Improving population care with an integrated electronic panel support tool

Tailoring remote patient management in cardiovascular risk management for healthcare professionals using panel management: a qualitative study

BACKGROUND

While remote patient management (RPM) has the potential to assist in achieving treatment targets for cardiovascular risk factors in primary care, its effectiveness may vary among different patient subgroups. Panel management, which involves proactive care for specific patient risk groups, could offer a promising approach to tailor RPM to these groups. This study aims to (i) assess the perception of healthcare professionals and other stakeholders regarding the adoption and (ii) identify the barriers and facilitators for successfully implementing such a panel management approach.

METHODS

In total, nineteen semi-structured interviews and two focus groups were conducted in the Netherlands. Three authors reviewed the audited transcripts. The Consolidated Framework for Implementation Strategies (CFIR) domains were used for the thematic analysis.

RESULTS

A total of 24 participants (GPs, nurses, health insurers, project managers, and IT consultants) participated. Overall, a panel management approach to RPM in primary care was considered valuable by various stakeholders. Implementation barriers encompassed concerns about missing necessary risk factors for patient stratification, additional clinical and technical tasks for nurses, and reimbursement agreements. Facilitators included tailoring consultation frequency and early detection of at-risk patients, an implementation manager accountable for supervising project procedures and establishing agreements on assessing implementation metrics, and ambassador roles.

CONCLUSION

Panel management could enhance proactive care and accurately identify which patients could benefit most from RPM to mitigate CVD risk. For successful implementation, we recommend having clear agreements on technical support, financial infrastructure and the criteria for measuring evaluation outcomes.

The effect of an HIV preexposure prophylaxis panel management strategy to increase preexposure prophylaxis prescriptions

OBJECTIVE

The HIV preexposure prophylaxis optimization intervention (PrEP-OI) study evaluated the efficacy of a panel management intervention using PrEP coordinators and a web-based panel management tool to support healthcare providers in optimizing PrEP prescription and ongoing PrEP care.

DESIGN

The PrEP-OI study was a stepped-wedge randomized clinical trial conducted across 10 San Francisco Department of Public Health primary care sites between November 2018 and September 2019. Each month, clinics one-by-one initiated PrEP-OI in random order until all sites received the intervention by the study team.

METHODS

The primary outcome was the number of PrEP prescriptions per month. Secondary outcomes compared pre- and postintervention periods on whether PrEP was discussed and whether PrEP-related counseling (e.g., HIV risk assessment, risk reduction counseling, PrEP initiation/continuation assessment) was conducted. Prescription and clinical data were abstracted from the electronic health records. We calculated incidence rate ratios (IRR) and risk ratios (RR) to estimate the intervention effect on primary and secondary outcomes.

RESULTS

The number of PrEP prescriptions across clinics increased from 1.85/month (standard deviation [SD] = 2.55) preintervention to 2.44/month (SD = 3.44) postintervention (IRR = 1.34; 95% confidence interval [CI] = 1.05-1.73; P  = 0.021). PrEP-related discussions during clinic visits (RR = 1.13; 95% CI = 1.04-1.22; P  = 0.004), HIV risk assessment (RR = 1.40; 95% CI = 1.14-1.72; P  = 0.001), and risk reduction counseling (RR = 1.16; 95% CI = 1.03-1.30; P  = 0.011) increased from the pre- to the postintervention period. Assessment of PrEP initiation/continuation increased over time during the postintervention period (RR = 1.05; 95% CI = 0.99-1.11; P  = 0.100).

CONCLUSIONS

A panel management intervention using PrEP coordinators and a web-based panel management tool increased PrEP prescribing and improved PrEP-related counseling in safety-net primary care clinics.

