Where are we on the diffusion curve? Trends and drivers of primary care physicians' use of health information technology

Association of Physician Characteristics With Early Adoption of Virtual Health Care

IMPORTANCE

The rapid transition to virtual health care has depended on physician and patient abilities to adopt new technology and workflows. Physicians transitioning more slowly or not at all could result in access challenges for their patients.

OBJECTIVE

To identify physician characteristics associated with the transition to virtual health care in a large regional health care system.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study uses administrative health system databases to analyze data from all 3473 physicians providing ambulatory care through a large New England health care system, which includes 12 hospitals and their ambulatory practices, from October 1, 2019, through December 31, 2020.

EXPOSURES

Physicians characterized based on gender, popularized generational demographic cohort (Silent Generation, born 1928-1945; Baby Boomers, born 1946-1964; Generation X, born 1965-1980; and Millennials, born 1981-1996), specialty (behavioral health, primary care, medical, and surgical), and hospital affiliation as well as selected patient characteristics (number of visits and proportion of patients with self-pay or Medicaid insurance, aged 65 years or older, preference for speaking a language other than English, from a racial or ethnic minority group, and with an active patient portal).

MAIN OUTCOMES AND MEASURES

Early adoption of virtual health care. Bivariate comparisons were made, and regression modeling was used to examine characteristics associated with the likelihood of early adoption of virtual health care.

RESULTS

Of 3473 physicians conducting ambulatory visits during the study period, 1624 (46.8%) were women, 83 (2.4%) were in the Silent Generation, 994 (28.6%) were Baby Boomers, 1637 (47.1%) were in Generation X, and 759 (21.9%) were Millennials. There were 1649 physicians (47.5%) in medical specialties, 749 physicians (21.6%) in surgical specialties, and 248 physicians (7.1%) in behavioral health. After accounting for other characteristics, female (odds ratio [OR], 1.23; 95% CI, 1.06-1.44), behavioral health (OR, 2.92; 95% CI, 2.11-4.04), and primary care (OR, 1.69; 95% CI, 1.36-2.09) physicians had greater odds of being early adopters, and physicians in the Silent Generation (OR, 0.39, 95% CI, 0.24-0.65) and in surgical specialties (OR, 0.46; 95% CI, 0.38-0.57) were less likely to be early adopters. Patient characteristics were less strongly associated with physician adoption.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, there was physician-level variation in the adoption of virtual health care, with female, primary care, and behavioral health physicians in this system most likely to lead the transformation to virtual health care.

Factors affecting the mature use of electronic medical records by primary care physicians: a systematic review

BACKGROUND

Despite a substantial increase in the adoption of electronic medical records (EMRs) in primary health care settings, the use of advanced EMR features is limited. Several studies have identified both barriers and facilitating factors that influence primary care physicians' (PCPs) use of advanced EMR features and the maturation of their EMR use. The purpose of this study is to explore and identify the factors that impact PCPs' mature use of EMRs.

METHODS

A systematic review was conducted in accordance with the Cochrane Handbook. The MEDLINE, Embase, and PsycINFO electronic databases were searched from 1946 to June 13, 2019. Two independent reviewers screened the studies for eligibility; to be included, studies had to address factors influencing PCPs' mature use of EMRs. A narrative synthesis was conducted to collate study findings and to report on patterns identified across studies. The quality of the studies was also appraised.

RESULTS

Of the 1893 studies identified, 14 were included in this study. Reported factors that influenced PCPs' mature use of EMRs fell into one of the following 5 categories: technology, people, organization, resources, and policy. Concerns about the EMR system's functionality, lack of physician awareness of EMR functionality, limited physician availability to learn more about EMRs, the habitual use of successfully completing clinical tasks using only basic EMR features, business-oriented organizational objectives, lack of vendor training, limited resource availability, and lack of physician readiness were reported as barriers to PCPs' mature use of EMRs. The motivation of physicians, user satisfaction, coaching and peer mentoring, EMR experience, gender, physician perception, transition planning for changes in roles and work processes, team-based care, adequate technical support and training, sharing resources, practices affiliated with an integrated delivery system, financial incentives, and policies to increase EMR use all had a favorable impact on PCPs' use of advanced EMR features.

CONCLUSIONS

By using a narrative synthesis to synthesize the evidence, we identified interrelated factors influencing the mature use of EMRs by PCPs. The findings underline the need to provide adequate training and policies that facilitate the mature use of EMRs by PCPs.

