Hospital readiness for health information exchange: development of metrics associated with successful collaboration for quality improvement

Capacity-Building for Collecting Patient-Reported Outcomes and Experiences (PRO) Data Across Hospitals

PURPOSE

Patient-reported outcomes and experiences (PRO) data are an integral component of health care quality measurement and PROs are now being collected by many healthcare systems. However, hospital organizational capacity-building for the collection and sharing of PROs is a complex process. We sought to identify the factors that facilitated capacity-building for PRO data collection in a nascent quality improvement learning collaborative of 16 hospitals that has the goal of improving the childbirth experience.

DESCRIPTION

We used standard qualitative case study methodologies based on a conceptual framework that hypothesizes that adequate organizational incentives and capacities allow successful achievement of project milestones in a collaborative setting. The 4 project milestones considered in this study were: (1) Agreements; (2) System Design; (3) System Development and Operations; and (4) Implementation. To evaluate the success of reaching each milestone, critical incidents were logged and tracked to determine the capacities and incentives needed to resolve them.

ASSESSMENT

The pace of the implementation of PRO data collection through the 4 milestones was uneven across hospitals and largely dependent on limited hospital capacities in the following 8 dimensions: (1) Incentives; (2) Leadership; (3) Policies; (4) Operating systems; (5) Information technology; (6) Legal aspects; (7) Cross-hospital collaboration; and (8) Patient engagement. From this case study, a trajectory for capacity-building in each dimension is discussed.

CONCLUSION

The implementation of PRO data collection in a quality improvement learning collaborative was dependent on multiple organizational capacities for the achievement of project milestones.

Leadership in Integrated Care Networks: A Literature Review and Opportunities for Future Research

Introduction

In many countries, elderly patients with chronic conditions require a web of services delivered by several providers collaborating in inter-organisational networks. In view of their global importance, it is surprising how little we know how these networks are led. Like traditional organisations, networks require leadership to function effectively. This paper reviews central characteristics of leadership in integrated care networks and proposes opportunities for future research.

Theory and methods

Analysing 73 studies published in leading academic journals, this paper consolidates research on leadership media, practices, activities and outcomes, covering the network, policy and organisation levels of analysis.

Results

Findings indicate that the field has focused on leadership media and outcomes at the network level. They also suggest that leadership in integrated care networks faces multiple tensions. Future research could usefully provide a fuller picture by examining leadership practices, activities and outcomes at the policy and organisation level, integrating advances in the wider leadership literature.

Discussion and conclusion

These findings contribute to the debate on leadership in integrated care networks. They also inform practice, drawing attention to persistent tensions as a core leadership challenge and offering latest scholarly evidence practitioners can use to reflect on and advance their own leadership practice.

Key Factors Affecting Ambulatory Care Providers' Electronic Exchange of Health Information With Affiliated and Unaffiliated Partners: Web-Based Survey Study

Background

Despite the potential benefits of electronic health information exchange (HIE) to improve the quality and efficiency of care, HIE use by ambulatory providers remains low. Ambulatory providers can greatly improve the quality of care by electronically exchanging health information with affiliated providers within their health care network as well as with unaffiliated, external providers.

Objective

This study aimed to examine the extent of electronic HIE use by ambulatory clinics with affiliated providers within their health system and with external providers, as well as the key technological, organizational, and environmental factors affecting the extent of HIE use within and outside the health system.

Methods

A Web-based survey of 320 ambulatory care providers was conducted in the state of Illinois. The study examined the extent of HIE usage by ambulatory providers with hospitals, clinics, and other facilities within and outside their health care system–encompassing seven kinds of health care data. Ten factors pertaining to technology (IT [information technology] Compatibility, External IT Support, Security & Privacy Safeguards), organization (Workflow Adaptability, Senior Leadership Support, Clinicians Health-IT Knowledge, Staff Health-IT Knowledge), and environment (Government Efforts & Incentives, Partner Readiness, Competitors and Peers) were assessed. A series of multivariate regressions were used to examine predictor effects.

