The next step towards making use meaningful: electronic information exchange and care coordination across clinicians and delivery sites

From "wading through treacle" to "making haste slowly": A comprehensive yet parsimonious model of drivers and challenges to implementing patient data sharing projects based on an EPaCCS evaluation and four pre-existing literature reviews

Conceptually, this study aimed to 1) identify the challenges and drivers encountered by England's Electronic Palliative Care Coordination System (EPaCCS) projects in the context of challenges and drivers in other projects on data sharing for individual care (also referred to as Health Information Exchange, HIE) and 2) organise them in a comprehensive yet parsimonious framework. The study also had a strong applied goal: to derive specific and non-trivial recommendations for advancing data sharing projects, particularly ones in early stages of development and implementation. Primary data comprised 40 in-depth interviews with 44 healthcare professionals, patients, carers, project team members and decision makers in Cambridgeshire, UK. Secondary data were extracted from four pre-existing literature reviews on Health Information Exchange and Health Information Technology implementation covering 135 studies. Thematic and framework analysis underpinned by "pluralist" coding were the main analytical approaches used. We reduced an initial set of >1,800 parameters into >500 challenges and >300 drivers to implementing EPaCCS and other data sharing projects. Less than a quarter of the 800+ parameters were associated primarily with the IT solution. These challenges and drivers were further condensed into an action-guiding, strategy-informing framework of nine types of "pure challenges", four types of "pure drivers", and nine types of "oppositional or ambivalent forces". The pure challenges draw parallels between patient data sharing and other broad and complex domains of sociotechnical or social practice. The pure drivers differ in how internal or external to the IT solution and project team they are, and thus in the level of control a project team has over them. The oppositional forces comprise pairs of challenges and drivers where the driver is a factor serving to resolve or counteract the challenge. The ambivalent forces are factors perceived simultaneously as a challenge and a driver depending on context, goals and perspective. The framework is distinctive in its emphasis on: 1) the form of challenges and drivers; 2) ambivalence, ambiguity and persistent tensions as fundamental forces in the field of innovation implementation; and 3) the parallels it draws with a variety of non-IT, non-health domains of practice as a source of fruitful learning. Teams working on data sharing projects need to prioritise further the shaping of social interactions and structural and contextual parameters in the midst of which their IT tools are implemented. The high number of "ambivalent forces" speaks of the vital importance for data sharing projects of skills in eliciting stakeholders' assumptions; managing conflict; and navigating multiple needs, interests and worldviews.

Impact of coordination mechanisms based on information and communication technologies on cross-level clinical coordination: A scoping review

Background

Coordination mechanisms based on information and communication technologies (ICTs) are gaining attention, especially since the pandemic, due to their potential to improve communication between health professionals. However, their impact on cross-level clinical coordination remains unclear. The aim is to synthesize the evidence on the impact of ICT-based coordination mechanisms on clinical coordination between primary care and secondary care (SC) doctors and to identify knowledge gaps.

Methods

A scoping review was conducted by searching for original articles in six electronic databases and a manual search, with no restrictions regarding time, area, or methodology. Titles and abstracts were screened. Full texts of the selected articles were reviewed and analysed to assess the impact of each mechanism, according to the cross-level clinical coordination conceptual framework.

Results

Of the 6555 articles identified, 30 met the inclusion criteria. All had been conducted in high-income countries, most (n = 26) evaluated the impact of a single mechanism - asynchronous electronic consultations via electronic health records (EHR) - and were limited in terms of design and types and dimensions of cross-level clinical coordination analysed. The evaluation of electronic consultations showed positive impacts on the appropriateness of referrals and accessibility to SC, yet the qualitative studies also highlighted potential risks. Studies on other mechanisms were scarce (shared EHR, email consultations) or non-existent (videoconferencing, mobile applications).

Conclusions

Evidence of the impact of ICT-based mechanisms on clinical coordination between levels is limited. Rigorous evaluations are needed to inform policies and strategies for improving coordination between healthcare levels, thus contributing to high-quality, efficient healthcare.