TRIAL REGISTRATION

PROSPERO CRD42019137526.

Attitudes and Perceptions of General Practitioners towards the National Electronic Health Record (NEHR) in Singapore

Background: In Singapore, the National Electronic Health Record (NEHR) was launched in 2011. The central ethos of the initiative was that of “One Patient, One Health Record”, as NEHR allows registered doctors to review and upload patient data. However, uptake of the system has been slow in the private sector, with only 27% of doctors with private licenses, including general practitioners (GP) and specialists in the ambulatory care setting, accessing it. A questionnaire-based study was therefore conducted to find out the proportion of GP who used NEHR, and the barriers faced by those who do not. Methods: This study involved a self-administered questionnaire, randomly sampling private GP in Singapore. The questionnaire ascertained the number of GP who used NEHR and gathered their demographic information. A 5-point Likert scale was used to measure the perceived barriers to NEHR use. Results: Of the 315 responses, multinomial logistics regression showed that solo-practising GP who were >40 years old and who had practised for >15 years were less likely to review, or review and upload, data onto NEHR. Doctors who regarded themselves as computer users with lower levels of technical aptitude and those who perceived an inadequate level of support were less likely to use the NEHR. The majority of GP had a positive attitude towards NEHR. Conclusions: This study highlighted key demographics and perceived barriers affecting NEHR use. By raising awareness of these issues to policy makers and working to overcome these barriers, NEHR use may be increased.

VS-GRU: A Variable Sensitive Gated Recurrent Neural Network for Multivariate Time Series with Massive Missing Values

Multivariate time series are often accompanied with missing values, especially in clinical time series, which usually contain more than 80% of missing data, and the missing rates between different variables vary widely. However, few studies address these missing rate differences and extract univariate missing patterns simultaneously before mixing them in the model training procedure. In this paper, we propose a novel recurrent neural network called variable sensitive GRU (VS-GRU), which utilizes the different missing rate of each variable as another input and learns the feature of different variables separately, reducing the harmful impact of variables with high missing rates. Experiments show that VS-GRU outperforms the state-of-the-art method in two real-world clinical datasets (MIMIC-III, PhysioNet).

Primary care physicians' attitudes to the adoption of electronic medical records: a systematic review and evidence synthesis using the clinical adoption framework

BACKGROUND

Recent decades have seen rapid growth in the implementation of Electronic Medical Records (EMRs) in healthcare settings in both developed regions as well as low and middle income countries. Yet despite substantial investment, the implementation of EMRs in some primary care systems has lagged behind other settings, with piecemeal adoption of EMR functionality by primary care physicians (PCPs) themselves. We aimed to review and synthesise international literature on the attitudes of PCPs to EMR adoption using the Clinical Adoption (CA) Framework.

METHODS

MEDLINE, PsycINFO, and EMBASE were searched from 1st January 1996 to 1st August 2017 for studies investigating PCP attitudes towards EMR adoption. Papers were screened by two independent reviewers, and eligible studies selected for further assessment. Findings were categorised against the CA Framework and the quality of studies assessed against one of three appropriate tools.

RESULTS

Out of 2263 potential articles, 33 were included, based in North and South America, Europe, Middle East and Hong Kong. Concerns about the accessibility, reliability and EMR utility exerted an adverse influence on PCPs' attitudes to adoption. However many were positive about their potential to improve clinical productivity, patient safety and care quality. Younger, computer-literate PCPs, based in large/multi-group practices, were more likely to be positively inclined to EMR use than older physicians, less-skilled in technology use, based in solo practices. Adequate training, policies and procedures favourably impacted on PCPs' views on EMR implementation. Financial factors were common system level influencers shaping EMR adoption, from start-up costs to the resources required by ongoing use.

CONCLUSIONS

By using the CA Framework to synthesise the evidence, we identified a linked series of factors influencing PCPs attitudes to EMR adoption. Findings underline the need to involve end-users in future implementation programmes from the outset, to avoid the development of an EMR which is neither feasible nor acceptable for use in practice.

TRIAL REGISTRATION

PROSPERO CRD42016038790 .

What drives adoption of a computerised, multifaceted quality improvement intervention for cardiovascular disease management in primary healthcare settings? A mixed methods analysis using normalisation process theory

Background

A computerised, multifaceted quality improvement (QI) intervention for cardiovascular disease (CVD) management in Australian primary healthcare was evaluated in a cluster randomised controlled trial. The intervention was associated with improved CVD risk factor screening but there was no improvement in prescribing rates of guideline-recommended medicines. The aim of this study was to conduct a process evaluation to identify and explain the underlying mechanisms by which the intervention did and did not have an impact.