The Impact of Guideline Integration into Electronic Medical Records on Outcomes for Patients with Diabetes: A Systematic Review

Optimal strategies for integration of clinical practice guidelines into electronic medical records and its impact on processes of care and clinical outcomes in diabetic patients are not well understood. A systematic review of CINAHL, MEDLINE, PubMed, and Cochrane Library databases in August 2016, November 2017, and June 2020 was conducted. Studies investigating integration of diabetes guidelines into ambulatory care electronic medical records reporting quantitative results were included. After screening 15,783 records, 21 articles were included. Lipid and blood pressure control consistently improved with guideline integration, but A1c control remained equivocal. Electronic guideline integration improved microvascular complication screening, vaccination, and documentation of cardiovascular risk factors, while medication prescription and blood pressure, lipid, and A1c documentation did not improve. Studies employing a combination of electronic record intervention strategies were associated with improvement in monitoring and attainment of guideline and screening targets. Thus, strategies employing combinations of interventions to incorporate guidelines into electronic records may improve processes of care and some clinical outcomes.

Value-Based Pay-for-Performance Gaps in the Care Delivery Framework for a Large-Scale Health System

Many health systems are engaging in pay-for-performance agreements with payers that focus primarily on improving ambulatory preventive screenings. These also are referred to as gaps in care. Gaps in care are typically measured by the Healthcare Effectiveness Data and Information Set measures of health care quality. To address gaps in care effectively, the physician-led Gaps in Care program at Northwell Health works to improve processes related to measurement, data attribution, patient outreach, and patient engagement. Following a structured framework to address patient gaps in care is a successful strategy for accomplishing complex value-based care delivery.

Heart Failure Management Innovation Enabled by Electronic Health Records

Patients with congestive heart failure (CHF) require complex medical management across the continuum of care. Electronic health records (EHR) are currently used for traditional tasks of documentation, reviewing and managing test results, computerized order entry, and billing. Unfortunately many clinicians view EHR as merely digitized versions of paper charts, which create additional work and cognitive burden without improving quality or efficiency of care. In fact, EHR are revolutionizing the care of chronic diseases such as CHF. This review describes how appropriate use of technologies offered by EHR can help standardize CHF care, promote adherence to evidence-based guidelines, optimize workflow efficiency, improve performance metrics, and facilitate patient engagement. This review discusses a number of tools including documentation templates, telehealth and telemedicine, health information exchange, order sets, clinical decision support, registries, and analytics. Where available, evidence of their potential utility in management of CHF is presented. Together these EHR tools can also be used to enhance quality improvement, patient management, and clinical research as part of a learning health care system model. This review describes how existing EHR tools can support patients, cardiologists, and care teams to deliver consistent, high-quality, coordinated, patient-centered, and guideline-concordant care of CHF.

A Simple Pre-Exposure Prophylaxis (PrEP) Optimization Intervention for Health Care Providers Prescribing PrEP: Pilot Study

Background

Pre-exposure prophylaxis (PrEP) has been shown to be highly effective for the prevention of HIV in clinical trials and demonstration projects, but PrEP uptake and adherence outside of these settings in the United States has been limited. Lack of knowledge and willingness of health care providers (HCPs) to prescribe PrEP is an important barrier to implementation.

Objective

The objective of this study was to describe and examine the feasibility and acceptability of a PrEP Optimization Intervention (PrEP-OI) targeted at HCPs. The ultimate purpose of this intervention was to increase PrEP uptake, adherence, and persistence among those at risk for HIV acquisition.

Methods

This intervention included the following: (1) a Web-based panel management tool called PrEP-Rx, which provides comprehensive HIV risk assessment, automates reminders for follow-up, and reports patients' history of PrEP use; and (2) centralized PrEP coordination by a clinical support staff member (ie, the PrEP coordinator) who can identify individuals at risk for HIV, provide medical insurance navigation, and support multiple HCPs. Feasibility was evaluated based on HCPs' ability to log in to PrEP-Rx and use it as needed. Acceptability was assessed via individual formative qualitative interviews with HCPs after 1 month of the intervention.