Investigating the effect of the Vula Mobile app on coordination of care and capacity building in district health services, Cape Town: Convergent mixed methods study

BACKGROUND

Coordinating care is a defining characteristic of high quality primary care. Currently, very little is known about coordination of care in South Africa's primary care setting. The Vula Mobile app was introduced in 2018 to assist with referring patients from primary care facilities to the Eerste River District Hospital (ERDH) emergency centre. The aim of this study was to evaluate the use of the app and its effect on coordination of care and capacity building of staff.

METHODS

Convergent mixed methods were used with quantitative data collected from hospital records and the Vula Mobile database, and with qualitative data collected from health professionals in primary care and the district hospital.

RESULTS

Out of 13 321 patients seen in the emergency centre of the district hospital over the 6-month study period, only 1932 (14.5%) of the patients were referred with Vula. Most of these referrals were accepted (85.5%). Sometimes, advice was given to (35.0%) or additional information was requested (27.4%) from the referring doctor. There was little use of Vula in providing other feedback (0.6%). The introduction of the Vula app led to a decrease in the number of inappropriately referred patients (6.7% to 4.2%, p = 0.004). Doctors using the Vula app perceived that it improved care coordination and had the potential for useful feedback.

CONCLUSION

Vula improved coordination of patients referred from primary care facilities in the Metro Health Services to the district hospital, but missed the opportunity to support continuing professional development and learning. Utilisation of the Vula app should be increased and its potential to provide feedback should be enhanced. Attention should be given to reducing the number of patients self-referred or referred without using the Vula app.

Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions

IMPORTANCE

Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care.

OBJECTIVE

To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions.

DESIGN, SETTING, AND PARTICIPANTS

This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020.

MAIN OUTCOMES AND MEASURES

Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders.

RESULTS

Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions.

CONCLUSIONS AND RELEVANCE

Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

Coordinating women's preventive health care for rural veterans

PURPOSE

As the number of women veterans receiving care from the Veterans Health Administration (VHA) continues to increase, so does the need to access gender-specific preventive health care services through the VHA. In rural areas, women veterans are the numeric minority, so many preventive screenings are performed outside of the VA by community providers. As the numbers of veterans utilizing both VHA and non-VHA providers for their preventive care continue to increase, so does the need to coordinate this care. This research examines the role of the Women Veterans' Care Coordinator (WVCC) at rural facilities and their perceptions of coordinating preventive care.

METHODS

Between March and July 2019, semi-structured telephone interviews were conducted with WVCCs at 26 rural VA facilities. Each interview was digitally recorded and transcribed verbatim. Transcripts were loaded into Atlas.ti for further analysis. Once the codes were refined, the investigators coded the 26 interviews independently and conferred to achieve consensus on the underlying themes.

FINDINGS

Five themes arose from the WVCC interviews: (1) Rural women veterans have varying needs of coordination; (2) Fragmented communication between the VA and non-VA care settings hinders effective coordination; (3) Difficulties in prioritizing rural care coordination; (4) Care coordination impacts patient care; and (5) WVCC recommendations to improve rural care coordination.

CONCLUSIONS

The recent addition of WVCCs to rural facilities has expanded the VA's reach to veterans living in the most rural areas. As a result, many of these women are now receiving timely, quality, and coordinated health care.

Patients' Perceived Continuity of Care and Adherence to Oral Anticancer Therapy: a Prospective Cohort Mediation Study

BACKGROUND

Oral anticancer therapy (OACT) poses adherence-related challenges to patients while generating a setting in which both primary care physicians (PCPs) and oncologists are involved in the active treatment of cancer. Continuity of care (COC) was shown to be associated with medication adherence. While maintaining COC is a central role of the PCP, how this affects continuity with oncologists, and jointly affects OACT adherence, is yet unknown.

OBJECTIVES

To explore how aspects of COC act together to promote OACT adherence. Specifically, to examine whether better personal continuity with the PCP leads to better personal continuity with the oncologist, which together lead to better cross-boundary continuity between the oncologist and the PCP, jointly leading to good adherence to OACT.

DESIGN AND SETTING

A prospective cohort study conducted in five oncology centers in Israel. A bootstrapping method was used to test the serial mediation model.

PARTICIPANTS

Adult patients (age > 18 years) receiving a first OACT prescription (n = 119) were followed for 120 days.