Methods/design

Normalisation process theory (NPT) was used to understand factors that supported or constrained normalisation of the intervention into routine practice. A case study design was used in which six of the 30 participating intervention sites were purposively sampled to obtain a mix of size, governance, structure and performance. Multiple data sources were drawn on including trial outcome data, surveys of job satisfaction and team climate (68 staff) and in-depth interviews (19 staff). Data were primarily analysed within cases and compared with quantitative findings in other trial intervention and usual care sites.

Results

We found a complex interaction between implementation processes and several contextual factors affecting uptake of the intervention. There was no clear association between team climate, job satisfaction and intervention outcomes. There were four spheres of influence that appeared to enhance or detract from normalisation of the intervention: organisational mission and history (e.g. strategic investment to promote a QI culture enhanced cognitive participation), leadership (e.g. ability to energise or demotivate others influenced coherence), team environment (e.g. synergistic activities of team members with different skill sets influenced collective action) and technical integrity of the intervention (e.g. tools that slowed computer systems limited reflective action).

Discussion

Use of NPT helped explain how certain contextual factors influence the work that is done by individuals and teams when implementing a novel intervention. Although these factors do not necessarily distil into a recipe for successful uptake, they may assist system planners, intervention developers, and health professionals to better understand the trajectory that primary health care services may take when developing and engaging with QI interventions.

Trial registration

ACTRN 12611000478910. Registered 08 May 2011.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0830-x) contains supplementary material, which is available to authorized users.

Characterization of Patient Interest in Provider-Based Consumer Health Information Technology: Survey Study

BACKGROUND

Consumer health information technology can improve patient engagement in their health care and assist in navigating the complexities of health care delivery. However, the consumer health information technology offerings of health systems are often driven by provider rather than patient perspectives and inadequately address patient needs, thus limiting their adoption by patients. Consideration given to patients as stakeholders in the development of such technologies may improve adoption, efficacy, and consumer health information technology resource allocation.

OBJECTIVE

The aims of this paper were to measure patient interest in different health system consumer health information technology apps and determine the influence of patient characteristics on consumer health information technology interest.

METHODS

Patients seen at the Cleveland Clinic Neurological Institute were electronically surveyed on their interest in using different consumer health information technology apps. A self-efficacy scale, Patient Health Questionnaire-9 depression screen, and EuroQol 5 dimensions health-related quality of life scale were also completed by patients. Logistic regression was used to determine the influence of patient characteristics on interest in consumer health information technology in the categories of self-management, education, and communication.

RESULTS

The majority of 3852 patient respondents had an interest in all technology categories assessed in the survey. The highest interest was in apps that allow patients to ask questions of providers (3476/3852, 90.24%) and to schedule appointments (3211/3839, 83.64%). Patient interest in consumer health information technology was significantly associated with greater depression symptoms, worse quality of life, greater health self-efficacy, and smartphone ownership (P<.001 for all listed).

CONCLUSIONS

Patients should be viewed as active stakeholders in consumer health information technology development and their perspectives should consistently guide development efforts. Health systems should consider focusing on consumer health information technologies that assist patients in scheduling appointments and asking questions of providers. Patients with depression should also be considered for targeted consumer health information technology implementation. Health self-efficacy is a valid predictor of consumer health information technology interest and may play a role in the utilization of consumer health information technologies. Health systems, broadly, should put forth greater effort to understand the needs and interests of patients in the consumer health information technology development process. Consumer health information technology design and implementation may be improved by understanding which technologies patients want.

Who Uses eConsult? Investigating Physician Characteristics Associated with Usage (and Nonusage)

BACKGROUND

The Champlain BASE™ eConsult Service was developed in a Local Health Integration Network (LHIN) in Ontario, Canada in 2010 to reduce wait times and improve access to specialist care. The service allows primary care providers to receive advice from specialists via a secure electronic platform without necessarily requiring a face-to-face consultation.

INTRODUCTION

As of 2015, over half of the LHIN's family physicians were registered and trained to use the service. However, 24% of registrants never went on to submit a case. The purpose of this study is to examine the demographic characteristics associated with usage.