Results

The intervention was feasible and acceptable among HCPs (N=6). HCPs identified system-level barriers to PrEP provision, many of which can be addressed by this intervention. HCPs noted that the intervention improved their PrEP knowledge; increased ease of PrEP prescription; and was likely to improve patient engagement and retention in care, enhance communication with patients, and improve patient monitoring and follow-up.

Conclusions

Given the critical role HCPs serve in disseminating PrEP, we created an easy-to-use PrEP optimization intervention deemed feasible and acceptable to providers. Further research on this tool and its ability to impact the PrEP continuum of care is needed.

Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization

BACKGROUND

In 2006, recognizing variations in performance in quality, safety, service, and efficiency, Kaiser Permanente leaders initiated the development of a performance improvement (PI) system. Kaiser Permanente has implemented a strategy for creating the systemic capacity for continuous improvement that characterizes a learning organization. Six "building blocks" were identified to enable Kaiser Permanente to make the transition to becoming a learning organization: real-time sharing of meaningful performance data; formal training in problem-solving methodology; workforce engagement and informal knowledge sharing; leadership structures, beliefs, and behaviors; internal and external benchmarking; and technical knowledge sharing. Putting each building block into place required multiple complex strategies combining top-down and bottom-up approaches.

SUCCESSES AND CHALLENGES

Although the strategies have largely been successful, challenges remain. The demand for real-time meaningful performance data can conflict with prioritized changes to health information systems. It is an ongoing challenge to teach PI, change management, innovation, and project management to all managers and staff without consuming too much training time. Challenges with workforce engagement include low initial use of tools intended to disseminate information through virtual social networking. Uptake of knowledge-sharing technologies is still primarily by innovators and early adopters. Leaders adopt new behaviors at varying speeds and have a range of abilities to foster an environment that is psychologically safe and stimulates inquiry.

CONCLUSIONS

A learning organization has the capability to improve, and it develops structures and processes that facilitate the acquisition and sharing of knowledge.

Innovative methods for parents and clinics to create tools for kids' care (IMPACCT Kids' Care) study protocol

BACKGROUND

Despite expansions in public health insurance, many children remain uninsured or experience gaps in coverage. Community health centers (CHCs) provide primary care to many children at risk for uninsurance and are well-positioned to help families obtain and retain children's coverage. Recent advances in health information technology (HIT) capabilities provide the means to create tools that could enhance CHCs' insurance outreach efforts.

OBJECTIVE

To present the study design, baseline patient characteristics, variables, and statistical methods for the Innovative Methods for Parents And Clinics to Create Tools for Kids' Care (IMPACCT Kids' Care) study.

METHODS/DESIGN

In this mixed methods study, we will design, test and refine health insurance outreach HIT tools through a user-centered process. We will then implement the tools in four CHCs and evaluate their effectiveness and barriers and facilitators to their implementation. To measure effectiveness, we will quantitatively assess health insurance coverage continuity and utilization of healthcare services for pediatric patients in intervention CHCs compared to matched control sites using electronic health record (EHR) and Oregon Medicaid administrative data over 18months pre- and 18months post-implementation (n=34,867 children). We will also qualitatively assess the implementation process to understand how the tools fit into the clinics' workflows and the CHC staff experiences with the tools.

CONCLUSIONS

This study creates, implements, and evaluates health insurance outreach HIT tools. The use of such tools will likely improve care delivery and health outcomes, reduce healthcare disparities for vulnerable populations, and enhance overall healthcare system performance. ClinicalTrials.gov Identifier: NCT02298361.

Health information technology: an untapped resource to help keep patients insured

The recent confluence of: (1) changing state and national insurance-related policies, and (2) the rapid growth in electronic health record (EHR) use, yields an unprecedented opportunity for patient-centered medical homes (PCMHs) and other primary care practices or care settings to use health information technology (HIT) and health information exchange (HIE) in novel ways to impact patient health. We propose that HIT is an untapped resource for supporting clinic-based efforts to help eligible patients obtain and maintain insurance coverage. This commentary presents a conceptual model and guiding principles for this idea. Additionally, it describes insurance support tools that could be used to conduct 'inreach' and 'outreach' with patients around health insurance, similar to how HIT is used to manage chronic disease and panels of patients, and to improve population health outcomes.

