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Saffer H, Cunningham A. Comparing "Meaningful Use" of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties. Popul Health Manag 2024; 27:114-119. [PMID: 38411668 DOI: 10.1089/pop.2023.0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
The Health Information Technology for Economic and Clinical Health Act incentivized the adoption of electronic health records (EHRs). Health systems looked to leverage technology to assist in serving populations in health professional shortage areas. Qualitative research points to EHR usability as a source of health inequities in rural settings, making the challenges of EHR usage a subject of interest. Pennsylvania offers a model for investigating rural health infrastructure with it having the third largest rural population in the United States. This study analyzed the adoption of Electronic Prescribing in the 67 Pennsylvania (PA) counties. Physician adoption and usage data for PA and the United States were compared using a t-test to establish a basis for comparison. PA counties were categorized using the United States Department of Agriculture (USDA)'s Rural-Urban Commuting Areas (RUCAs) system. Surescript use percentages were plotted against the RUCA scores of each PA county to create a polynomial regression model. PA office-based physicians, on average, utilize e-prescription tools at the same rate as the national average with 59% of practices utilizing Surescripts as of 2013. There was no significant correlation between Surescript usage and the rural/urban classification of counties in Pennsylvania (R-squared value of 0.06). Pennsylvania was able to adopt health information technology (HIT) infrastructure at the same rate as the national average. Rural and metropolitan definitions do not correlate to meaningful use of HIT, thus usability of HIT cannot be tied to health outcomes. Future studies looking at specific forms of HIT and their ability to decrease the burden of administrative work for clinicians.
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Affiliation(s)
- Heath Saffer
- Department of Family and Community Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Amy Cunningham
- Department of Family and Community Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
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Kim SY, Cho MK. Concept Analysis of Nursing Surveillance Using a Hybrid Model. Healthcare (Basel) 2023; 11:healthcare11111613. [PMID: 37297753 DOI: 10.3390/healthcare11111613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/24/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
This study aims to analyze the concept of nursing surveillance among nurses caring for patients in acute care hospitals in Korea. The conceptual analysis was conducted using the hybrid model proposed by Schwartz-Barcott and Kim. In the theoretical phase, the attributes of nursing surveillance were explored through a literature review. In the fieldwork phase, the attributes of nursing surveillance were derived by analyzing interview materials. In the final analysis phase, nursing surveillance attributes and the related factors were integrated and confirmed. The attributes of nursing surveillance were systematic assessment, pattern recognition, the anticipation of problems, effective communication, decision-making, and performing nursing practice. Based on the theoretical basis of the nursing surveillance concept, this study identified the nursing surveillance concept as perceived by Korean nurses, and examined strategies to promote nursing surveillance.
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Affiliation(s)
- Se Young Kim
- Department of Nursing, Changwon National University, 20 Changwondaehak-ro, Uichang-gu, Changwon 51140, Republic of Korea
| | - Mi-Kyoung Cho
- Department of Nursing Science, College of Medicine, Chungbuk National University, 1 Chungdae-ro, Seowon-gu, Cheongju 28644, Republic of Korea
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Tubaishat A. The Adoption of Electronic Health Records in Primary Healthcare Settings. Comput Inform Nurs 2021; 39:883-889. [PMID: 34101659 DOI: 10.1097/cin.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Little is known about the adoption rate of electronic health records in primary healthcare settings. This study aimed to estimate this adoption rate in Jordan, using a national survey with a descriptive cross-sectional design. The first step was to review the annual report of the Jordanian Ministry of Health as a basis for identifying the sample, which are primary healthcare settings. Then, Electronic Health Solutions, the company that vends electronic health record systems in Jordan, was used to determine which primary healthcare settings were using these electronic record systems. The final task was to determine which functionalities of the system were being used in these settings, and for this, a telephone survey of key personnel was conducted. It was found that 21.6% of the primary healthcare settings were using electronic health records, while the other 78.4% were still relying on paper records. The results also showed that the adoption rate of electronic health records was significantly associated with the type of the setting (P < .001), its size (P < .001), location (P < .001), and region (P = .04). As a conclusion, the adoption rate in Jordan is still in its infancy compared with those in developed countries. Policy and decision makers should therefore be focused on minimizing any challenges or obstacles to such adoption.
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Affiliation(s)
- Ahmad Tubaishat
- Author Affiliation: Department of Adult Health Nursing, School of Nursing, Al Al-Bayt University, Mafraq, Jordan
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Mithas S, Hofacker CF, Bilgihan A, Dogru T, Bogicevic V, Sharma A. Information technology and Baumol's cost disease in healthcare services: a research agenda. JOURNAL OF SERVICE MANAGEMENT 2020. [DOI: 10.1108/josm-11-2019-0339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThis paper advances a research agenda for service researchers at the intersection of healthcare and information technologies to improve access to quality healthcare at affordable prices. The article reviews key trends to provide an agenda for research focusing on strategies, governance and management of key service processes.Design/methodology/approachThis paper synthesizes literature in information systems, service management, marketing and healthcare operations to suggest a research agenda. The authors draw on frameworks such as the interpretive model of technology, technology acceptance model, assemblage theories and Baumol's cost disease to develop their arguments.FindingsThe paper situates strategy-related service management questions that service providers and consumers face in the context of emerging healthcare and technology trends. It also derives implications for governance choices and questions related to that.Research limitations/implicationsThe paper discusses service management challenges and concludes with an agenda for future research that touches on governance and service management issues.Practical implicationsThis paper provides implications for healthcare service providers and policymakers to understand new trends in healthcare delivery, technologies and facilities management to meet evolving customer needs.Social implicationsThis paper provides implications for managing healthcare services that touch on many social and societal concerns.Originality/valueThis conceptual paper provides background and review of the work at the intersections of information systems, marketing and healthcare operations to draw implications for future research.