MAIN MEASURES

The Nijmegen Continuity Questionnaire was used to assess patients' perceived personal and cross-boundary continuity. The medication possession ratio was used to measure adherence.

KEY RESULTS

Better personal continuity with the PCP was associated with better personal continuity with the oncologist (B = 0.35, p < 0.001), which was associated with better cross-boundary continuity (B = 0.33, p < 0.001), which, in turn, was associated with good adherence to OACT (B = 0.46, p = 0.03). Additionally, the indirect effect of personal continuity with the PCP on adherence to OACT through the mediation of personal continuity with the oncologist and cross-boundary continuity was found to be statistically significant (B = 0.053, 95% CI 0.0006-0.17).

CONCLUSIONS

In a system where the PCP is the case manager, cancer patients' perceived personal continuity with the PCP has an essential role for initiating a sequence of care delivery events that positively affect OACT adherence.

Transitional Care Models for High-Need, High-Cost Adults in the United States: A Scoping Review and Gap Analysis

Purpose of Study:

This scoping review explored research literature on the integration and coordination of services for high-need, high-cost (HNHC) patients in an attempt to answer the following questions: What models of transitional care are utilized to manage HNHC patients in the United States ? and How effective are they in reducing low-value utilization and in improving continuity ?

Primary Practice Settings:

U.S. urban, suburban, and rural health care sites within primary care, veterans’ services, behavioral health, and palliative care.

Methodology and Sample:

Utilizing the Joanna Briggs Institute and PRISMA guidelines for scoping reviews, a stepwise method was applied to search multiple databases for peer-reviewed published research on transitional care models serving HNHC adult patients in the United States from 2008 to 2018. All eligible studies were included regardless of quality rating. Exclusions were foreign models, studies published prior to 2008, review articles, care reports, and studies with participants younger than 18 years. The search returned 1,088 studies, of which 19 were included.

Results:

Four studies were randomized controlled trials and other designs included case reports and observational, quasi-experimental, cohort, and descriptive studies. Studies focused on Medicaid, Medicare, dual-eligible patients, veterans, and the uninsured or underinsured. High-need, high-cost patients were identified on the basis of prior utilization patterns of inpatient and emergency department visits, high cost, multiple chronic medical diagnoses, or a combination of these factors. Tools used to identify these patients included the hierarchical condition category predictive model, the Elder Risk Assessment, and the 4-year prognostic index score. The majority of studies combined characteristics of multiple case management models with varying levels of impact.

Implications for Case Management Practice:

Healthcare professionals' experiences of inter-professional collaboration during patient's transfers between care settings in palliative care: A focus group study

BACKGROUND

Continuity of care is challenging when transferring patients across palliative care settings. These transfers are common due to the complexity of palliative care, which has increased significantly since the advent of palliative care services. It is unclear how palliative care services and professionals currently collaborate and communicate to ensure the continuity of care across settings, and how patient and family members are involved.

AIM

To explore healthcare professionals' experiences regarding the communicative aspects of inter-professional collaboration and the involvement of patient and family members.

DESIGN

Qualitative design, including focus group discussions.

SETTING/PARTICIPANTS

The study focused on one palliative care network in Belgium and involved all palliative care settings: hospital, hospital's palliative care unit, home care, nursing home. Nine group discussions were conducted, with diverse professionals (n = 53) from different care settings.

RESULTS

Timely and effective inter-professional information exchange was considered fundamental. A perceived barrier for interprofessional collaboration was the lack of a shared electronic health record. Efficiency regarding multidisciplinary team meetings and inter-professional communication were subject to improvement.A striking study finding was the perceived insufficient open communication of specialists towards patients and the lack of shared decision making. This not only hampered advance care planning discussions and early integration of palliative home care, but also the functioning of other professionals.

CONCLUSION

From the perspective of the integrated care framework, several areas of improvement on different levels of care and collaboration are identified. Support from policymakers and researchers is required to achieve integrated palliative care in regional networks.