Improving care for older adults: a model to segment the senior population

CONTEXT

Risk stratification and tailored interventions are key population-level care management strategies among older adults, whose needs range from screening and prevention to end-of-life care.

OBJECTIVE

To validate the Senior Segmentation Algorithm, a tool using administrative and clinical data from the electronic health record to identify each member aged 65 years and older as belonging to 1 of 4 Care Groups with similar needs: those without chronic conditions, with one or more chronic conditions, with advanced illness or end-organ failure, or with extreme frailty or nearing the end of life.

DESIGN

Multiple validation methods.

MAIN OUTCOME MEASURES

Concordance with physician judgment, stability of segmentation over time, convergence with mortality, hospitalization, and readmission rates, and costs of care.

RESULTS

Concordance of the algorithm with physician-assessed segmentation of 1615 Medicare recipients was 85%. After 1 year, approximately 85% of 86,140 surviving seniors remained in the same care group; 3.9% moved to a lower need group; and 11% moved to a higher need group. Six-month and 12-month mortality rates varied substantially across care groups. The algorithm performed similarly to the likelihood of hospitalization score in predicting hospitalization and readmissions.

CONCLUSIONS

The Senior Segmentation Algorithm accurately identifies older adults in care groups with similar needs, trajectories, and utilization patterns. It is being implemented in all Kaiser Permanente Regions, with the goal of determining key elements of care for members in each group. In addition, future efforts will aim to slow progression to higher need care groups and to identify necessary improvements in delivery system design.

A multilingual population health management program

Many small- and medium-sized physician practices have developed specific programs and models toward becoming a successful patient-centered medical home. This article reports on a case-control quality improvement study of a multilingual population health management program for chronic disease management at International Community Health Services. In its first 2.5 years of operation, the International Community Health Services Population Health Management program for patients with hypertension and diabetes is associated with significant improvements in key health outcome measures for blood pressure and hemoglobin A1c control. This has significant implications for similar practices.

Electronic health records as a tool for recruitment of participants' clinical effectiveness research: lessons learned from tobacco cessation

Translating tobacco dependence treatments that are effective in research settings into real-world clinical settings remains challenging. Electronic health record (EHR) technology can facilitate this process. This paper describes the accomplishments and lessons learned from a translational team science (clinic/research) approach to the development of an EHR tool for participant recruitment and clinic engagement in tobacco cessation research. All team stakeholders-research, clinical, and IT-were engaged in the design and planning of the project. Results over the first 17 months of the study showed that over one half of all smokers, coming in for any type of clinic appointment, were offered participation in the study, a very high level of adherent use of the EHR. Study recruitment over this period was 1,071 individuals, over 12 % of smokers in the participating clinics.

Use of IndiGO individualized clinical guidelines in primary care

Objective

To determine if IndiGO individualized clinical guidelines could be implemented in routine practice and assess their effects on care and care experience.

Methods

Matched comparison observational design. IndiGO individualized guidelines, based on a biomathematical simulation model, were used in shared decision-making. Physicians and patients viewed risk estimates and tailored recommendations in a dynamic user interface and discussed them for 5–10 min. Outcome measures were prescribing and dispensing of IndiGO-recommended medications, changes in physiological markers and predicted 5-year risk of heart attack and stroke, and physician and patient perceptions.

Results

489 patients using IndiGO were 4.9 times more likely to receive a statin prescription than were matched usual care controls (p=0.015). No effect was observed on prescribing of antihypertensive medications, but IndiGO-using patients were more likely to pick up at least one dispensing (p<0.05). No significant changes were observed in blood pressure or serum lipid levels. Predicted risk of heart attack or stroke decreased 1.6% among patients using IndiGO versus 1.0% among matched controls (p<0.01). Physician and patient experiences were positive to neutral.