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Villumsen S, Adler-Milstein J, Nøhr C. National monitoring and evaluation of eHealth: a scoping review. JAMIA Open 2020; 3:132-140. [PMID: 32607495 PMCID: PMC7309231 DOI: 10.1093/jamiaopen/ooz071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/13/2019] [Accepted: 12/22/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE There has been substantial growth in eHealth over the past decade, driven by expectations of improved healthcare system performance. Despite substantial eHealth investment, little is known about the monitoring and evaluation strategies for gauging progress in eHealth availability and use. This scoping review aims to map the existing literature and depict the predominant approaches and methodological recommendations to national and regional monitoring and evaluation of eHealth availability and use, to advance national strategies for monitoring and evaluating eHealth. METHODS Peer-reviewed and grey literature on monitoring and evaluation of eHealth availability and use published between January 1, 2009, and March 11, 2019, were eligible for inclusion. A total of 2354 publications were identified and 36 publications were included after full-text review. Data on publication type (eg, empirical research), country, level (national or regional), publication year, method (eg, survey), and domain (eg, provider-centric electronic record) were charted. RESULTS The majority of publications monitored availability alone or applied a combination of availability and use measures. Surveys were the most common data collection method (used in 86% of the publications). Organization for Economic Co-operation and Development (OECD), European Commission, Canada Health Infoway, and World Health Organization (WHO) have developed comprehensive eHealth monitoring and evaluation methodology recommendations. DISCUSSION Establishing continuous national eHealth monitoring and evaluation, based on international approaches and recommendations, could improve the ability for cross-country benchmarking and learning. This scoping review provides an overview of the predominant approaches to and recommendations for national and regional monitoring and evaluation of eHealth. It thereby provides a starting point for developing national eHealth monitoring strategies.
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Affiliation(s)
- Sidsel Villumsen
- Center for Health Informatics and Technology, Maersk Mc-Kinney Moller Institute, University of Southern Denmark, Odense, Denmark
| | - Julia Adler-Milstein
- Center for Clinical Informatics and Improvement Research, School of Medicine, University of California, San Francisco, California, USA
| | - Christian Nøhr
- Center for Health Informatics and Technology, Maersk Mc-Kinney Moller Institute, University of Southern Denmark, Odense, Denmark
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Orsak G, McGaha P, Brandon P, Swan A, Singh KP. A Longitudinal Pilot Study for Examining Symptom Reduction in Patients With Cancer in a Palliative Care Program: A Primarily Rural Northeast Texas Population. Hosp Top 2019; 97:54-59. [PMID: 31012812 DOI: 10.1080/00185868.2019.1605322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Many patients with cancer live in rural areas and research is lacking on the efficacy of palliative care programs in rural community settings. This pilot study was conducted in a primarily rural setting where healthcare professionals delivered palliative care to 52 mostly lower income patients with a variety of cancers. They were assessed for physical, financial, psychosocial and overall symptom intensity at baseline and at three consequent assessments. This pilot study demonstrated the potential efficacy of an outpatient palliative care program in a mostly rural setting in the reduction of physical, psychosocial, and overall symptom intensity in patients with cancer.
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Affiliation(s)
- Gabriela Orsak
- a Department of Epidemiology and Biostatistics, School of Rural and Community Health , University of Texas Health Science Center at Tyler , Tyler , TX , USA
| | - Paul McGaha
- b Department of Community Health, School of Rural and Community Health , University of Texas Health Science Center at Tyler , Tyler , TX , USA
| | - Paula Brandon
- c Department of Clinical and Quality Support , Community Hospital Corporation , Dallas , TX , USA
| | - Amy Swan
- d Department of Family Medicine , University of Texas Health Science Center at Tyler , Tyler , TX , USA
| | - Karan P Singh
- a Department of Epidemiology and Biostatistics, School of Rural and Community Health , University of Texas Health Science Center at Tyler , Tyler , TX , USA
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Lin YK, Lin M, Chen H. Do Electronic Health Records Affect Quality of Care? Evidence from the HITECH Act. INFORMATION SYSTEMS RESEARCH 2019. [DOI: 10.1287/isre.2018.0813] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yu-Kai Lin
- Center for Process Innovation, Department of Computer Information Systems, J. Mack Robinson College of Business, Georgia State University, Atlanta, Georgia 30303
| | - Mingfeng Lin
- Information Technology Management, Scheller College of Business, Georgia Institute of Technology, Atlanta, Georgia 30308
| | - Hsinchun Chen
- Department of Management Information Systems, Eller College of Management, University of Arizona, Tucson, Arizona 85721
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Chauhan Z, Samarah M, Unertl KM, Jones MW. Adoption of Electronic Dental Records: Examining the Influence of Practice Characteristics on Adoption in One State. Appl Clin Inform 2018; 9:635-645. [PMID: 30112742 PMCID: PMC6094025 DOI: 10.1055/s-0038-1667331] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Compared with medicine, less research has focused on adoption rates and factors contributing to the adoption of electronic dental records (EDRs) and certified electronic health records (EHRs) in the field of dentistry. We ran two multivariate models on EDR adoption and certification-capable EHR adoption to determine environmental and organizational factors associated with adoption. METHODS We conducted telephone survey of a 10-item questionnaire using disproportionate stratified sampling procedure of 149 dental clinics in Tennessee in 2017 measuring adoption of dental information technology (IT) (EDRs and certification-capable EHRs) and practice characteristics, including region, rurality, specialty, and practice size. We used binomial logistic regression models to