Perceived Value of Electronic Medical Records in Community Health Services: A National Cross-Sectional Survey of Primary Care Workers in Mainland China

Objective: To evaluate the degree to which electronic medical records (EMRs) were used in primary care and the value of EMRs as perceived by primary care workers in China. Methods: A cross-sectional survey was conducted on 2719 physicians (n = 2213) and nurses (n = 506) selected from 462 community health centres across all regions of mainland China except for Tibet. Regional differences in the responses regarding the functionality of existing EMR systems and the perceived value of EMRs were examined using Chi-square tests and ordinal regression analyses. Results: Less than 59% of the community health centres had adopted EMRs. More than 89% of the respondents believed that it was necessary to adopt EMRs in primary care. Of the existing EMR systems, 50% had access to telehealth support for laboratory, imaging or patient consultation services. Only 38.4% captured data that met all task needs and 35.4% supported referral arrangements. “Management of chronic conditions” was voted (66%) as the top preferred feature of EMRs. Higher levels of recognition of the value of EMRs were found in the relatively more developed eastern region compared with their counterparts in other regions. Conclusions: Rapid EMR adoption in primary care is evident in mainland China. The low level of functionality in data acquisition and referral arrangements runs counter to the requirements for “management of chronic conditions”, the most preferred feature of EMRs in primary care. Regional disparities in the realised value of EMRs in primary care deserve policy attention.

Inter-organizational information sharing and bundled payment reimbursement: Do hospitals in the US use health information exchange to collaborate?

OBJECTIVE

The purpose of this study is to examine the relationship between the greater need for information generated by bundled payment reimbursement and the use of Health Information Exchange (HIE).

METHODS

The study is based on a secondary data analysis using theAmerican Hospital Association (AHA) Healthcare IT Database and the AHA Annual Survey. A logistic regression was used to test the likelihood of hospitals participating in HIE if they were involved in bundled payment reimbursement. Negative binomial, ordered logistic and Poisson regression models were used to determine the associations between bundled payment reimbursement and health information sharing in terms of breadth, volume, and diversity, respectively.

RESULTS

Hospitals in bundled payment programs were more likely to send and receive information through HIE and tosend information to different types of health providers but not to receive. They were also more likely to exchange different types of health information and to use HIE more often.

CONCLUSIONS

The greater need for collaboration of hospitals participating in bundled payment programs was associated with greater information sharing among organizations through HIE, but different providers involved in the episode of care play different roles in HIE.

Utility and Perceived Value of a Provincial Digital Diagnostic Imaging Repository: Multimethod Study

Background

Timely and comprehensive diagnostic image sharing across institutional and regional boundaries can produce multiple benefits while supporting integrated models of care. In Ontario, Canada, the Diagnostic Imaging Common Service (DICS) was created as a centralized imaging repository to enable the sharing and viewing of diagnostic images and associated reports across hospital-based and community-based clinicians throughout the province.

Objective

The aims of this study were as follows: (1) to explore real-world utilization and perceived clinical value of the DICS following the provision of system-wide access and (2) to identify strategies to optimize the technology platform functionality and encourage adoption.

Methods

This multimethod study included semistructured interviews with physicians and administrative stakeholders and descriptive analysis of the current DICS usage data.

Results

In this study, 41 participants were interviewed, that is, 34 physicians and 7 administrative stakeholders. The following 4 key themes emerged: (1) utilization of the DICS depended on the awareness of the technology and the preferred channels for accessing images, which varied widely, (2) clinical responsibilities and available institutional resources were the drivers of utilization (or lack thereof), (3) centralized image repositories were perceived to offer value at the patient, clinician, and health care system levels, and (4) the enabling factors to realize value included aspects of technology infrastructure (ie, available functionality) alongside policy supports. High-volume DICS usage was not evenly distributed throughout the province.

Conclusions

Suboptimal adoption of the DICS was driven by poor awareness and variations in the clinical workflow. Alignment with physician workflow, policy supports, and investment in key technological features and infrastructure would improve functionality and data comprehensiveness, thereby optimizing health system performance, patient and provider experience, population health, and health care costs.