Limitations

We could not assess the separate effects of individualized guidelines, user interface, and physician–patient discussions. Patient selection could have influenced results. The measure of risk reduction was not independent of the individualized guidelines.

Conclusions

IndiGO individualized clinical guidelines were successfully implemented in primary care and were associated with increases in the use of cardioprotective medications and reduction in the predicted risk of adverse events, suggesting that a larger trial could be warranted.

The use of patient-reported outcomes (PRO) within comparative effectiveness research: implications for clinical practice and health care policy

BACKGROUND

The goal of comparative effectiveness research (CER) is to explain the differential benefits and harms of alternate methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. To inform decision making, information from the patient's perspective that reflects outcomes that patients care about are needed and can be collected rigorously using appropriate patient-reported outcomes (PRO). It can be challenging to select the most appropriate PRO measure given the proliferation of such questionnaires over the past 20 years.

OBJECTIVE

In this paper, we discuss the value of PROs within CER, types of measures that are likely to be useful in the CER context, PRO instrument selection, and key challenges associated with using PROs in CER.

METHODS

We delineate important considerations for defining the CER context, selecting the appropriate measures, and for the analysis and interpretation of PRO data. Emerging changes that may facilitate CER using PROs as an outcome are also reviewed including implementation of electronic and personal health records, hospital and population-based registries, and the use of PROs in national monitoring initiatives. The potential benefits of linking the information derived from PRO endpoints in CER to decision making is also reviewed.

CONCLUSIONS

The recommendations presented for incorporating PROs in CER are intended to provide a guide to researchers, clinicians, and policy makers to ensure that information derived from PROs is applicable and interpretable for a given CER context. In turn, CER will provide information that is necessary for clinicians, patients, and families to make informed care decisions.

Collaborative development of a randomized study to adapt a diabetes quality improvement initiative for federally qualified health centers

This case study describes how we are translating a diabetes care quality improvement initiative from an insured (HMO) setting into federally qualified health centers (FQHCs). We outline the innovative collaborative processes whereby researchers and FQHC providers adapted this initiative, which includes health information technology tools, to meet the FQHCs' needs.

Health care worker perspectives inform optimization of patient panel-support tools: a qualitative study

Electronic decision-support systems appear to enhance care, but improving both tools and work practices may optimize outcomes. Using qualitative methods, the authors' aim was to evaluate perspectives about using the Patient Panel-Support Tool (PST) to better understand health care workers' attitudes toward, and adoption and use of, a decision-support tool. In-depth interviews were conducted to elicit participant perspectives about the PST-an electronic tool implemented in 2006 at Kaiser Permanente Northwest. The PST identifies "care gaps" and recommendations in screening, medication use, risk-factor control, and immunizations for primary care panel patients. Primary care physician (PCP) teams were already grouped (based on performance pre- and post-PST introduction) into lower, improving, and higher percent-of-care-needs met. Participants were PCPs (n=21), medical assistants (n=11), and quality and other health care managers (n=20); total n=52. Results revealed that the most commonly cited benefit of the PST was increased in-depth knowledge of patient panels, and empowerment of staff to do quality improvement. Barriers to PST use included insufficient time, competing demands, suboptimal staffing, tool navigation, documentation, and data issues. Facilitators were strong team staff roles, leadership/training for tool implementation, and dedicated time for tool use. Higher performing PCPs and their assistants more often described a detailed team approach to using the PST. In conclusion, PCP teams and managers provided important perspectives that could help optimize use of panel-support tools to improve future outcomes. Improvements are needed in tool function and navigation; training; staff accountability and role clarification; and panel management time.

Use of electronic health records and administrative data for public health surveillance of eye health and vision-related conditions in the United States

PURPOSE

To discuss the current trend toward greater use of electronic health records and how these records could enhance public health surveillance of eye health and vision-related conditions.