determine associations of adoption with predictor variables. RESULTS A total of 77% of surveyed dental clinics in Tennessee had adopted some type of EDR system. When the definitions of certification capable were applied, the adoption rates in dental clinics dropped to 58%. A binomial logistic regression model for the effects of rurality, specialization, and practice size on the likelihood that a clinic would adopt an EHR product was statistically significant (chi-square (3) = 12.41, p = 0.0061). Of the three predictor variables, specialization and practice size were significant: Odds of adopting an EHR is 67% lower for specialists than for general dentists; and clinics with two or more practicing dentists were associated with a much greater likelihood of adopting an EHR-capable system (adjusted odds ratio = 3.09, p = 0.009). CONCLUSION Findings from this study indicate moderate to high levels of overall dental IT adoption. However, adoption rates in dental clinics do remain lower than those observed in office-based physician practices in medicine. Specialization and practice size were significant predictors of EHR-capable system adoption. Efforts to increase EHR adoption in dentistry should be mindful of potential disparities in smaller practices and between dental specialties and generalists.
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Affiliation(s)
- Zain Chauhan
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, University of Miami, Miami, Florida, United States
- Center for Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee, United States
| | - Mohammad Samarah
- Computer Science and Big Data Analytics, Florida Polytechnic University, Lakeland, Florida, United States
| | - Kim M. Unertl
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, Tennessee, United States
| | - Martha W. Jones
- Center for Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee, United States
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Huang MZ, Gibson CJ, Terry AL. Measuring Electronic Health Record Use in Primary Care: A Scoping Review. Appl Clin Inform 2018; 9:15-33. [PMID: 29320797 DOI: 10.1055/s-0037-1615807] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Simple measures of electronic health record (EHR) adoption may be inadequate to evaluate EHR use; and positive outcomes associated with EHRs may be better gauged when varying degrees of EHR use are taken into account. In this article, we aim to assess the current state of the literature regarding measuring EHR use. OBJECTIVE This article conducts a scoping review of the literature to identify and classify measures of primary care EHR use with a focus on the Canadian context. METHODS We conducted a scoping review. Multiple citation databases were searched, as well as gray literature from relevant Web sites. Resulting abstracts were screened for inclusion. Included full texts were reviewed by two authors. Data from the articles were extracted; we synthesized the findings. Subsequently, we reviewed these results with seven EHR stakeholders in Canada. RESULTS Thirty-seven articles were included. Eighteen measured EHR function use individually, while 19 incorporated an overall level of use. Eight frameworks for characterizing overall EHR use were identified. CONCLUSION There is a need to create standardized frameworks for assessing EHR use.
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Brown EL, Ruggiano N, Li J, Clarke PJ, Kay ES, Hristidis V. Smartphone-Based Health Technologies for Dementia Care: Opportunities, Challenges, and Current Practices. J Appl Gerontol 2017; 38:73-91. [DOI: 10.1177/0733464817723088] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Most of the 5.4 million people affected by Alzheimer’s disease and other forms of dementia (AD) are noninstitutionalized, receiving care by unpaid family caregivers and medically managed by a primary care provider (PCP). Health Information Technology has been recognized for its potential in improving efficiency and quality of AD care and support for AD caregivers. Simultaneously, smartphone technologies have become an increasingly common way to deliver physical and behavioral health care. However, little is known about how smartphone technologies have been used to support AD caregiving and care. This article highlights the current need for smartphone-based interventions for AD and systematically identified and appraised current smartphone apps targeting and available for AD caregivers. Findings indicate that individual available apps have limited functions (compared with the complex needs of caregivers) and little has been done to extend AD caregiving apps to Hispanic populations. Implications for research, practice, and policy are discussed.
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Affiliation(s)
| | | | - Juanjuan Li
- Florida International University, Miami, USA
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11
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Pharmacy and primary care perspectives on e-prescribing in a rural community: A focused ethnography. Res Social Adm Pharm 2017; 13:820-830. [DOI: 10.1016/j.sapharm.2016.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 08/07/2016] [Indexed: 11/23/2022]
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Wittie M, Ngo-Metzger Q, Lebrun-Harris L, Shi L, Nair S. Enabling Quality: Electronic Health Record Adoption and Meaningful Use Readiness in Federally Funded Health Centers. J Healthc Qual 2017; 38:42-51. [PMID: 24612263 DOI: 10.1111/jhq.12067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Health Resources and Services Administration has supported the adoption of electronic health records (EHRs) by federally funded health centers for over a decade; however, little is known about health centers' current EHR adoption rates, progress toward Meaningful Use, and factors related to adoption. We analyzed cross-sectional data from all 1,128 health centers in 2011, which served over 20 million patients during that year. As of 2011, 80% of health centers reported using an EHR, and high proportions reported using many advanced EHR functionalities. There were no indications of disparities in EHR adoption by census region, urban/rural location, patient sociodemographic composition, physician staffing, or health center funding; however, there were small variations in adoption by total patient cost and percent of revenue from grants. Findings revealed no evidence of a digital divide among health centers, indicating that health centers are implementing EHRs, in keeping with their mission to reduce health disparities.
