions of electronic medical record (EMR) intrusiveness during ambulatory visits to clinics associated with a large academic medical center.

METHOD

We conducted a survey of patients seen at any of 98 academic medical center clinics. The survey assessed demographics, visit satisfaction, computer use, and perceived intrusiveness of the computer.

RESULTS

Of 7,058 patients, slightly more than 80 percent reported that the physician had used the computer while in the room, but only 24 percent were shown results in the EMR. Most patients were very satisfied or satisfied with their visit and did not find the computer intrusive (83 percent). Younger respondents, those shown results, and those who reported that the physician used the computer were more likely to perceive the computer as intrusive. Qualitative comments suggest different perceptions related to computer intrusiveness than to EMR use more generally.

DISCUSSION

Patients were generally accepting of EMRs and therefore use of computers in the exam room. However, subgroups of patients may require greater study to better understand patient perceptions related to EMR use and intrusiveness.

CONCLUSION

Results suggest the need for greater focus on how physicians use computers in the exam room in a manner that facilitates maintaining good rapport with patients.

The Link Between Clinically Validated Patient Safety Indicators and Clinical Outcomes

There is a paucity of evidence on the association between clinically validated Patient Safety Indicators (PSIs) and inpatient length of stay, mortality, and 30-day unplanned readmission. The authors perform a retrospective analysis of patient discharges from an academic medical center comprising 6 hospitals from July 2012 to June 2014. Multivariable regression models are used to assess the relationship between length of stay, mortality, and 30-day unplanned readmission and the presence of a clinically validated PSI. Cases flagged with a clinically validated PSI are associated with a statistically greater length of stay, 30-day unplanned readmission, and mortality as compared to cases without a PSI. This study demonstrates a strong association between clinically validated PSIs and patient outcomes. The findings have important implications in policy and practice as health care reform dictates improvement in the experience of care, health of populations, and per capita costs.

High Touch and High Tech (HT2) Proposal: Transforming Patient Engagement Throughout the Continuum of Care by Engaging Patients with Portal Technology at the Bedside

Background

For patients with complex care needs, engagement in disease management activities is critical. Chronic illnesses touch almost every person in the United States. The costs are real, personal, and pervasive. In response, patients often seek tools to help them manage their health. Patient portals, personal health records tethered to an electronic health record, show promise as tools that patients value and that can improve health. Although patient portals currently focus on the outpatient experience, the Ohio State University Wexner Medical Center (OSUWMC) has deployed a portal designed specifically for the inpatient experience that is connected to the ambulatory patient portal available after discharge. While this inpatient technology is in active use at only one other hospital in the United States, health care facilities are currently investing in infrastructure necessary to support large-scale deployment. Times of acute crisis such as hospitalization may increase a patient’s focus on his/her health. During this time, patients may be more engaged with their care and especially interested in using tools to manage their health after discharge. Evidence shows that enhanced patient self-management can lead to better control of chronic illness. Patient portals may serve as a mechanism to facilitate increased engagement.

Objective

The specific aims of our study are (1) to investigate the independent effects of providing both High Tech and High Touch interventions on patient-reported outcomes at discharge, including patients’ self-efficacy for managing chronic conditions and satisfaction with care; and (2) to conduct a mixed-methods analysis to determine how providing patients with access to MyChart Bedside (MCB, High Tech) and training/education on patient portals, and MyChart Ambulatory (MCA, High Touch) will influence engagement with the patient portal and relate to longer-term outcomes.

Methods

Our proposed 4-year study uses a mixed-methods research (MMR) approach to evaluate a randomized controlled trial studying the effectiveness of a High Tech intervention (MCB, the inpatient portal), and an accompanying High Touch intervention (training patients to use the portal to manage their care and conditions) in a sample of hospitalized patients with two or more chronic conditions. This study measures how access to a patient portal tailored to the inpatient stay can improve patient experience and increase patient engagement by (1) improving patients’ perceptions of the process of care while in the hospital; (2) increasing patients’ self-efficacy for managing chronic conditions; and (3) facilitating continued use of a patient portal for care management after discharge. In addition, we aim to enhance patients’ use of the portal available to outpatients (MCA) once they are discharged.