MATERIALS AND METHODS

Usage data for the pool of physicians registered between January 1, 2011 and September 30, 2015 were linked to physician characteristics retrieved from the College of Physicians and Surgeons of Ontario database. Probit regressions were estimated to determine characteristics associated with usage.

RESULTS

Neither sex, being an international medical school graduate-documented predictors of electronic medical records adoption-nor proximity to specialists were found to explain usage. Only length of time in practice was found to be predictive. Being out of medical school an additional 10 years was estimated to decrease the probability of ever using eConsult by five percentage points (p < 0.01).

CONCLUSION

Lower use by veteran physicians may reflect their lower need for services like eConsult given their well-established specialist networks, or their greater confidence in practicing medicine. Future work should explore the reasons and barriers for not registering, or not using eConsult, with an aim toward increasing the appropriate use of this cost-effective and innovative service.

Health Information Exchange Use (1990-2015): A Systematic Review

Background:

In June 2014, the Office of the National Coordinator for Health Information Technology published a 10-year roadmap for the United States to achieve interoperability of electronic health records (EHR) by 2024. A key component of this strategy is the promotion of nationwide health information exchange (HIE). The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act provided significant investments to achieve HIE.

Objective:

We conducted a systematic literature review to describe the use of HIE through 2015.

Methods:

We searched MEDLINE, PsycINFO, CINAHL, and Cochrane databases (1990 – 2015); reference lists; and tables of contents of journals not indexed in the databases searched. We extracted data describing study design, setting, geographic location, characteristics of HIE implementation, analysis, follow-up, and results. Study quality was dual-rated using pre-specified criteria and discrepancies resolved through consensus.

Results:

We identified 58 studies describing either level of use or primary uses of HIE. These were a mix of surveys, retrospective database analyses, descriptions of audit logs, and focus groups. Settings ranged from community-wide to multinational. Results suggest that HIE use has risen substantially over time, with 82% of non-federal hospitals exchanging information (2015), 38% of physician practices (2013), and 17-23% of long-term care facilities (2013). Statewide efforts, originally funded by HITECH, varied widely, with a small number of states providing the bulk of the data. Characteristics of greater use include the presence of an EHR, larger practice size, and larger market share of the health-system.

Conclusions:

Use of HIE in the United States is growing but is still limited. Opportunities remain for expansion. Characteristics of successful implementations may provide a path forward.

The role of digital health in making progress toward Sustainable Development Goal (SDG) 3 in conflict-affected populations

PURPOSE

The progress of the Millennium Development Goals (MDGs) shows that sustained global action can achieve success. Despite the unprecedented achievements in health and education, more than one billion people, many of them in conflict-affected areas, were unable to reap the benefits of the MDG gains. The recently developed Sustainable Development Goals (SDGs) are even more ambitious then their predecessor. SDG 3 prioritizes health and well-being for all ages in specific areas such as maternal mortality, communicable diseases, mental health, and healthcare workforce. However, without a shift in the approach used for conflict-affected areas, the world's most vulnerable people risk being left behind in global development yet again. We must engage in meaningful discussions about employing innovative strategies to address health challenges fragile, low-resource, and often remote settings. In this paper, we will argue that to meet the ambitious health goals of SDG 3, digital health can help to bridge healthcare gaps in conflict-affected areas.

METHODS

First, we describe the health needs of populations in conflict-affected environments, and how they overlap with the SDG 3 targets. Secondly, we discuss how digital health can address the unique needs of conflict-affected areas. Finally, we evaluate the various challenges in deploying digital technologies in fragile environments, and discuss potential policy solutions.

DISCUSSION

Persons in conflict-affected areas may benefit from the diffusive nature of digital health tools. Innovations using cellular technology or cloud-based solutions overcome physical barriers. Additionally, many of the targets of SDG 3 could see significant progress if efficacious education and outreach efforts were supported, and digital health in the form of mHealth and telehealth offers a relatively low-resource platform for these initiatives. Lastly, lack of data collection, especially in conflict-affected or otherwise fragile states, was one of the primary limitations of the MDGs. Greater investment in data collection efforts, supported by digital health technologies, is necessary if SDG 3 targets are to be measured and progress assessed. Standardized EMR systems as well as context-specific data warehousing efforts will assist in collecting and managing accurate data. Stakeholders such as patients, providers, and NGOs, must be proactive and collaborative in their efforts for continuous progress toward SDG 3. Digital health can assist in these inter-organizational communication efforts.

