Challenges of EHR "Meaningful Use" in Rural Health Centers

The Centers for Disease Control and Prevention (CDC) continues to promote the utilization of electronic health records (EHRs) to support population health management and reduce disparities. However, access to EHRs with capabilities to disaggregate data or generate digital dashboards is not always readily available in rural areas. With funding from CDC's DP-18-1815, the Division of Diabetes and Heart Disease Management (Division) at the South Carolina Department of Health and Environmental Control designed a quality improvement initiative to reduce health disparities for people with hypertension and high blood cholesterol in rural areas. With support from a nonprofit partner, the Division used qualitative evaluation methods to evaluate the extent to which practices were able to disaggregate data and report quality measures.

The Impact of Market Factors on Meaningful Use of Electronic Health Records Among Primary Care Providers: Evidence From Florida Using Resource Dependence Theory and Information Uncertainty Perspective

BACKGROUND

Using federal funds from the 2009 Health Information Technology for Economic and Clinical Health Act, the Centers for Medicare and Medicaid Services funded the 2011-2021 Medicaid electronic health record (EHR) incentive programs throughout the country.

OBJECTIVE

Identify the market factors associated with Meaningful Use (MU) of EHRs after primary care providers (PCPs) enrolled in the Florida-EHR incentives program through Adopting, Improving, or Upgrading (AIU) an EHR technology.

RESEARCH DESIGN

Retrospective cohort study using 2011-2018 program records for 8464 Medicaid providers.

MAIN OUTCOME

MU achievement after first-year incentives.

INDEPENDENT VARIABLES

The resource dependence theory and the information uncertainty perspective were used to generate key-independent variables, including the county's rurality, educational attainment, poverty, health maintenance organization penetration, and number of PCPs per capita.

ANALYTICAL APPROACH

All the county rates were converted into 3 dichotomous measures corresponding to high, medium, and low terciles. Descriptive and bivariate statistics were calculated. A generalized hierarchical linear model was used because MU data were clustered at the county level (level 2) and measured at the practice level (level 1).

RESULTS

Overall, 41.9% of Florida Medicaid providers achieved MU after receiving first-year incentives. Rurality was positively associated with MU ( P <0.001). Significant differences in MU achievements were obtained when we compared the "high" terciles with the "low" terciles for poverty rates ( P =0.002), health maintenance organization penetration rates ( P =0.02), and number of PCPs per capita ( P =0.01). These relationships were negative.

CONCLUSIONS

Policy makers and health care managers should not ignore the contribution of market factors in EHR adoption.

The pursuit of health equity in digital transformation, health informatics, and the cardiovascular learning healthcare system

African Americans have a higher rate of cardiovascular morbidity and mortality and a lower rate of specialty consultation and treatment than Caucasians. These disparities also exist in the care and treatment of chemotherapy-related cardiovascular complications. African Americans suffer from cardiotoxicity at a higher rate than Caucasians and are underrepresented in clinical trials aimed at preventing cardiovascular injury associated with cancer therapies. To eliminate racial and ethnic disparities in the prevention of cardiotoxicity, an interdisciplinary and innovative approach will be required. Diverse forms of digital transformation leveraging health informatics have the potential to contribute to health equity if they are implemented carefully and thoughtfully in collaboration with minority communities. A learning healthcare system can serve as a model for developing, deploying, and disseminating interventions to minimize health inequities and maximize beneficial impact.

Facilitators and Barriers to Implementing a Digital Informed Decision Making Tool in Primary Care: A Qualitative Study

BACKGROUND

Informed decision aids provide information in the context of the patient's values and improve informed decision making (IDM). To overcome barriers that interfere with IDM, our team developed an innovative iPad-based application (aka "app") to help patients make informed decisions about colorectal cancer screening. The app assesses patients' eligibility for screening, educates them about their options, and empowers them to request a test via the interactive decision aid.

OBJECTIVE

The aim of the study is to explore how informed decision aids can be implemented successfully in primary care clinics, including the facilitators and barriers to implementation; strategies for minimizing barriers; adequacy of draft training materials; and any additional support or training desired by clinics.

DESIGN

This work deals with a multicenter qualitative study in rural and urban settings.

PARTICIPANTS

A total of 48 individuals participated including primary care practice managers, clinicians, nurses, and front desk staff.

APPROACH

Focus groups and semi-structured interviews, with data analysis were guided by thematic analysis.