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Abstract
In recent years, the potential use of mobile devices has significantly positively impacted healthcare globally. Despite global claims of widespread use of mobile devices in healthcare, its adoption in the Australian healthcare context is slow. Limited research is available on slow adoption of mobile devices in the Australian healthcare context. Therefore, this chapter is designed to investigate the factors influencing adoption of mobile devices from healthcare professionals' perspective and develop a health specific conceptual framework. The influential factors for the adoption of mobile devices in the Australian health context may be intention, individual readiness, advantages, safety issues, features, self-efficacy, complexity, training, compatibility, social influences, age and gender.
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Kim J, Ohsfeldt RL, Gamm LD, Radcliff TA, Jiang L. Hospital Characteristics are Associated With Readiness to Attain Stage 2 Meaningful Use of Electronic Health Records. J Rural Health 2016; 33:275-283. [PMID: 27424940 DOI: 10.1111/jrh.12193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 05/22/2016] [Accepted: 05/25/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE To examine the difference between rural and urban hospitals as to their overall level of readiness for stage 2 meaningful use of electronic health records (EHRs) and to identify other key factors that affect their readiness for stage 2 meaningful use. METHODS A conceptual framework based on the theory of organizational readiness for change was used in a cross-sectional multivariate analysis using 2,083 samples drawn from the HIMSS Analytics survey conducted with US hospitals in 2013. FINDINGS Rural hospitals were less likely to be ready for stage 2 meaningful use compared to urban hospitals in the United States (OR = 0.49) in our final model. Hospitals' past experience with an information exchange initiative, staff size in the information system department, and the Chief Information Officer (CIO)'s responsibility for health information management were identified as the most critical organizational contextual factors that were associated with hospitals' readiness for stage 2. Rural hospitals lag behind urban hospitals in EHR adoption, which will hinder the interoperability of EHRs among providers across the nation. The identification of critical factors that relate to the adoption of EHR systems provides insights into possible organizational change efforts that can help hospitals to succeed in attaining meaningful use requirements. CONCLUSION Rural hospitals have increasingly limited resources, which have resulted in a struggle for these facilities to attain meaningful use. Given increasing closures among rural hospitals, it is all the more important that EHR development focus on advancing rural hospital quality of care and linkages with patients and other organizations supporting the care of their patients.
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Affiliation(s)
- Jungyeon Kim
- World Innovation Summit for Health, Qatar Foundation, Doha, Qatar
| | - Robert L Ohsfeldt
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Larry D Gamm
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Tiffany A Radcliff
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Luohua Jiang
- Department of Epidemiology, School of Medicine, University of California-Irvine, Irvine, California
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15
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Kim MK, Park JH. Identifying and prioritizing critical factors for promoting the implementation and usage of big data in healthcare. INFORMATION DEVELOPMENT 2016. [DOI: 10.1177/0266666916652671] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Big data is expected to provide many benefits to healthcare organizations through cost reduction, disease prediction, and patient care improvement. Big data in healthcare at a nascent stage faces many challenges in satisfying expectations. This study investigates factors for promoting the implementation and usage of big data in healthcare in Korea, using an analytical hierarchy process (AHP). We established a research framework that considers four domains and 15 factors. We collected data by a survey of experts engaged in big data and healthcare IT. The results show that data and organization have greater impacts than technology and support domains. Organizational analytics capability, data quality, data privacy and security, organizational application capability, data standardization, and data experts are the most important factors for promoting the implementation and usage of big data in healthcare. The study presents the implications in terms of the policies and ecosystem for countries, including Korea, which intend to activate big data in healthcare.
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Affiliation(s)
- Moon-Koo Kim
- Korea Advanced Institute of Science and Technology (KAIST); Electronics and Telecommunications Research Institute (ETRI), Korea
| | - Jong-Hyun Park
- Electronics and Telecommunications Research Institute (ETRI), Korea
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Whitacre BE. The Influence of the Degree of Rurality on EMR Adoption, by Physician Specialty. Health Serv Res 2016; 52:616-633. [PMID: 27256561 DOI: 10.1111/1475-6773.12510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To explore the influence of varying degrees of remoteness on practice-level electronic medical record (EMR) adoption, including whether the effect differs across practice specialty. DATA SOURCES Survey data on over 270,000 office-based physician practices (representing over 1,250,000 providers) collected by SK&A information services during 2012. STUDY DESIGN This study examined differences in EMR adoption by practices located across the nine-category rural-urban continuum. Logistic regressions and associated marginal effects are used to assess how much a move up or down the rural-urban continuum code impacts the likelihood of EMR adoption, after controlling for characteristics likely to affect EMR adoption such as practice size and specialty. PRINCIPAL FINDINGS Overall practice-level EMR adoption rates generally increase with the degree of rurality and range from 47 percent in the most urban counties to over 60 percent in the most rural. Moving from the most urban county to the most rural corresponded to a 7 percent increase in the likelihood of EMR adoption (p < .01). CONCLUSIONS EMR adoption rates do vary significantly across nonmetropolitan counties, and they generally increase as a practice becomes more rural. From a policy perspective, this suggests that urban practices may in fact be the lowest hanging remaining fruit for increasing EMR adoption rates.