CONCLUSION

The SDGS are complex, ambitious, and comprehensive; even in the most stable environments, achieving full completion towards every goal will be difficult, and in conflict-affected environments, this challenge is much greater. By engaging in a collaborative framework and using the appropriate digital health tools, we can support humanitarian efforts to realize sustained progress in SDG 3 outcomes.

An Ethnographic Study of Health Information Technology Use in Three Intensive Care Units

OBJECTIVES

To identify the impact of a full suite of health information technology (HIT) on the relationships that support safety and quality among intensive care unit (ICU) clinicians.

DATA SOURCES

A year-long comparative ethnographic study of three academic ICUs was carried out. A total of 446 hours of observational data was collected in the form of field notes. A subset of these observations-134 hours-was devoted to job-shadowing individual clinicians and conducting a time study of their HIT usage.

PRINCIPAL FINDINGS

Significant variation in HIT implementation rates and usage was noted. Average HIT use on the two "high-use" ICUs was 49 percent. On the "low-use" ICU, it was 10 percent. Clinicians on the high-use ICUs experienced "silo" effects with potential safety and quality implications. HIT work was associated with spatial, data, and social silos that separated ICU clinicians from one another and their patients. Situational awareness, communication, and patient satisfaction were negatively affected by this siloing.

CONCLUSIONS

HIT has the potential to accentuate social and professional divisions as clinical communications shift from being in-person to electronically mediated. Socio-technically informed usability testing is recommended for those hospitals that have yet to implement HIT. For those hospitals already implementing HIT, we suggest rapid, locally driven qualitative assessments focused on developing solutions to identified gaps between HIT usage patterns and organizational quality goals.

Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange

BACKGROUND

Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments.

METHODS

All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments. An assessment was made of whether in-person visits were unnecessary by preconsultation exchange or whether the referrals remained unscheduled for other reasons. For the latter group, reasons why the referrals remained unscheduled were examined, and medical records were reviewed for actual patient harm when sufficient information was present in the chart or for potential harm when no further information about the referral complaint was available.

RESULTS

Eighty-six (32%) of 266 not-scheduled referrals were resolved via preconsultation exchange. For another 96 (36%), patients were not ultimately considered to require appointments or were scheduled via other routes. Nine patients received unplanned care while awaiting scheduling decisions, 5 of whom had harm that was related to referral complaints, although scheduling of appointments may not have avoided this harm. Of 75 patients for whom further information was not available about the referral complaints, most were not seen back in primary care, and 55 (73%) had potential for major harm.

CONCLUSION

Few adverse outcomes in electronic referrals not scheduled for in-person gastroenterology visits were found, and none were clearly due to communication lapses in the referral process. Contributors to the potential for harm in referrals that were unintentionally left unscheduled included discontinuity of care and lack of patient or provider follow-up.

Effect of implementation of a coded problem list entry subsystem

OBJECTIVES

Complete patient problem lists may improve the quality of care. To improve the completeness of the lists at our institution, we implemented the coded problem list entry subsystem (CPLES) in our electronic medical record system. Subsequently, physicians used the CPLES instead of handwritten notes to document coded problem lists and progress notes. We evaluated the effect of implementing the CPLES on the completeness of problem lists.

METHODS

We compared the completeness of coded problem lists input after CPLES implementation with that of problem lists handwritten before CPLES implementation and determined the differences. Moreover, the efficiency and usability of the CPLES were evaluated.

RESULTS

The efficiency and usability of CPLES were acceptable. However, the completeness of problem lists was reduced after CPLES implementation. The possible reasons for this reduction, namely system usability, efficacy, incentives, leadership, and education, were crucial for successful CPLES implementation and are discussed in the text.

CONCLUSION

CPLES implementation reduced the completeness of problem lists. Institutions may learn from our experience and carefully implement their own coded problem list systems to avoid this consequence.

General practitioners' attitudes towards electronic prescribing and the use of the national prescription centre

RATIONALE, AIMS AND OBJECTIVES

The purpose of this study was to assess general practitioners' (GP) experience of an electronic prescription (e-prescription) system and the use of a national prescription centre.

METHODS

A web-based survey with 29 structured questions and 8 open-ended questions was used. The technology acceptance model was used to explain first users' use of e-prescribing technology. GPs (n = 269) in two different primary health care organizations, which implemented the e-prescribing module as the first of its kind in Finland.