KEY RESULTS

Salient emergent themes were time, workflow, patient age, literacy, and electronic health record (EHR) integration. Saving time was important to most participants. Patient flow was a concern for all clinic staff, and they expressed that any slowdown due to patients using the iPad module or perceived additional work to clinic staff would make staff less motivated to use the program. Participants voiced concern about older patients being unwilling or unable to utilize the iPad and patients with low literacy ability being able to read or comprehend the information.

CONCLUSION

Integrating new IDM apps into the current clinic workflow with minimal disruptions would increase the probability of long-term adoption and ultimate sustainability.

NIH TRIAL REGISTRY NUMBER

R01CA218416-A1.

Differences in Secure Messaging, Self-management, and Glycemic Control Between Rural and Urban Patients: Secondary Data Analysis

BACKGROUND

Rural patients with diabetes have difficulty accessing care and are at higher risk for poor diabetes management. Sustained use of patient portal features such as secure messaging (SM) can provide accessible support for diabetes self-management.

OBJECTIVE

This study explored whether rural patients' self-management and glycemic control was associated with the use of SM.

METHODS

This secondary, cross-sectional, mixed methods analysis of 448 veterans with diabetes used stratified random sampling to recruit a diverse sample from the United States (rural vs urban and good vs poor glycemic control). Administrative, clinical, survey, and interview data were used to determine patients' rurality, use of SM, diabetes self-management behaviors, and glycemic control. Moderated mediation analyses assessed these relationships.

RESULTS

The sample was 51% (n=229) rural and 49% (n=219) urban. Mean participant age was 66.4 years (SD 7.7 years). More frequent SM use was associated with better diabetes self-management (P=.007), which was associated with better glycemic control (P<.001). Among rural patients, SM use was indirectly associated with better glycemic control through improved diabetes self-management (95% CI 0.004-0.927). These effects were not observed among urban veterans with diabetes (95% CI -1.039 to 0.056). Rural patients were significantly more likely than urban patients to have diabetes-related content in their secure messages (P=.01).

CONCLUSIONS

More frequent SM use is associated with engaging in diabetes self-management, which, in turn, is associated with better diabetes control. Among rural patients with diabetes, SM use is indirectly associated with better diabetes control. Frequent patient-team communication through SM about diabetes-related content may help rural patients with diabetes self-management, resulting in better glycemic control.

ENABLING THE UTILIZATION OF POTENTIALLY DISRUPTIVE DIGITAL INNOVATIONS BY INCUMBENTS: THE IMPACT OF CONTEXTUAL, ORGANISATIONAL, AND INDIVIDUAL FACTORS IN REGULATED CONTEXTS

Incumbents’ inertia in the face of disruptive innovations has been emphasised in prior literature. The relevance of inertia is particularly topical in the context of digital transformation. However, incumbents may be able to invest in disruptive digital innovations appropriately if they possess the motivation and ability to do so. In this paper, I use three streams of research in order to investigate contextual, organisational, and individual antecedents of incumbents’ motivation and ability to adopt and use potentially disruptive digital innovations in health care: institutional theory, the resource-based view, and technology acceptance literature. I employ factor analyses and logistic regressions to test the impact on the adoption and usage of telemedicine applications using a dataset of 9,196 European general practitioners. I examine B2B as well as B2C applications in order to determine the effect of the antecedents on different business models. My findings suggest that only isomorphic pressure, complementary assets, and perceived output quality significantly influence both adoption and usage as well as B2B and B2C business models in the same way. Formal institutions and individual factors yield ambiguous results. These findings provide important implications for the understanding of incumbents’ response to potentially disruptive digital innovations in regulated contexts.

Technology-facilitated care coordination in rural areas: What is needed?

BACKGROUND

Health is poorer in rural areas and a major challenge is care coordination for complex chronic conditions. The HITECH and 21st Century Cure Acts emphasize health information exchange which underpins activities required to improve care coordination.

OBJECTIVE AND METHODS

Using semi-structured interviews and surveys, we examined how providers experience electronic health information exchange during care coordination since these Acts were implemented, with a focus on rural settings where health disparities exist. We used a purposive sample that included primary care, acute care hospitals, and community health services in the United States.

FINDINGS

We identified seven themes related to care coordination and information exchange: 'insufficient trust of data'; 'please respond'; 'just fax it'; 'care plans'; 'needle in the haystack'; 're-documentation'; and 'rural reality'. These gaps were magnified when information exchange was required between unaffiliated electronic health records (EHRs) about shared patients, which was more pronounced in rural settings.

CONCLUSION

Policy and incentive modifications are likely needed to overcome the observed health information technology (HIT) shortcomings. Rural settings in the United States accentuate problems that can be addressed through international medical informatics policy makers and the implementation and evaluation of interoperable HIT systems.