Results

The 6 regressions produced adjusted R-squared values ranging from 0.44 to 0.63. We found that ambulatory clinics exchanged more health information electronically with affiliated entities within their health system as compared with those outside their health system. Partner readiness emerged as the most significant predictor of HIE usage with all entities. Governmental initiatives for HIE, clinicians’ prior familiarity and knowledge of health IT systems, implementation of appropriate security, and privacy safeguards were also significant predictors. External information technology support and workflow adaptability emerged as key predictors for HIE use outside a clinic’s health system. Differences based on clinic size, ownership, and specialty were also observed.

Conclusions

This study provides exploratory insights into HIE use by ambulatory providers within and outside their health care system and differential predictors that impact HIE use. HIE use can be further improved by encouraging large-scale interoperability efforts, improving external IT support, and redesigning adaptable workflows.

Does participation in health information exchange improve hospital efficiency?

The federal government allocated nearly $30 billion to spur the development of information technology infrastructure capable of supporting the exchange of interoperable clinical data, leading to growth in hospital participation in health information exchange (HIE) networks. HIEs have the potential to improve care coordination across healthcare providers, leading ultimately to increased productivity of health services for hospitals. However, the impact of HIE participation on hospital efficiency remains unclear. This dynamic prompts the question asked by this study: does HIE participation improve hospital efficiency. This study estimates the effect of HIE participation on efficiency using a national sample of 1017 hospitals from 2009 to 2012. Using a two-stage analytic design, efficiency indices were determined using the Malmquist algorithm and then regressed on a set of hospital characteristics. Results suggest that any participation in HIE can improve both technical efficiency change and total factor productivity (TFP). A second model examining total years of HIE participation shows a benefit of one and three years of participation on TFP. These results suggest that hospital investment in HIE participation may be a useful strategy to improve hospital operational performance, and that policy should continue to support increased participation and use of HIE. More research is needed to identify the exact mechanisms through which HIE participation can improve hospital efficiency.

Factors that impact Patient Web Portal Readiness (PWPR) among the underserved

OBJECTIVE

Healthcare organizations in the US are increasingly using Patient Portals as a means to provide patients with partial access to their health records and thereby comply with the 'meaningful use' of Health Information Technology policy issued by the US federal government. Patient portals are used to not only provide access to parts of the health records such as lab results but also offer services such as customized educational materials and appointment scheduling. While prior studies examining the adoption rates of these patient portals have not offered consistent findings, many of the studies have reported limited adoption and use [1] of patient portals, especially among the underserved population. This study explores the factors behind the reduced adoption rate of patient portals among the underserved by focusing on their Patient Web Portal Readiness (PWPR).

DESIGN

The study empirically evaluates the impact of three important variables on PWPR among the underserved: (a) Personal Health Information Management (PHIM) activities, (b) patient attitude toward personal health record keeping; and (c) use of Internet for health information seeking. The study also incorporates three other factors: (d) access to Internet; (e) demographics; and (f) presence of chronic illness.

MEASUREMENTS

Data were collected through a survey from 132 patients from the underserved population who visited 5 free clinics in the Northern Virginia area in the US. The paper-based survey was administered to the patients who visited these free clinics for care.

RESULTS

The study findings show support for the hypotheses related to the impact of the two key factors - Personal Health Information Management (PHIM) activities and attitude toward personal health record keeping - on PWPR. The findings also indicate that the use of Internet for health information seeking has relatively more impact than patient's Internet access on PWPR. Overall, the findings imply the critical importance of complementary activities - e.g., PHIM activities, Internet-based health information seeking - to enhance PWPR among the underserved population.

Health Information Exchange (HIE): A literature review, assimilation pattern and a proposed classification for a new policy approach

OBJECTIVES

Literature shows existence of barriers to Healthcare Information Exchange (HIE) assimilation process. A number of studies have considered assimilation of HIE as a whole phenomenon without regard to its multifaceted nature. Thus, the pattern of HIE assimilation in healthcare providers has not been clearly studied due to the effects of contingency factors on different assimilation phases. This study is aimed at defining HIE assimilation phases, recognizing assimilation pattern, and proposing a classification to highlight unique issues associated with HIE assimilation.