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Affiliation(s)
- Brian E Whitacre
- Department of Agricultural Economics, Oklahoma State University, Stillwater, OK
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Mack D, Zhang S, Douglas M, Sow C, Strothers H, Rust G. Disparities in Primary Care EHR Adoption Rates. J Health Care Poor Underserved 2016; 27:327-338. [PMID: 27587942 DOI: 10.1353/hpu.2016.0016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study evaluates electronic health record (EHR) adoption by primary care providers in Georgia to assess adoption disparities according to practice size and type, payer mix, and community characteristics. Frequency variances of EHR "Go Live" status were estimated. Odds ratios were calculated by univariate and multivariate logistic regression models. Large practices and community health centers (CHCs) were more likely to Go Live (>80% EHR adoption) than rural health clinics and other underserved settings (53%). A significantly lower proportion (68.9%) of Medicaid predominant providers had achieved Go Live status and had a 47% higher risk of not achieving Go Live status than private insurance predominant practices. Disparities in EHR adoption rates may exacerbate existing disparities in health outcomes of patients served by these practices. Targeted support such as that provided to CHCs would level the playing field for practices now at a disadvantage.
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Affiliation(s)
- Dominic Mack
- National Center for Primary Care (NCPC) and Family Medicine, Morehouse School of Medicine, Atlanta, GA
| | | | | | | | | | - George Rust
- NCPC and Family Medicine, Morehouse School of Medicine
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Wiggins C, Peterson T, Moss C. Ambulatory surgery centers׳ use of Health Information Technology. HEALTH POLICY AND TECHNOLOGY 2015. [DOI: 10.1016/j.hlpt.2015.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pearce KA, Jarrett TD, Scutchfield FD, Talbert JC, Bolt WD, Barron MA, Houlihan JM, Dignan MB. Research Partnerships with Healthcare Providers in Rural Community Health Centers: Needs and Challenges in Diabetes Research. ACTA ACUST UNITED AC 2015; 4:1-6. [PMID: 26457246 DOI: 10.5963/phf0401001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Kentucky has among the highest rates of diabetes and obesity in the United States. The Kentucky Diabetes and Obesity Collaborative (KDOC) was designed to develop a novel research infrastructure that can be used by researchers focusing on obesity and diabetes among patients cared for by Federally Qualified Health Centers (FQHC) serving rural Kentucky. Focus groups were carried out to develop an understanding of the needs and interests of FQHC practitioners and staff regarding participation in KDOC. Focus groups were conducted with 6 FQHCs and included a total of 41 individuals including health care providers, administrative staff and clinical staff. The discussions ranged in time from 30 to 70 minutes and averaged 45 minutes. Analysis of the transcripts of the focus groups revealed 4 themes: 1) contextual factors, 2) infrastructure, 3) interpersonal relationships, and 4) clinical features. The participants also noted four requirements that should be met for a research project to be successful in rural primary care settings: 1) there must be a shared understanding of health priorities of rural communities between the researcher and the practices/providers; 2) the proposed research must be relevant to clinics and their communities; 3) research and recommendations for evidence-based interventions need to reflect the day-to-day challenges of rural primary care providers; and 4) there needs to be an understanding of community norms and resources. Although research-clinic partnerships were viewed favourably overall, challenges in data integration to support both research and clinical outcomes were identified.
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Affiliation(s)
- Kevin A Pearce
- Department of Family & Community Medicine, University of Kentucky, Lexington, KY 40536, United States
| | - Traci D Jarrett
- School of Public Health, West Virginia University, Morgantown, WV 26506, United States
| | - F Douglas Scutchfield
- College of Public Health, University of Kentucky, Lexington, KY 40536, United States
| | - Jeffery C Talbert
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY 40536, United States
| | - W David Bolt
- Kentucky Primary Care Association, Frankfort, KY 40601, United States
| | - Mary A Barron
- Department of Family & Community Medicine, University of Kentucky, Lexington, KY 40536, United States
| | - Jessica M Houlihan
- Department of Family & Community Medicine, University of Kentucky, Lexington, KY 40536, United States
| | - Mark B Dignan
- Department of Internal Medicine, University of Kentucky, Lexington, KY 40536, United States
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Whitacre BE. Rural EMR adoption rates overtake those in urban areas. J Am Med Inform Assoc 2015; 22:399-408. [PMID: 25665701 PMCID: PMC8485927 DOI: 10.1093/jamia/ocu035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/23/2014] [Accepted: 11/24/2014] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess rural-urban differences in electronic medical record (EMR) adoption among office-based physician practices in the United States. METHODS Survey data on over 270 000 office-based physician sites (representing over 1 280 000 physicians) in the United States from 2012 was used to assess differences in EMR adoption rates among practices in rural and urban areas. Logistic regression tests for differences in the determinants of EMR adoption by geography, and a nonlinear decomposition is used to quantify how much of the rural-urban gap is due to differences in measureable characteristics (such as type of practice or affiliation with a health system). RESULTS Overall EMR adoption rates were significantly higher for practices in rural areas (56%) vs those in urban areas (49%) in 2012 (P < 0.001). Twenty-nine states had statistically significantly different adoption rates between rural and urban areas, with only two states demonstrating higher rates in urban areas. EMR adoption continues to be higher for primary care practices when compared to specialists (51% vs 49%, P < 0.001), and state-level rural-urban differences in adoption are more pronounced for specialists. The decomposition technique finds that only 14% of the rural-urban gap can be explained by differences in measurable characteristics between practices. CONCLUSIONS At the national level, rates of EMR adoption are higher for rural practices than for their urban counterparts, reversing earlier trends. This suggests that outreach efforts, namely the Regional Extension Centers created by the Office of the National Coordinator, have been particularly effective in increasing EMR adoption in rural areas.