Horizontal and vertical integration's role in meaningful use attestation over time

OBJECTIVE

To compare rates of attestation and attrition from the MU program by independent, horizontally integrated, and vertically integrated physicians and to assess whether MU created pressure for independent physicians to join integrated organizations.

DATA SOURCE/STUDY SETTING

Secondary Data from SK&A and Medicare MU Files, 2011-2016. Office-based physicians in the 50 United States and District of Columbia.

STUDY DESIGN

We compared attestation rates among physicians that remained independent or integrated throughout the study period. We then assessed the association between changing integration and MU attestation in multivariate regression models.

PRINCIPAL FINDINGS

Our sample included 291 234 physicians. Forty nine percent of physicians that remained independent throughout the period attested to MU at least once during the program, compared with 70 percent of physicians that remained horizontally or vertically integrated physicians. Only approximately 50 percent of independent physicians that attested between 2011 and 2013 attested in 2015, representing significantly more attrition than we observed among integrated physicians. In multivariate regression models, physicians that joined these organizations were more likely to have attested to MU prior to integrating and this difference increased following integration.

CONCLUSIONS

These findings point toward a growing digital divide between physicians who remain independent and integrated physicians that may have been exacerbated by the MU program. Targeted public policy, such as new regional extension centers, should be considered to address this disparity.

Do Years of Experience With Electronic Health Records Matter for Productivity in Community Health Centers?

This study investigated how years of experience with an electronic health record (EHR) related to productivity in community health centers (CHCs). Using data from the 2012 Uniform Data System, we regressed average annual medical visits, weighted for service intensity, as a function of full-time equivalent medical staff controlling for CHC size and location. Physician productivity significantly improved. Although the productivity of all other staff types was not significantly different by years of EHR experience, the trends showed lower productivity among nurses and other medical staff in CHCs with fewer years of EHR experience versus more years of experience.

Rural Patients' and Primary Care Clinic Staffs' Perceptions of EHR Implementation: An Ethnographic Exploration

This focused ethnographic research study explores patients' and clinic staffs' experience of electronic health record (EHR) implementation in a small, independent, rural primary care practice. On the basis of participant observation of clinic staff, staff focus group, and patient interviews, results demonstrate that both patients and clinic staff have distrust and disconnect from technology. Yet, patients and clinic staff embrace patient-centered approaches and value team-based care. Understanding patients' and staffs' experience can facilitate the EHR implementation in the rural primary care setting and facilitate online access, patient portals, and other technologically based patient-centered approaches.

A Bridging Opportunities Work-frame to develop mobile applications for clinical decision making

Background:

Mobile applications (apps) providing clinical decision support (CDS) may show the greatest promise when created by and for frontline clinicians. Our aim was to create a generic model enabling healthcare providers to direct the development of CDS apps.

Methods:

We combined Change Management with a three-tier information technology architecture to stimulate CDS app development.

Results:

A Bridging Opportunities Work-frame model was developed. A test case was used to successfully develop an app.

Conclusion:

Healthcare providers can re-use this globally applicable model to actively create and manage regional decision support applications to translate evidence-based medicine in the use of emerging medication or novel treatment regimens.

Medical information needs to be structured in a way that it can be used in a time-constrained environment. This project looked at the process of creating mobile applications (apps), to help medical professionals rapidly apply new knowledge to better treat patients. We developed a novel system that allowed medical professionals to have a leading role in development. With the input from a pharmacist we created an app to deal with pharmacy and patient-related decisions surrounding newly available anticancer pills. Other medical professionals could also use this method to make apps to provide information with relevance to their medical decisions.

Diabetes self-management interventions for adults with type 2 diabetes living in rural areas: a systematic literature review

In rural communities, high rates of diabetes and its complications are compounded by limited access to health care and scarce community resources. We systematically reviewed the evidence for the impact of diabetes self-management education interventions designed for patients living in rural areas on glycemic control and other diabetes outcomes. Fifteen studies met inclusion criteria. Ten were randomized controlled trials. Intervention strategies included in-person diabetes (n = 9) and telehealth (n = 6) interventions. Four studies demonstrated between group differences for biologic outcomes, four studies demonstrated changes in behavior, and three studies demonstrated changes in knowledge. Intervention dose was associated with improved A1c or weight loss in two studies and session attendance in one study. Interventions that included collaborative goal-setting were associated with improved metabolic outcomes and self-efficacy. Telehealth and face-to-face diabetes interventions are both promising strategies for rural communities. Effective interventions included collaborative goal-setting. Intervention dose was linked to better outcomes and higher attendance.