Mobile Technology Care Coordination of Long-Term Services and Support: Cluster Randomized Clinical Trial

The purpose of the study was to assess whether the effects of a mobile predictive intervention used by Service Coordinators (SCs) reduce hospital utilization in a Medicaid Long-Term Services and Supports (LTSS) population in Baltimore city during a 5-month intervention. SC participants (n = 11) were recruited to treatment or control groups. LTSS clients (n = 420) followed their SC randomization assignment. Utilization data were obtained from the Maryland Chesapeake Regional Information System for our Patients (CRISP) Health Information Exchange (HIE) system and linked to service coordination records. Study groups were similar in age, gender, race, and years receiving LTSS. SCs' satisfaction with use of the mobile tool was surveyed. SC perceptions were neutral (mean scores ranged from 2.3 to 3.3 on a 5-point scale). No significant differences between groups were observed for all utilization metrics. The mobile technology software system used in this study did not improve health care utilization for a LTSS population needing ongoing clinical and social services coordinated care.

Interventions to improve the use of EMRs in primary health care: a systematic review and meta-analysis

Background

Electronic medical record (EMR) adoption in primary care has grown exponentially since their introduction in the 1970s. However, without their proper use benefits cannot be achieved. This includes: 1) the complete and safe documentation of patient information; 2) improved coordination of care; 3) reduced errors and 4) more involved patients. The use of EMRs is defined by practitioners using EMRs and their features to perform daily practice functions.

Objective

The purpose of this systematic review was to identify interventions aimed at improving EMR use in primary healthcare settings.

Methods

Ten online databases were searched to identify studies conducted in primary healthcare settings aimed at implementing interventions to observe the use of EMRs and directly measure the use of EMR functions or outcomes effected by the use of EMR functions.

Results

Of 2098 identified studies, 12 were included in the review. Results showed that interventions focused on the use of EMR functions, including referrals, electronic communication, reminders, use of clinical decision support systems and workflow management support functions, were five times more likely to show improvements in EMR use compared with controls. Interventions focused on data quality were five and a half times more likely to show improvements in EMR use compared with controls.

Conclusions

Individuals in primary healthcare settings aiming to improve EMR use would benefit from implementing interventions focused on EMR feature add-ons such as clinical decision support systems and customised referral templates, and provisions of educational materials, or financial incentives targeted at improving the use of EMR functions and data quality.

Organizational Coordination and Patient Experiences of Specialty Care Integration

BACKGROUND

Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes.

OBJECTIVE

Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists.

DESIGN

Cross-sectional surveys of patients and primary care providers (PCPs).

PARTICIPANTS

Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder.

MAIN MEASURES

Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient's specialty services used with corresponding PCP ratings of that specialty.

KEY RESULTS

Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b = - .20; b = - .17, respectively) or rated feedback coordination lower (b = - .08 for both). Teamwork was significantly related to specialist knowledge management (b = .06), knowledge integration (b = .04); and knowledge fragmentation (b = - .04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b = .09) and (ii) mental health provider (b = .12).

CONCLUSIONS

Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness.

Exploring the association of care fragmentation and patient ratings of care quality: A mediation analysis of women Veterans' experience with VA care

OBJECTIVE

To examine the relationship between care fragmentation and patient ratings of care quality and identify potentially actionable mediators.

DATA SOURCES/STUDY SETTING

2015 telephone survey of 1395 women Veterans with three or more visits in primary care and/or women's health care in the prior year at 12 Veterans Affairs (VA) medical centers.

STUDY DESIGN

Cross-sectional analysis.

DATA COLLECTION/EXTRACTION METHODS

We operationalized lower care fragmentation as receiving VA-only care versus dual use of VA/non-VA care. Participants rated VA care quality (overall care, women's health care (WH), and primary care (PC)) and three aspects of their patient experience (ease of access to services, provider communication, and gender sensitivity of VA environments). We examined associations between care fragmentation and care ratings and applied the Karlson-Holm-Breen decomposition method to test for mediation by aspects of patients' experience.