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Affiliation(s)
- Brian E Whitacre
- Department of Agricultural Economics, Oklahoma State University 504 Ag Hall Stillwater, OK 74074, , (405) 744-9825
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Whitacre BE, Williams RS. Electronic medical record adoption in Oklahoma practices: rural-urban differences and the role of broadband availability. J Rural Health 2014; 31:47-57. [PMID: 25124874 DOI: 10.1111/jrh.12086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Most recent research has not found significant differences in electronic medical record (EMR) adoption rates between rural and urban physicians. However, few studies have assessed rural/urban differences at a lower level--for instance, by specialty or size of practice. Determinants of EMR adoption by physician practices in Oklahoma are explored, including the potential role of broadband availability (which is required for EMR interoperability). METHODS Surveys of 2,800 unique Oklahoma physician practices in 2011 were meshed with data from the National Broadband Map for that same year. Summary statistics from the survey data allowed for comparison of EMR adoption rates by sub category. Logistic regressions were used to tease out the impact of location, specialty, and broadband availability on the EMR adoption decision. FINDINGS Similar overall EMR adoption rates in rural and urban practices masked significant differences among specific subcategories. In particular, solo practices in rural areas are much more likely to adopt EMRs than are their urban counterparts (41% vs 33%, P < .01); rural psychiatric practices also have measurably higher adoption rates (59% vs 25%, P < .01). Logistic regression results demonstrate that determinants of adoption do vary between rural and urban practices. No statistical relationship between EMR adoption and measures of broadband availability was found. CONCLUSIONS Measurable differences in EMR adoption rates do exist between rural and urban practices for specific physician categories in Oklahoma. Targeted policies may be important for increasing EMR adoption, but policy efforts focusing solely on broadband availability for private practices are likely misguided.
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Affiliation(s)
- Brian E Whitacre
- Department of Agricultural Economics, Oklahoma State University, Stillwater, Oklahoma
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Najaftorkaman M, Ghapanchi AH, Talaei-Khoei A, Ray P. A taxonomy of antecedents to user adoption of health information systems: A synthesis of thirty years of research. J Assoc Inf Sci Technol 2014. [DOI: 10.1002/asi.23181] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mohammadreza Najaftorkaman
- School of Information and Communication Technology, Room 2.31, Building G23; Griffith University; Gold Coast Campus, Parklands Drive Southport Qld 4222 Australia
| | - Amir Hossein Ghapanchi
- School of Information and Communication Technology, Room 1.60, Building G09; Griffith University; Gold Coast Campus, Parklands Drive Southport Qld 4222 Australia
- Institute for Integrated and Intelligent Systems; Gold Coast Qld 4222 Australia
| | - Amir Talaei-Khoei
- School of Systems; Management and Leadership; University of Technology Sydney; CB10.04.346, P.O. Box 123, Broadway Ultimo NSW 2007 Australia
| | - Pradeep Ray
- Asia-Pacific ubiquitous Healthcare research Centre (APuHC), Room 1039, Quadrangle Building; Australian School of Business; University of New South Wales; Sydney NSW 2052 Australia
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Montague E, Asan O. Considering social ergonomics: the effects of HIT on interpersonal relationships between patients and clinicians. ACTA ACUST UNITED AC 2014; 41 Suppl 1:4479-83. [PMID: 22317411 DOI: 10.3233/wor-2012-0748-4479] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study explored physicians' interactions with EHRs to understand the qualities that contribute to patient satisfaction with their use of the technologies and patient satisfaction with physician. Video-taped observations of 100 medical consultations were used to distinguish interaction patterns between physicians and EHRs. Quantified observational methods were used to contribute to ecological validity. Ten primary care physicians and 100 patients from five clinics participated in the study. Visits were videotaped and coded using an objective coding methodology to understand how physicians interacted with electronic health records. Results indicate, a variety of EHR interaction styles may be effective in providing patient-centered care.