RESULTS

Of the 269 GPs, 69 (26%) completed the survey. E-prescribing had influenced GP work and their management of patients' medication positively. Electronic health records and e-prescribing increased GPs' flexibility at work. There was a notable improvement in the management of prescription of narcotics with the introduction of e-prescribing. Issues with the e-prescribing system software delayed data processing and produced negative experience as users were forced to browse through too many pages to write a prescription.

CONCLUSIONS

E-prescribing has improved GP's patient medication management, meeting Finland's national objectives. E-prescriptions not only reinforce the process of writing, transmitting and checking the authenticity of prescriptions but also make it mandatory for all key prescription information to be present for transmission. The perceived usefulness of e-prescribing by GPs could lead to more widespread adoption of the technology. Making e-prescribing more user friendly requires reforming work processes, which in turn would enhance the effectiveness of GP work.

Patient-powered research networks aim to improve patient care and health research

The era of big data, loosely defined as the development and analysis of large or complex data sets, brings new opportunities to empower patients and their families to generate, collect, and use their health information for both clinical and research purposes. In 2013 the Patient-Centered Outcomes Research Institute launched a large national research network, PCORnet, that includes both clinical and patient-powered research networks. This article describes these networks, their potential uses, and the challenges they face. The networks are engaging patients, family members, and caregivers in four key ways: contributing data securely, with privacy protected; including diverse and representative groups of patients in research; prioritizing research questions, participating in research, and disseminating results; and participating in the leadership and governance of patient-powered research networks. If technical, regulatory, and organizational challenges can be overcome, PCORnet will allow research to be conducted more efficiently and cost-effectively and results to be disseminated quickly back to patients, clinicians, and delivery systems to improve patient health.

Adoption Factors of the Electronic Health Record: A Systematic Review

Background

The Health Information Technology for Economic and Clinical Health (HITECH) was a significant piece of legislation in America that served as a catalyst for the adoption of health information technology. Following implementation of the HITECH Act, Health Information Technology (HIT) experienced broad adoption of Electronic Health Records (EHR), despite skepticism exhibited by many providers for the transition to an electronic system. A thorough review of EHR adoption facilitator and barriers provides ongoing support for the continuation of EHR implementation across various health care structures, possibly leading to a reduction in associated economic expenditures.

Objective

The purpose of this review is to compile a current and comprehensive list of facilitators and barriers to the adoption of the EHR in the United States.

Methods

Authors searched Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE, 01/01/2012–09/01/2015, core clinical/academic journals, MEDLINE full text, and evaluated only articles germane to our research objective. Team members selected a final list of articles through consensus meetings (n=31). Multiple research team members thoroughly read each article to confirm applicability and study conclusions, thereby increasing validity.

Results

Group members identified common facilitators and barriers associated with the EHR adoption process. In total, 25 adoption facilitators were identified in the literature occurring 109 times; the majority of which were efficiency, hospital size, quality, access to data, perceived value, and ability to transfer information. A total of 23 barriers to adoption were identified in the literature, appearing 95 times; the majority of which were cost, time consuming, perception of uselessness, transition of data, facility location, and implementation issues.

Conclusions

The 25 facilitators and 23 barriers to the adoption of the EHR continue to reveal a preoccupation on cost, despite incentives in the HITECH Act. Limited financial backing and outdated technology were also common barriers frequently mentioned during data review. Future public policy should include incentives commensurate with those in the HITECH Act to maintain strong adoption rates.

National findings regarding health IT use and participation in health care delivery reform programs among office-based physicians

OBJECTIVE

Our objective was to characterize physicians' participation in delivery and payment reform programs over time and describe how participants in these programs were using health information technology (IT) to coordinate care, engage patients, manage patient populations, and improve quality.

MATERIALS AND METHODS

A nationally representative cohort of physicians was surveyed in 2012 (unweighted N = 2567) and 2013 (unweighted N = 2399). Regression analyses used those survey responses to identify associations between health IT use and participation in and attrition from patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and pay-for-performance programs (P4Ps).

RESULTS

In 2013, 45% of physicians participated in PCMHs, ACOs, or P4Ps. While participation in each program increased (P < .05) between 2012 and 2013, program attrition ranged from 31-40%. Health IT use was associated with greater program participation (RR = 1.07-1.16). PCMH, ACO, and P4P participants were more likely than nonparticipants to perform quality improvement and patient engagement activities electronically (RR = 1.09-1.14); only ACO participants were more likely to share information electronically (RR = 1.07-1.09).