DESIGN

Perspective, comparing systems.

METHODS

We describe 3 currently available sources of electronic health data (Kaiser Permanente, the Veterans Health Administration, and the Centers for Medicare & Medicaid Services) and how these sources can contribute to a comprehensive vision and eye health surveillance system.

RESULTS

Each of the 3 sources of electronic health data can contribute meaningfully to a comprehensive vision and eye health surveillance system, but none currently provide all the information required. The use of electronic health records for vision and eye health surveillance has both advantages and disadvantages.

CONCLUSIONS

Electronic health records may provide additional information needed to create a comprehensive vision and eye health surveillance system. Recommendations for incorporating electronic health records into such a system are presented.

A multi-perspective analysis of lessons learned from building an Integrated Care Coordination Information System (ICCIS)

Care coordination is at the forefront of current health reform efforts, yet most electronic health records (EHRs) lack the functionality needed to facilitate and document care coordination activities. The Integrated Care Coordination Information System (ICCIS) was iteratively developed with user input to meet these needs. Following 16 months of system use, ICCIS users and developers were interviewed about their experiences. These interviews, along with quantitative information about system use, were analyzed using a combination of Linstone's Multiple Perspective approach and the ABC framework to determine lessons learned about novel system creation. Overall, clinicians saw value in specialized health information technology (HIT) tools for care coordination as long as development focuses on providing user-requested functionality that integrates closely with existing HIT systems and workflows. Close integration between novel HIT and EHRs may increase use by relieving the cited fatigues of duplicative data entry, multiple system logins, and potential data inconsistencies.

Effects of proactive population-based nephrologist oversight on progression of chronic kidney disease: a retrospective control analysis

Background

Benefits of early nephrology care are well-established, but as many as 40% of U.S. patients with end-stage renal disease (ESRD) do not see a nephrologist before its onset. Our objective was to evaluate the effect of proactive, population-based nephrologist oversight (PPNO) on chronic kidney disease (CKD) progression.

Methods

Retrospective control analysis of Kaiser Permanente Hawaii members with CKD using propensity score matching methods. We matched 2,938 control and case pairs of individuals with stage 3a CKD for the pre-PPNO period (2001–2004) and post-PPNO period (2005–2008) that were similar in other characteristics: age, gender, and the presence of diabetes and hypertension. After three years, we classified the stage outcomes for all individuals. We assessed the PPNO effect across all stages of progression with a χ²- test. We used the z-score test to assess the proportional differences in progression within a stage.

Results

The progression within the post-PPNO period was less severe and significantly different from the pre-PPNO period (p = 0.027). Within the stages, there were 2.6% more individuals remaining in 3a in the post-period (95% confidence interval [CI], 1.5% to 3.8%; P value < 0.00001). Progression from 3a to 3b was 2.2% less in the post-period (95% [CI], 0.7% to 3.6%; P value = 0.0017), 3a to 4/5 was 0.2% less (95% CI, 0.0% to 0.87%; P value = 0.26), and 3a to ESRD was 0.24% less (95% CI, 0.0% to 0.66%, P value = 0.10).

Conclusions

Proactive, population-based nephrologist oversight was associated with a statistically significant decrease in progression. With enabling health information technology, risk stratification and targeted intervention by collaborative primary and specialty care achieves population-level care improvements. This model may be applicable to other chronic conditions.

An educational intervention to increase internists' confidence with and provision of preventive services to adolescents and young adults

BACKGROUND

Internal medicine (IM) physicians report inadequate preparation to care for adolescents and young adults.

PURPOSE

The aim is to (a) improve IM residents' comfort and confidence caring for adolescents/young adults and (b) increase the percentage of adolescent/young adult patients receiving preventive healthcare.

METHODS

Fifty-two PGY1 IM residents were assigned to treatment or control groups. Residents in the treatment group interviewed and received feedback from adolescent instructors. We developed a survey to measure residents' comfort and confidence caring for adolescents/young adults and evaluated their adherence to screening guidelines for patients ages 16 to 26.