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Affiliation(s)
- Enid Montague
- UW-Madison, Industrial and System Engineering, 3017 Mechanical Engineering Building 1513 University Avenue Madison, WI 53706-1572, USA
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King J, Furukawa MF, Buntin MB. Geographic variation in ambulatory electronic health record adoption: implications for underserved communities. Health Serv Res 2013; 48:2037-59. [PMID: 23800087 PMCID: PMC3876400 DOI: 10.1111/1475-6773.12078] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To describe small area variation in ambulatory electronic health record (EHR) adoption and assess evidence of a "digital divide" in whether adoption is lagging in traditionally underserved communities. DATA SOURCES Survey data on U.S. ambulatory health care sites (261,973 sites representing 716,160 providers) collected by SK&A Information Services in 2011. STUDY DESIGN We examined cross-sectional variation in two measures of local area EHR adoption: share of providers at sites using an EHR with e-prescribing functionality; and predicted probability of EHR adoption for the average site. Local areas were defined as Public Use Microdata Areas (n = 2,068). Using multivariate regression, we examined the association between adoption and three area characteristics: high concentration of minority population; high concentration of low-income population; and metropolitan status. PRINCIPAL FINDINGS EHR adoption varied significantly across local areas, ranging from 8 to 88 percent with a median of 41 percent. Adoption was lower in large metropolitan areas; areas with high concentration of minority population in the Northeast and West; and areas with high concentration of low-income population in the Midwest. CONCLUSIONS Our 2011 estimates suggest there was substantial room for increased EHR adoption across the United States, including some underserved areas with relatively low EHR adoption rates. Further research should monitor policy initiatives in these areas and examine sources of heterogeneity in low- and high-adoption communities.
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Affiliation(s)
- Jennifer King
- Office of the National Coordinator for Health Information Technology200 Independence Ave SW, Washington, DC 20201
| | - Michael F Furukawa
- Office of the National Coordinator for Health Information Technology200 Independence Ave SW, Washington, DC 20201
| | - Melinda B Buntin
- Office of the National Coordinator for Health Information Technology200 Independence Ave SW, Washington, DC 20201
- Congressional Budget Office (work initiated while affiliated with ONC)
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Davis MM, Currey JM, Howk S, DeSordi MR, Boise L, Fagnan LJ, Vuckovic N. A qualitative study of rural primary care clinician views on remote monitoring technologies. J Rural Health 2013; 30:69-78. [PMID: 24383486 DOI: 10.1111/jrh.12027] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Remote monitoring technologies (RMTs) may improve the quality of care, reduce access barriers, and help control medical costs. Despite the role of primary care clinicians as potential key users of RMTs, few studies explore their views. This study explores rural primary care clinician interest and the resources necessary to incorporate RMTs into routine practice. METHODS We conducted 15 in-depth interviews with rural primary care clinician members of the Oregon Rural Practice-based Research Network (ORPRN) from November 2011 to April 2012. Our multidisciplinary team used thematic analysis to identify emergent themes and a cross-case comparative analysis to explore variation by participant and practice characteristics. RESULTS Clinicians expressed interest in RMTs most relevant to their clinical practice, such as supporting chronic disease management, noting benefits to patients of all ages. They expressed concern about the quantity of data, patient motivation to utilize equipment, and potential changes to the patient-clinician encounter. Direct data transfer into the clinic's electronic health record (EHR), availability in multiple formats, and review by ancillary staff could facilitate implementation. Although participants acknowledged the potential system-level benefits of using RMTs, adoption would be difficult without payment reform. CONCLUSIONS Adoption of RMTs by rural primary care clinicians may be influenced by equipment purpose and functionality, implementation resources, and payment. Clinician and staff engagement will be critical to actualize RMT use in routine primary care.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon; Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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Bramble JD, Abbott AA, Fuji KT, Paschal KA, Siracuse MV, Galt K. Patient safety perspectives of providers and nurses: the experience of a rural ambulatory care practice using an EHR with E-prescribing. J Rural Health 2013; 29:383-91. [PMID: 24088212 DOI: 10.1111/jrh.12015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to identify and describe safety improvements and concerns indicated by providers and nurses in a rural community ambulatory care practice using an electronic health record with an e-prescribing feature (EHR with eRx). METHODS Two focus groups were conducted; 1 with providers and the other with nurses. Participants responded to questions and discussed their perceptions of safety improvements and concerns with use of an EHR with eRx. Transcripts were analyzed using sequential and continuous analytic methods. FINDINGS Three themes centered on efficiency and patient safety emerged from data analysis: (1) EHR with eRx adoption has led to new improvements and concerns for patient safety, (2) the EHR with eRx has affected efficiency in the clinic, and (3) EHR with eRx adoption has led to workarounds. CONCLUSIONS Concerns remain among providers and nurses regarding the use of EHR with eRx applications, although concerns differed between groups. Therefore, When EHR improvements are planned, it is important to consider the differing needs of the professionals who deliver care.
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Affiliation(s)
- James D Bramble
- Department of Pharmacy Sciences and Center for Health Services Research and Patient Safety, School of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska
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Montague E, Asan O. Physician Interactions with Electronic Health Records in Primary Care. Health Syst (Basingstoke) 2012; 1:96-103. [PMID: 24009982 PMCID: PMC3760434 DOI: 10.1057/hs.2012.11] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE It is essential to design technologies and systems that promote appropriate interactions between physicians and patients. This study explored how physicians interact with Electronic Health Records (EHRs) to understand the qualities of the interaction between the physician and the EHR that may contribute to positive physician-patient interactions. STUDY DESIGN Video-taped observations of 100 medical consultations were used to evaluate interaction patterns between physicians and EHRs. Quantified observational methods were used to contribute to ecological validity. METHODS Ten primary care physicians and 100 patients from five clinics participated in the study. Clinical encounters were recorded with video cameras and coded using a validated objective coding methodology in order to examine how physicians interact with electronic health records. RESULTS Three distinct styles were identified that characterize physician interactions with the EHR: technology-centered, human-centered, and mixed. Physicians who used a technology-centered style spent more time typing and gazing at the computer during the visit. Physicians who used a mixed style shifted their attention and body language between their patients and the technology throughout the visit. Physicians who used the human-centered style spent the least amount of time typing and focused more on the patient. CONCLUSION A variety of EHR interaction styles may be effective in facilitating patient-centered care. However, potential drawbacks of each style exist and are discussed. Future research on this topic and design strategies for effective health information technology in primary care are also discussed.