DISCUSSION

Participation in delivery and payment reform programs increased between 2012 and 2013. Participating physicians were more likely to use health IT. There was significant attrition from and switching between PCMHs, ACOs, and P4Ps.

CONCLUSION

This work provides the basis for understanding physician participation in and attrition from delivery and payment reform programs, as well as how health IT was used to support those programs. Understanding health IT use by program participants may help to identify factors enabling a smooth transition to alternative payment models.

User perception and experience of the introduction of a novel critical care patient viewer in the ICU setting

OBJECTIVE

Failure to rapidly identify high-value information due to inappropriate output may alter user acceptance and satisfaction. The information needs for different intensive care unit (ICU) providers are not the same. This can obstruct successful implementation of electronic medical record (EMR) systems. We evaluated the implementation experience and satisfaction of providers using a novel EMR interface-based on the information needs of ICU providers-in the context of an existing EMR system.

METHODS

This before-after study was performed in the ICU setting at two tertiary care hospitals from October 2013 through November 2014. Surveys were delivered to ICU providers before and after implementation of the novel EMR interface. Overall satisfaction and acceptance was reported for both interfaces.

RESULTS

A total of 246 before (existing EMR) and 115 after (existing EMR+novel EMR interface) surveys were analyzed. 14% of respondents were prescribers and 86% were non-prescribers. Non-prescribers were more satisfied with the existing EMR, whereas prescribers were more satisfied with the novel EMR interface. Both groups reported easier data gathering, routine tasks & rounding, and fostering of team work with the novel EMR interface. This interface was the primary tool for 18% of respondents after implementation and 73% of respondents intended to use it further. Non-prescribers reported an intention to use this novel interface as their primary tool for information gathering.

CONCLUSION

Compliance and acceptance of new system is not related to previous duration of work in ICU, but ameliorates with the length of EMR interface usage. Task-specific and role-specific considerations are necessary for design and successful implementation of a EMR interface. The difference in user workflows causes disparity of the way of EMR data usage.

Health Information Exchange Readiness for Demonstrating Return on Investment and Quality of Care

OBJECTIVE

To study the extent to which community health information exchanges (HIEs) deliver and measure return on investment (ROI) and improvements in the quality of care.

MATERIALS AND METHODS

We surveyed operational HIEs for their characteristics, information domains, impact on quality of care, and ROI.

RESULTS

A 60 percent response rate was achieved. Two-thirds of respondents agreed that community HIEs demonstrated a positive ROI, while one-third had no opinion or disagreed. One-fourth or fewer respondents reported using various metrics to calculate ROI. Most respondents agreed that HIEs improve the quality of care, though several were not sure and were awaiting further evidence. Most respondents indicated that they did not deliver reports on quality measures (76 percent) and that data were not being used to measure quality performance of participating providers (73 percent).

DISCUSSION

Respondents from most HIEs believe that the HIEs are demonstrating a positive ROI; however, a minority of them indicated they had used or will use specific metrics to calculate ROI. HIE representatives overwhelmingly reported that they believe the HIE activities improve the quality of healthcare delivered, but only a few are using data to evaluate provider performance or generate reports on quality measures.

CONCLUSION

This study demonstrates the challenge faced by policy makers and healthcare organizations that are investing millions of dollars in HIEs that are believed to improve health outcomes and increase efficiency, but still need more time to develop the evidence to confirm that belief. Our study shows that calculating ROI for HIEs or their impact on quality of care remains a secondary priority for most HIEs. This finding raises serious questions for the sustained support of HIEs, both financially and as a policy lever, given the end of Health Information Technology for Economic and Clinical Health (HITECH) Act funding.

Electronic health record usage behaviors in primary care medical practices: A survey of family physicians in Canada

OBJECTIVE

The importance and potential value of office-based electronic health record (EHR) systems is being recognized internationally. We thus sought to better understand how EHRs are actually being used by family physicians and what they perceive to be the main performance outcomes for themselves and their medical practices.

METHODS

We conducted a survey of family physicians practicing in medical practices in Quebec, Canada (n =331). Bivariate and multivariate statistical analyses were conducted to characterize EHR usage behaviors and assess the perceived performance outcomes of these systems.

RESULTS

EHR systems "as-used" vary substantively from one family physician to another in terms of the capabilities that are actually mobilized by them. Significant differences between "basic" and "advanced" users were observed in terms of the EHR system's characteristics and perceived performance outcomes. Physicians were also clustered under three profiles that could be clearly distinguished from one another, in terms of the extent to which their performance and their practice's performance was impacted by their EHR usage. Physicians that are "highly impacted" by their EHR system are those who have the longest usage experience and make the most extended use of their system's capabilities.