PRINCIPAL FINDINGS

Lower care fragmentation was associated with higher ratings of care quality (odds ratios [95% CI] for overall care: 1.57 [1.14;2.17]; WH: 1.65 [1.20;2.27]; PC: 1.41 [1.10;1.82]). Relationships were mediated by patient-rated provider communication and gender sensitivity (26-54 percent and 14-15 percent of total effects, respectively). Ease of access was associated with higher care ratings (odds ratios [95% CI] for overall care: 2.93 [2.25;3.81]; WH: 2.81 [2.15;3.68]; PC: 2.33 [1.63;3.33], in models with the three types of patient care experiences included), but did not mediate the association of care fragmentation and care ratings.

CONCLUSIONS

Potential negative effects of care fragmentation on care quality ratings could be mitigated by attention to quality of patient-provider communication and gender sensitivity of VA environments.

Indicators and Measurement Tools for Health Systems Integration: A Knowledge Synthesis

Background:

Despite far reaching support for integrated care, conceptualizing and measuring integrated care remains challenging. This knowledge synthesis aimed to identify indicator domains and tools to measure progress towards integrated care.

Methods:

We used an established framework and a Delphi survey with integration experts to identify relevant measurement domains. For each domain, we searched and reviewed the literature for relevant tools.

Findings:

From 7,133 abstracts, we retrieved 114 unique tools. We found many quality tools to measure care coordination, patient engagement and team effectiveness/performance. In contrast, there were few tools in the domains of performance measurement and information systems, alignment of organizational goals and resource allocation. The search yielded 12 tools that measure overall integration or three or more indicator domains.

Discussion:

Our findings highlight a continued gap in tools to measure foundational components that support integrated care. In the absence of such targeted tools, “overall integration” tools may be useful for a broad assessment of the overall state of a system.

Conclusions:

Continued progress towards integrated care depends on our ability to evaluate the success of strategies across different levels and context. This study has identified 114 tools that measure integrated care across 16 domains, supporting efforts towards a unified measurement framework.

The Effectiveness of Information Technology-Supported Shared Care for Patients With Chronic Disease: A Systematic Review

Background

In patients with chronic disease, many health care professionals are involved during treatment and follow-up. This leads to fragmentation that in turn may lead to suboptimal care. Shared care is a means to improve the integration of care delivered by various providers, specifically primary care physicians (PCPs) and specialty care professionals, for patients with chronic disease. The use of information technology (IT) in this field seems promising.

Objective

Our aim was to systematically review the literature regarding the effectiveness of IT-supported shared care interventions in chronic disease in terms of provider or professional, process, health or clinical and financial outcomes. Additionally, our aim was to provide an inventory of the IT applications' characteristics that support such interventions.

Methods

PubMed, Scopus, and EMBASE were searched from 2006 to 2015 to identify relevant studies using search terms related to shared care, chronic disease, and IT. Eligible studies were in the English language, and the randomized controlled trials (RCTs), controlled trials, or single group pre-post studies used reported on the effects of IT-supported shared care in patients with chronic disease and cancer. The interventions had to involve providers from both primary and specialty health care. Intervention and IT characteristics and effectiveness—in terms of provider or professional (proximal), process (intermediate), health or clinical and financial (distal) outcomes—were extracted. Risk of bias of (cluster) RCTs was assessed using the Cochrane tool.

Results

The initial search yielded 4167 results. Thirteen publications were used, including 11 (cluster) RCTs, a controlled trial, and a pre-post feasibility study. Four main categories of IT applications were identified: (1) electronic decision support tools, (2) electronic platform with a call-center, (3) electronic health records, and (4) electronic communication applications. Positive effects were found for decision support-based interventions on financial and health outcomes, such as physical activity. Electronic health record use improved PCP visits and reduced rehospitalization. Electronic platform use resulted in fewer readmissions and better clinical outcomes—for example, in terms of body mass index (BMI) and dyspnea. The use of electronic communication applications using text-based information transfer between professionals had a positive effect on the number of PCPs contacting hospitals, PCPs’ satisfaction, and confidence.

Conclusions

IT-supported shared care can improve proximal outcomes, such as confidence and satisfaction of PCPs, especially in using electronic communication applications. Positive effects on intermediate and distal outcomes were also reported but were mixed. Surprisingly, few studies were found that substantiated these anticipated benefits. Studies showed a large heterogeneity in the included populations, outcome measures, and IT applications used. Therefore, a firm conclusion cannot be drawn. As IT applications are developed and implemented rapidly, evidence is needed to test the specific added value of IT in shared care interventions. This is expected to require innovative research methods.