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Affiliation(s)
- Enid Montague
- Department of Industrial and Systems Engineering, University of Wisconsin - Madison, Madison, Wisconsin, USA
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Affiliation(s)
- Brian Grady
- Department of Psychiatry, School of Medicine, University of Maryland, 701 W. Pratt St., Baltimore, MD 21201, USA
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Abstract
PURPOSE Health information technology (HIT) holds promise for improving the quality of health care and reducing health care system inefficiencies. Numerous studies have examined HIT availability, specifically electronic health records (EHRs), and utilization among physicians in individual countries. However, no one has examined EHR use among physicians who train in one country and move to practice in another country. In the United States, physicians who complete medical school outside the country but practice within the United States are commonly referred to as International Medical Graduates (IMGs). IMGs have a growing presence in the United States, yet little is known about the availability and use of HIT among these physicians. The purpose of this study is to explore the availability and use of HIT among IMGs practicing in United States. DESIGN/METHODOLOGY/APPROACH The Health Tracking Physician Survey (2008) was used to examine the relationship between availability and use of HIT and IMG status controlling for several physician and practice characteristics. Our analysis included responses from 4,720 physicians, 20.7% of whom were IMGs. FINDINGS Using logistic regression, controlling for physician gender, specialty, years in practice, practice type, ownership status and geographical location, we found IMGs were significantly less likely to have a comprehensive EHR in their practices (OR = 0.84; p = 0.005). In addition, findings indicate that IMGs are more likely to have and use several so-called first generation HIT capabilities, such as reminders for clinicians about preventive services (OR = 1.31; p = 0.001) and other needed patient follow-up (OR = 1.26; p = 0.007). ORIGINALITY/VALUE This study draws attention to the need for further research regarding barriers to HIT adoption and use among IMGs.
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Bassi J, Lau F, Lesperance M. Perceived impact of electronic medical records in physician office practices: a review of survey-based research. Interact J Med Res 2012; 1:e3. [PMID: 23611832 PMCID: PMC3626136 DOI: 10.2196/ijmr.2113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 07/03/2012] [Accepted: 07/06/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Physician office practices are increasingly adopting electronic medical records (EMRs). Therefore, the impact of such systems needs to be evaluated to ensure they are helping practices to realize expected benefits. In addition to experimental and observational studies examining objective impacts, the user's subjective view needs to be understood, since ultimate acceptance and use of the system depends on them. Surveys are commonly used to elicit these views. OBJECTIVE To determine which areas of EMR implementation in office practices have been addressed in survey-based research studies, to compare the perceived impacts between users and nonusers for the most-addressed areas, and to contribute to the knowledge regarding survey-based research for assessing the impact of health information systems (HIS). METHODS We searched databases and systematic review citations for papers published between 2000 and 2012 (May) that evaluated the perceived impact of using an EMR system in an office-based practice, were based on original data, had providers as the primary end user, and reported outcome measures related to the system's positive or negative impact. We identified all the reported metrics related to EMR use and mapped them to the Clinical Adoption Framework to analyze the gap. We then subjected the impact-specific areas with the most reported results to a meta-analysis, which examined overall positive and negative perceived impacts for users and nonusers. RESULTS We selected 19 papers for the review. We found that most impact-specific areas corresponded to the micro level of the framework and that appropriateness or effectiveness and efficiency were well addressed through surveys. However, other areas such as access, which includes patient and caregiver participation and their ability to access services, had very few metrics. We selected 7 impact-specific areas for meta-analysis: security and privacy; quality of patient care or clinical outcomes; patient-physician relationship and communication; communication with other providers; accessibility of records and information; business or practice efficiency; and costs or savings. All the results for accessibility of records and information and for communication with providers indicated a positive view. The area with the most mixed results was security and privacy. CONCLUSIONS Users sometimes were likelier than nonusers to have a positive view of the selected areas. However, when looking at the two groups separately, we often found more positive views for most of the examined areas regardless of use status. Despite limitations of a small number of papers and their heterogeneity, the results of this review are promising in terms of finding positive perceptions of EMR adoption for users and nonusers. In addition, we identified issues related to survey-based research for HIS evaluation, particularly regarding constructs for evaluation and quality of study design and reporting.
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Affiliation(s)
- Jesdeep Bassi
- School of Health Information Science, University of Victoria, Victoria, BC, Canada.
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“Meaningful Use” of ambulatory EMR: Does it improve the quality and efficiency of health care? HEALTH POLICY AND TECHNOLOGY 2012. [DOI: 10.1016/j.hlpt.2012.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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