METHODS

A literature review of existing studies related to HIE efforts from 2005 was undertaken. Four electronic research databases (PubMed, Web of Science, CINAHL, and Academic Search Premiere) were searched for articles addressing different phases of HIE assimilation process.

RESULTS

Two hundred and fifty-four articles were initially selected. Out of 254, 44 studies met the inclusion criteria and were reviewed. The assimilation of HIE is a complicated and a multi-staged process. Our findings indicated that HIE assimilation process consisted of four main phases: initiation, organizational adoption decision, implementation and institutionalization. The data helped us recognize the assimilation pattern of HIE in healthcare organizations.

CONCLUSIONS

The results provide useful theoretical implications for research by defining HIE assimilation pattern. The findings of the study also have practical implications for policy makers. The findings show the importance of raising national awareness of HIE potential benefits, financial incentive programs, use of standard guidelines, implementation of certified technology, technical assistance, training programs and trust between healthcare providers. The study highlights deficiencies in the current policy using the literature and identifies the "pattern" as an indication for a new policy approach.

Assessing organizational capacity for achieving meaningful use of electronic health records

BACKGROUND

Health care institutions are scrambling to manage the complex organizational change required for achieving meaningful use (MU) of electronic health records (EHR). Assessing baseline organizational capacity for the change can be a useful step toward effective planning and resource allocation.

PURPOSE

The aim of this article is to describe an adaptable method and tool for assessing organizational capacity for achieving MU of EHR. Data on organizational capacity (people, processes, and technology resources) and barriers are presented from outpatient clinics within one integrated health care delivery system; thus, the focus is on MU requirements for eligible professionals, not eligible hospitals.

METHODS

We conducted 109 interviews with representatives from 46 outpatient clinics.

FINDINGS

Most clinics had core elements of the people domain of capacity in place. However, the process domain was problematic for many clinics, specifically, capturing problem lists as structured data and having standard processes for maintaining the problem list in the EHR. Also, nearly half of all clinics did not have methods for tracking compliance with their existing processes. Finally, most clinics maintained clinical information in multiple systems, not just the EHR. The most common perceived barriers to MU for eligible professionals included EHR functionality, changes to workflows, increased workload, and resistance to change.

PRACTICE IMPLICATIONS

Organizational capacity assessments provide a broad institutional perspective and an in-depth clinic-level perspective useful for making resource decisions and tailoring strategies to support the MU change effort for eligible professionals.

Tracking and sustaining improvement initiatives: leveraging quality dashboards to lead change in a neurosurgical department

Increasingly, hospitals and physicians are becoming acquainted with business intelligence strategies and tools to improve quality of care. In 2007, the University of California Los Angeles (UCLA) Department of Neurosurgery created a quality dashboard to help manage process measures and outcomes and ultimately to enhance clinical performance and patient care. At that time, the dashboard was in a platform that required data to be entered manually. It was then reviewed monthly to allow the department to make informed decisions. In 2009, the department leadership worked with the UCLA Medical Center to align mutual quality-improvement priorities. The content of the dashboard was redesigned to include 3 areas of priorities: quality and safety, patient satisfaction, and efficiency and use. Throughout time, the neurosurgery quality dashboard has been recognized for its clarity and its success in helping management direct improvement strategies and monitor impact. We describe the creation and design of the neurosurgery quality dashboard at UCLA, summarize the evolution of its assembly process, and illustrate how it can be used as a powerful tool of improvement and change. The potential challenges and future directions of this business intelligence tool are also discussed.

Barriers over time to full implementation of health information exchange in the United States

BACKGROUND

Although health information exchanges (HIE) have existed since their introduction by President Bush in his 2004 State of the Union Address, and despite monetary incentives earmarked in 2009 by the health information technology for economic and clinical health (HITECH) Act, adoption of HIE has been sparse in the United States. Research has been conducted to explore the concept of HIE and its benefit to patients, but viable business plans for their existence are rare, and so far, no research has been conducted on the dynamic nature of barriers over time.