RESULTS

Significantly more residents in the intervention group felt confident identifying sexually transmitted infections (STIs) and substance abuse and treating STIs, substance abuse, and depression compared to residents in the control group. Residents in the intervention group were no more likely to screen adolescents/young adults for Chlamydia, HIV, alcohol misuse, or depression in the 6 months following the intervention.

CONCLUSIONS

An educational intervention utilizing adolescent instructors improves resident confidence but does not increase adherence to screening guidelines.

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

OBJECTIVES

To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes.

DESIGN

Interrupted time series analysis, 2003-2009.

SETTING

A large US not-for-profit integrated health care organization.

PARTICIPANTS

29 hospitals in Northern and Southern California.

INTERVENTION

An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools.

MAIN OUTCOME MEASURES

Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures).

RESULTS

EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; -3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient -0.76, 95% CI -1.37 to -0.16) but no decrease in fall rates (-0.091; -0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (-0.16; -0.20 to -0.13), while fall rates did not (0.0052; -0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72).

CONCLUSIONS

The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.

Analysis of the treatment effect of Healthways' Medicare Health Support Phase 1 Pilot on Medicare costs

The objective of this analysis is to evaluate the treatment effect of Healthways' Medicare Health Support Pilot Program on total Medicare expenditures. Previous studies have analyzed the first 6 months of the program for all Medicare Health Support Organizations. The purpose of this analysis is to supplement and extend the previous work. The policy question addressed in this article is whether, on net, the intervention lowered total Medicare expenditures. The study was a retrospective analysis of data claims and membership databases. We used ordinary least squares regression techniques to estimate the effect of the intervention on total costs. We also stratified the data using risk scores calculated prior to the intervention. Our analysis found that the intervention consistently had little or no effect across the entire sample, but was associated with a statistically significant decrease in spending when the analysis concentrated on the sample that fully participated in the program. Overall, our analysis finds that total annual Medicare costs for the participating sample were 15.7% lower in 2007 ($3240) than for the control group, controlling for age, sex, race, and baseline risk. On balance, our analysis supports a conclusion that the program did successfully reduce costs for its target population. We find that Medicare expenditures were lower among enrollees in the program than they would have been without the intervention. This article shows that significant cost reductions among high-cost, chronically ill Medicare beneficiaries are possible.

Pediatric palliative care and eHealth opportunities for patient-centered care

BACKGROUND

Pediatric palliative care currently faces many challenges including unnecessary pain from insufficiently personalized treatment, doctor-patient communication breakdowns, and a paucity of usable patient-centric information. Recent advances in informatics for consumer health through eHealth initiatives have the potential to bridge known communication gaps, but overall these technologies remain under-utilized in practice.

PURPOSE

This paper seeks to identify effective uses of existing and developing health information technology (HIT) to improve communications and care within the clinical setting.

METHODS

A needs analysis was conducted by surveying seven pediatric oncology patients and their extended support network at the Lombardi Pediatric Clinic at Georgetown University Medical Center in May and June of 2010. Needs were mapped onto an existing inventory of emerging HIT technologies to assess what existing informatics solutions could effectively bridge these gaps.

RESULTS

Through the patient interviews, a number of communication challenges and needs in pediatric palliative cancer care were identified from the interconnected group perspective surrounding each patient. These gaps mapped well, in most cases, to existing or emerging cyberinfrastructure. However, adoption and adaptation of appropriate technologies could improve, including for patient-provider communication, behavioral support, pain assessment, and education, all through integration within existing work flows.

CONCLUSIONS

This study provides a blueprint for more optimal use of HIT technologies, effectively utilizing HIT standards-based technology solutions to improve communication. This research aims to further stimulate the development and adoption of interoperable, standardized technologies and delivery of context-sensitive information to substantially improve the quality of care patients receive within pediatric palliative care clinics and other settings.