Results

This study has been funded by the Agency for Healthcare Research and Quality (AHRQ). Research is ongoing and expected to conclude in August 2019.

Conclusions

Providing patients real-time access to health information can be a positive force for change in the way care is provided. Meaningful use policies require minimum demonstrated use of patient portal technology, most often in the ambulatory setting. However, as the technology matures to bridge the care transition, there is a greater need to understand how patient portals transform care delivery. By working in concert with patients to address and extend current technologies, our study aims to advance efforts to increase patients’ engagement in their care and develop a template for how other hospitals might integrate similar technologies.

Quality Improvement Intervention to Decrease Prolonged Mechanical Ventilation After Coronary Artery Bypass Surgery

BACKGROUND

In 2010, the incidence of prolonged mechanical ventilation (> 24 hours) after isolated coronary artery bypass graft (CABG) surgery was 26.9% at the study site, The Ohio State University Wexner Medical Center, compared with the national like-hospital rate of 10.9%.

OBJECTIVES

To use the principles of lean management to reduce the incidence of prolonged mechanical ventilation and to assess the sustainability of that reduction over time.

METHODS

A multidisciplinary prolonged ventilation task force conducted a gap analysis leading to 3 interventions: (1) a standardized extubation protocol, (2) dry erase boards in patients' rooms to facilitate team communication, and (3) edits of the postoperative order set within the electronic health record. Outcomes of mechanical ventilation in CABG patients before and after the interventions are compared.

RESULTS

All target outcomes changed significantly after the interventions, including a reduction in the median hours of initial mechanical ventilation (from 11.4 hours to 6.9 hours, P < .001). The percentage of patients reintubated did not increase (a decrease from 11.8% to 3.5% was not significant, P = .08). The rate of prolonged ventilation decreased from 29.4% to 8.6% (P = .004), and this reduction was sustained for 4 years after the interventions.

CONCLUSIONS

Success factors included the multidisciplinary task force and continual protocol reeducation among front-line staff.

Cultural Transformation After Implementation of Crew Resource Management: Is It Really Possible?

Crew resource management (CRM) has the potential to improve safety culture and reduce patient safety errors across different hospitals and inherent cultures, but hospital-wide implementations have not been studied. The authors examined the impact of a systematic CRM implementation across 8 departments spanning 3 hospitals and 2 campuses. The Hospital Survey on Patient Safety Culture (HSOPS) was administered electronically to all employees before CRM implementation and about 2 years after; changes in percent positive composite scores were compared in pre-post analyses. Across all respondents, there was a statistically significant increase in composite score for 10 of the 12 HSOPS dimensions ( P < .05). These significant results persisted across the 8 departments studied and among both practitioners and staff. Consideration of score changes across dimensions reveals that the teamwork and communication dimensions of patient safety culture may be more highly influenced by CRM training than supervisor and management dimensions.

What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Academic Medical Center?

Crew Resource Management (CRM) training has been used successfully within hospital units to improve quality and safety. This article presents a description of a health system-wide implementation of CRM focusing on the return on investment (ROI). The costs included training, programmatic fixed costs, time away from work, and leadership time. Cost savings were calculated based on the reduction in avoidable adverse events and cost estimates from the literature. Between July 2010 and July 2013, roughly 3000 health system employees across 12 areas were trained, costing $3.6 million. The total number of adverse events avoided was 735—a 25.7% reduction in observed relative to expected events. Savings ranged from a conservative estimate of $12.6 million to as much as $28.0 million. Therefore, the overall ROI for CRM training was in the range of $9.1 to $24.4 million. CRM presents a financially viable way to systematically organize for quality improvement.

An Effective Web Presence for Substance Abuse Treatment Facilities

BACKGROUND

Website development for health care has only been prevalent in the last two and a half decades. The first websites were electronic versions of brochures providing hardly any interaction with the consumer or potential consumer. The percentage of consumers that use the internet during the decision-making process for health care providers continues to rise. As a result, the websites of health care providers are becoming more of a representation of the facility and creating an organizational image rather than a brochure-like informational page.