OBJECTIVE

The aim of this study is to map the barriers mentioned in the literature to illustrate the effect, if any, of barriers discussed with respect to the HITECH Act from 2009 to the early months of 2014.

METHODS

We conducted a systematic literature review from CINAHL, PubMed, and Google Scholar. The search criteria primarily focused on studies. Each article was read by at least two of the authors, and a final set was established for evaluation (n=28).

RESULTS

The 28 articles identified 16 barriers. Cost and efficiency/workflow were identified 15% and 13% of all instances of barriers mentioned in literature, respectively. The years 2010 and 2011 were the most plentiful years when barriers were discussed, with 75% and 69% of all barriers listed, respectively.

CONCLUSIONS

The frequency of barriers mentioned in literature demonstrates the mindfulness of users, developers, and both local and national government. The broad conclusion is that public policy masks the effects of some barriers, while revealing others. However, a deleterious effect can be inferred when the public funds are exhausted. Public policy will need to lever incentives to overcome many of the barriers such as cost and impediments to competition. Process improvement managers need to optimize the efficiency of current practices at the point of care. Developers will need to work with users to ensure tools that use HIE resources work into existing workflows.

Evaluating a De-Centralized Regional Delivery System for Breast Cancer Screening and Patient Navigation for the Rural Underserved

Providing breast cancer screening services in rural areas is challenging due to the fractured nature of healthcare delivery systems and complex reimbursement mechanisms that create barriers to access for the under- and uninsured. Interventions that reduce structural barriers to mammography, like patient navigation programs, are effective and recommended, especially for minority and underserved women. Although the literature on rural healthcare is significant, the field lacks studies of adaptive service delivery models and rigorous evaluation of evidence-based programs that facilitate routine screening and appropriate follow-up across large geographic areas.

OBJECTIVES

To better understand how to implement a decentralized regional delivery "hub & spoke" model for rural breast cancer screening and patient navigation, we have designed a rigorous, structured, multi-level and mixed-methods evaluation based on Glasgow's RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance).

METHODS AND DESIGN

The program is comprised of three core components: 1) Outreach to underserved women by partnering with county organizations; 2) Navigation to guide patients through screening and appropriate follow-up; and 3) Centralized Reimbursement to coordinate funding for screening services through a central contract with Medicaid Breast and Cervical Cancer Services (BCCS). Using Glasgow's RE-AIM model, we will: 1) assess which counties have the resources and capacity to implement outreach and/or navigation components, 2) train partners in each county on how to implement components, and 3) monitor process and outcome measures in each county at regular intervals, providing booster training when needed.

DISCUSSION

This evaluation strategy will elucidate how the heterogeneity of rural county infrastructure impacts decentralized service delivery as a navigation program expands. In addition to increasing breast cancer screening access, our model improves and maintains time to diagnostic resolution and facilitates timely referral to local cancer treatment services. We offer this evaluation approach as an exemplar for scientific methods to evaluate the translation of evidence-based federal policy into sustainable health services delivery in a rural setting.

Risk Management Information System Architecture for a Hospital Center

In modern day’s institutions, risk management plays a crucial role as it aims to minimize the likelihood of adverse events and contributes to improve the quality of services delivery. In health care, an effective risk management is only possible if supported by information systems that can produce high quality measures and meaningful risk indicators. These indicators will then allow the healthcare organization to self-assess by identifying critical gaps and opportunities for improvement in several frontiers. Such an organizational thrust is not only warranted for competitiveness but also fundamental for the purpose of benchmarking, accreditation and certification. Additionally, monitoring of specific indicators is often required by the tutelage. However, the development of a risk management system can be an arduous process due to the inherent complexity of clinical systems. This paper presents an architecture for the implementation of a risk management information system, using as example the case of CHTMAD, a Portuguese hospital center.