Between "the best way to deliver patient care" and "chaos and low clinical value": General Practitioners' and Practice Managers' views on data sharing

OBJECTIVE

In the UK, General Practitioners and Practice Managers are key to enabling health information exchange (typically referred to as 'data sharing'). This study aimed to survey GPs and PMs for familiarity, engagement with and perceptions of patient data sharing.

METHODS

Cross-sectional survey. All 107 general practices in England's second largest Clinical Commissioning Group, Cambridgeshire & Peterborough CCG. Descriptive statistics; hierarchical logistic regression; thematic analysis.

RESULTS

405 (64%) responses were received - from 338 (62%) GPs and 67 (71%) PMs. Familiarity and engagement were highest for local frail elderly and end of life care projects (>76% had used). The greatest difference in use concerned the now suspended national care.data initiative: PMs had odds of reporting use 75 times higher than GP partners (95% CI 27-211). Patient confusion was the most pronounced challenge and improved coordination the most pronounced expected benefit. Frequency of discussions with patients varied with IT competence (OR 4.2 for most competent users relative to least, 95% CI 1.7-10.7) and clinical system (OR 0.3, 95% CI 0.1-0.5). Patient reservations were reported more frequently by respondents who rated their IT competence as highest (OR 3.3, 95% CI 1.5-7.6), perceived more data sharing challenges (OR for a 1-point increase in challenges perception score 3.4, 95% CI 2.1-5.6) and by PMs (relative to GP partners, OR 18.0, 95% CI 7.9-41.3).

CONCLUSIONS

Familiarity with and use of data sharing projects was high among GPs and PMs. Both their individual and organisational characteristics were associated with the reported frequency of discussions and patients' responses. Improved awareness of the impact of provider characteristics and attitudes on patients' decisions about data sharing may enhance the equity and autonomy of those decisions.

Patient-centered communication in the era of electronic health records: What does the evidence say?

OBJECTIVE

Patient-physician communication is essential for patient-centered health care. Physicians are concerned that electronic health records (EHRs) negatively affect communication with patients. This study identified a framework for understanding communication functions that influence patient outcomes. We then conducted a systematic review of the literature and organized it within the framework to better understand what is known.

METHOD

A comprehensive search of three databases (CINAHL, Medline, PsycINFO) yielded 41 articles for analysis.

RESULTS

Results indicated that EHR use improves capture and sharing of certain biomedical information. However, it may interfere with collection of psychosocial and emotional information, and therefore may interfere with development of supportive, healing relationships. Patient access to the EHR and messaging functions may improve communication, patient empowerment, engagement, and self-management.

CONCLUSION

More rigorous examination of EHR impacts on communication functions and their influences on patient outcomes is imperative for achieving patient-centered care. By focusing on the role of communication functions on patient outcomes, future EHRs can be developed to facilitate care.

PRACTICE IMPLICATIONS

Training alone is likely to be insufficient to address disruptions to communication processes. Processes must be improved, and EHRs must be developed to capture useful data without interfering with physicians' and patients' abilities to effectively communicate.

The EHR and building the patient's story: A qualitative investigation of how EHR use obstructs a vital clinical activity

BACKGROUND

Recent research has suggested that using electronic health records (EHRs) can negatively impact clinical reasoning (CR) and interprofessional collaborative practices (ICPs). Understanding the benefits and obstacles that EHR use introduces into clinical activities is essential for improving medical documentation, while also supporting CR and ICP.

METHODS

This qualitative study was a longitudinal pre/post investigation of the impact of EHR implementation on CR and ICP at a large pediatric hospital. We collected data via observations, interviews, document analysis, and think-aloud/-after sessions. Using constructivist Grounded Theory's iterative cycles of data collection and analysis, we identified and explored an emerging theme that clinicians described as central to their CR and ICP activities: building the patient's story. We studied how building the patient's story was impacted by the introduction and implementation of an EHR.