OBJECTIVES

The purpose of this study was to analyze substance abuse treatment center's websites in the State of California with the goal of informing the management of substance abuse centers regarding an effective and inexpensive means to closing the marketing gaps in the industry.

METHODS

This brief research report presents the results of employing an automated web-crawler to assess website quality along five dimensions: accessibility, content, marketing, technology, and usability score.

RESULTS

The sample mean scores for all dimensions were between 4 and 6 on a 10-point scale. On average larger facilities had higher quality websites.

CONCLUSIONS

The low mean scores on these dimensions indicate that that substance abuse centers have significant room for improvement of their website's. Efficiently spending marketing funds to increase the effectiveness of a treatment center's website can be a low cost way for even small facilities to increase market competitiveness.

Getting to Zero: Goal Commitment to Reduce Blood Stream Infections

While preventing health care-associated infections (HAIs) can save lives and reduce health care costs, efforts designed to eliminate HAIs have had mixed results. Variability in contextual factors such as work culture and management practices has been suggested as a potential explanation for inconsistent results across organizations and interventions. We examine goal-setting as a factor contributing to program outcomes in eight hospitals focused on preventing central line-associated bloodstream infections (CLABSIs). We conducted qualitative case studies to compare higher- and lower-performing hospitals, and explored differences in contextual factors that might contribute to performance variation. We present a goal commitment framework that characterizes factors associated with successful CLABSI program outcomes. Across 194 key informant interviews, internal and external moderators and characteristics of the goal itself differentiated actors' goal commitment at higher- versus lower-performing hospitals. Our findings have implications for organizations struggling to prevent HAIs, as well as informing the broader goal commitment literature.

Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center

Electronic medical record (EMR) implementation efforts face many challenges, including individual and organizational barriers and concerns about loss of productivity during the process. These issues may be particularly complex in large and diverse settings with multiple specialties providing inpatient and outpatient care. This case report provides an example of a successful EMR implementation that emphasizes the importance of flexibility and adaptability on the part of the implementation team. It also presents the top 10 lessons learned from this EMR implementation in a large midwestern academic medical center. Included are five overarching lessons related to leadership, initial approach, training, support, and optimization as well as five lessons related to the EMR system itself that are particularly important elements of a successful implementation.

Antiplatelet and Statin Use in US Patients With Coronary Artery Disease Categorized by Race/Ethnicity and Gender, 2003 to 2012

Antiplatelets and statins are efficacious for preventing future cardiovascular events in patients with coronary heart disease. Disparity in cardiovascular outcomes exists by race/ethnicity and gender; however, few studies have explored potential disparities in long-term antiplatelet and statin use by race/ethnicity and gender. We conducted a repeated cross-sectional analysis using the nationally representative Medical Expenditure Panel Survey from 2003 to 2012. The sample consisted of 14,334 men and women >29 years with coronary heart disease. We identified antiplatelet and statin use, medical conditions, and sociodemographic characteristics. Rates of use did not change for statins or the combination of statins and antiplatelets from 2003 to 2012 but decreased for antiplatelets (p = 0.015). Of the total sample, 70.9% (95% confidence interval [CI] 69.7 to 72.1) reported use of antiplatelets, 52.5% (95% CI 51.1 to 53.8) reported statin use, and 43.1% (95% CI 41.8 to 44.4) reported the combination. Use of antiplatelets and statins were associated with one another (odds ratio 3.22; 95% CI 2.87 to 3.62). From 2009 to 2012, black and Hispanic men along with all race/ethnicities of women were less likely to report use of statins, antiplatelets, and the combination of the 2 compared with white men, even after controlling for sociodemographics. Changing the definition of a medication use, inclusion of cardiovascular risk factors, or the inclusion of warfarin in the antiplatelet category did not substantially change the results. Future practice and policy goals should focus on increasing the number of high-risk patients on appropriate preventative medications while focusing particular attention on decreasing the identified disparity.