CONCLUSIONS

Our study indicates that only a minority of family physicians in our sample use most of the features available in their EHR system. Consequently, few physicians perceive gaining significant performance improvements from such systems. Future research must identify the factors that motivate primary care physicians to assimilate EHR systems in a more extensive manner.

The Prevalence and Characteristics of Emergency Medicine Patient Use of New Media

Background

Little is known about “new media” use, defined as media content created or consumed on demand on an electronic device, by patients in emergency department (ED) settings. The application of this technology has the potential to enhance health care beyond the index visit.

Objective

The objectives are to determine the prevalence and characteristics of ED patients’ use of new media and to then define and identify the potential of new media to transcend health care barriers and improve the public’s health.

Methods

Face-to-face, cross-sectional surveys in Spanish and English were given to 5,994 patients who were sequentially enrolled from July 12 to August 30, 2012. Data were collected from across a Southern Connecticut health care system’s 3 high-volume EDs for 24 hours a day, 7 days a week for 6 weeks. The EDs were part of an urban academic teaching hospital, an urban community hospital, and an academic affiliate hospital.

Results

A total of 5,994 (89% response rate) ED patients reported identical ownership of cell phones (85%, P<.001) and smartphones (51%, P<.001) that were used for calling (99%, P<.001). The older the patient, however, the less likely it was that the patient used the phone for texting (96% vs 16%, P<.001). Income was positively associated with smartphone ownership (P<.001) and the use of health apps (P>.05) and personal health records (P<.001). Ownership of iPhones compared to Android phones were similar (44% vs 45%, P<.05). Race and ethnicity played a significant role in texting and smartphone ownership, with Hispanics reporting the highest rates of 79% and 56%, respectively, followed by black non-Hispanics at 77% and 54%, respectively, and white non-Hispanics at 65% and 42%, respectively (P<.05).

Conclusions

There is a critical mass of ED patients who use new media. Older persons are less comfortable texting and using smartphone apps. Income status has a positive relationship with smartphone ownership and use of smartphone apps. Regardless of income, however, texting and ownership of smartphones was highest for Latinos and black non-Latinos. These findings have implications for expanding health care beyond the ED visit through the use of cell phones, smartphones, texting, the Internet, and health care apps to improve the health of the public.

What Are Complex eHealth Innovations and How Do You Measure Them? Position Paper

OBJECTIVES

eHealth and innovation are often regarded as synonyms - not least because eHealth technologies and applications are new to their users. This position paper challenges this view and aims at exploring the nature of eHealth innovation against the background of common definitions of innovation and facts from the biomedical and health informatics literature. A good understanding of what constitutes innovative eHealth developments allows the degree of innovation to be measured and interpreted.

METHODS

To this end, relevant biomedical and health informatics literature was searched mainly in Medline and ACM digital library. This paper presents seven facts about implementing and applying new eHealth developments hereby drawing on the experience published in the literature.

RESULTS

The facts are: 1. eHealth innovation is relative. 2. Advanced clinical practice is the yardstick. 3. Only used and usable eHealth technology can give birth to eHealth innovatio. 4. One new single eHealth function does not make a complex eHealth innovation. 5. eHealth innovation is more evolution than revolution. 6. eHealth innovation is often triggered behind the scenes; and 7. There is no eHealth innovation without sociocultural change.

CONCLUSIONS

The main conclusion of the seven facts is that eHealth innovations have many ingredients: newness, availability, advanced clinical practice with proven outcomes, use and usability, the supporting environment, other context factors and the stakeholder perspectives. Measuring eHealth innovation is thus a complex matter. To this end we propose the development of a composite score that expresses comprehensively the nature of eHealth innovation and that breaks down its complexity into the three dimensions: i) eHealth adoption, ii) partnership with advanced clinical practice, and iii) use and usability of eHealth. In order to better understand the momentum and mechanisms behind eHealth innovation the fourth dimension, iv) eHealth supporting services and means, needs to be studied. Conceptualising appropriate measurement instruments also requires eHealth innovation to be distinguished from eHealth sophistication, performance and quality, although innovation is intertwined with these concepts. The demanding effort for defining eHealth innovation and measuring it properly seem worthwhile and promise advances in creating better systems. This paper thus intends to stimulate the necessary discussion.