RESULTS

Clinicians described the patient's story as a cognitive awareness and overview understanding of the patient's (1) current status, (2) relevant history, (3) data patterns that emerged during care, and (4) the future-oriented care plan. Constructed by consolidating and interpreting a wide array of patient data, building the patient's story was described as a vitally important skill that was required to provide patient-centered care, within an interprofessional team, that safeguards patient safety and clinicians' professional credibility. Our data revealed that EHR use obstructed clinicians' ability to build the patient's story by fragmenting data interconnections. Further, the EHR limited the number and size of free-text spaces available for narrative notes. This constraint inhibited clinicians' ability to read the why and how interpretations of clinical activities from other team members. This resulted in the loss of shared interprofessional understanding of the patient's story, and the increased time required to build the patient's story.

CONCLUSIONS

We discuss these findings in relation to research on the role of narratives for enabling CR and ICP. We conclude that EHRs have yet to truly fulfill their promise to support clinicians in their patient care activities, including the essential work of building the patient's story.

The Role of eHealth in Optimizing Preventive Care in the Primary Care Setting

Modifiable health risk behaviors such as smoking, overweight and obesity, risky alcohol consumption, physical inactivity, and poor nutrition contribute to a substantial proportion of the world’s morbidity and mortality burden. General practitioners (GPs) play a key role in identifying and managing modifiable health risk behaviors. However, these are often underdetected and undermanaged in the primary care setting. We describe the potential of eHealth to help patients and GPs to overcome some of the barriers to managing health risk behaviors. In particular, we discuss (1) the role of eHealth in facilitating routine collection of patient-reported data on lifestyle risk factors, and (2) the role of eHealth in improving clinical management of identified risk factors through provision of tailored feedback, point-of-care reminders, tailored educational materials, and referral to online self-management programs. Strategies to harness the capacity of the eHealth medium, including the use of dynamic features and tailoring to help end users engage with, understand, and apply information need to be considered and maximized. Finally, the potential challenges in implementing eHealth solutions in the primary care setting are discussed. In conclusion, there is significant potential for innovative eHealth solutions to make a contribution to improving preventive care in the primary care setting. However, attention to issues such as data security and designing eHealth interfaces that maximize engagement from end users will be important to moving this field forward.

Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians

PURPOSE

Health information technology (IT) offers promising tools for improving care coordination. We assessed the feasibility and acceptability of 6 proposed care coordination objectives for stage 3 of the Centers for Medicare and Medicaid Services electronic health record incentive program (Meaningful Use) related to referrals, notification of care from other facilities, patient clinical summaries, and patient dashboards.

METHODS

We surveyed physician-owned and hospital/health system-affiliated primary care practices that achieved patient-centered medical home recognition and participated in the Meaningful Use program, and community health clinics with patient-centered medical home recognition (most with certified electronic health record systems). The response rate was 35.1%. We ascertained whether practices had implemented proposed objectives and perceptions of their importance. We analyzed the association of organizational and contextual factors with self-reported use of health IT to support care coordination activities.

RESULTS

Although 78% of the 350 respondents viewed timely notification of hospital discharges as very important, only 48.7% used health IT systems to accomplish this task. The activity most frequently supported by health IT was providing clinical summaries to patients, in 76.6% of practices; however, merely 47.7% considered this activity very important. Greater use of health IT to support care coordination activities was positively associated with the presence of a nonclinician responsible for care coordination and the practice's capacity for systematic change.

CONCLUSIONS

Even among practices having a strong commitment to the medical home model, the use of health IT to support care coordination objectives is not consistent. Health IT capabilities are not currently aligned with clinicians' priorities. Many practices will need financial and technical assistance for health IT to enhance care coordination.

Data Content and Exchange in General Practice: a Review

BACKGROUND

efficient communication of data is inevitable requirement for general practice. Any issue in data content and its exchange among GP and other related entities hinders continuity of patient care.

METHODS

literature search for this review was conducted on three electronic databases including Medline, Scopus and Science Direct.

RESULTS

through reviewing papers, we extracted information on the GP data content, use cases of GP information exchange, its participants, tools and methods, incentives and barriers.

CONCLUSION

considering importance of data content and exchange for GP systems, it seems that more research is needed to be conducted toward providing a comprehensive framework for data content and exchange in GP systems.