Hospitals Ineligible For Federal Meaningful-Use Incentives Have Dismally Low Rates Of Adoption Of Electronic Health Records

A 3-year follow-up study of outcomes associated with patterns of traditional acute and preventive migraine treatment: An administrative claims-based cohort study in the United States

OBJECTIVE

To describe treatment patterns and direct healthcare costs over 3 years following initiation of standard of care acute and preventive migraine medications in patients with migraine in the United States.

BACKGROUND

There are limited data on long-term (>1 year) migraine treatments patterns and associated outcomes.

METHODS

This was a retrospective, observational cohort study using US claims data from the IBM® MarketScan® Research Database (January 2010-December 2017). Adults were included if they had a prescription claim for acute migraine treatments (AMT) or preventive migraine treatments (PMT) in the index period (January 2011-December 2014). The AMT cohort was categorized as persistent, cycled, or added-on subgroups; the PMT cohort was categorized PMT-persistent, switched without gaps, or cycled with gaps. Migraine-specific annual direct costs (2017 US$) across AMT and PMT cohort subgroups were summarized at baseline through 3 years from index (follow-up).

RESULTS

During the index period, 20,778 and 42,259 patients initiated an AMT and a PMT, respectively. At the 3-year follow-up, migraine-specific direct costs were lower in the persistent subgroup relative to the non-persistent subgroups in both AMT (mean [SD]: $789 [$1741] vs. $2847 [$8149] in the added-on subgroup and $862 [$5426] for the cycled subgroup) and PMT cohorts (mean [SD]: $1817 [$5892] in the persistent subgroup vs. $4257 [$11,392] in the switched without gaps subgroup and $3269 [$18,540] in the cycled with gaps subgroup). Acute medication overuse was lower in the persistent subgroup (1025/6504 [27.2%]) vs. non-persistent subgroups (11,236/58,863 [32.2%] in cycled with gaps subgroup and 1431/6504 [39.4%] in the switched without gaps subgroup). Most patients used multiple acute (19,717/20,778 [94.9%]) or preventive (38,494/42,259 [91.1%]) pharmacological therapies over 3 years following treatment initiation. Gaps in preventive therapy were common; an average gap ranged from 85 to 211 days (~3-7 months).

CONCLUSION

Migraine-specific annual healthcare costs and acute migraine medication overuse remained lowest among patients with persistent AMT and PMT versus non-persistent treatment. Study findings are limited to the US population. Future studies should compare costs and associated outcomes between newer preventive migraine medications in patients with migraine.

Associations between Florida counties' COVID-19 case and death rates and meaningful use among Medicaid providers: Cross-sectional ecologic study

Although the Health Information Technology for Economic and Clinical Health (HITECH) Act has accelerated adoption of Electronic Health Records (EHRs) among Medicaid providers, only half achieved Meaningful Use. Furthermore, Meaningful Use' impact on reporting and/or clinical outcomes remains unknown. To address this deficit, we assessed the difference between Medicaid providers who did and did not achieve Meaningful Use regarding Florida county-level cumulative COVID-19 death, case and case fatality rates (CFR), accounting for county-level demographics, socioeconomic and clinical markers, and healthcare environment. We found that cumulative incidence rates of COVID-19 deaths and CFRs were significantly different between the 5025 Medicaid providers not achieving Meaningful Use and the 3723 achieving Meaningful Use (mean 0.8334/1000 population; SD = 0.3489 vs. mean = 0.8216/1000; SD = 0.3227, respectively) (P = .01). CFRs were .01797 and .01781, respectively, P = .04. County-level characteristics independently associated with increased COVID-19 death rates and CFRs include greater concentrations of persons of African American or Black race, lower median household income, higher unemployment, and higher concentrations of those living in poverty and without health insurance (all P < .001). In accordance with other studies, social determinants of health were independently associated with clinical outcomes. Our findings also suggest that the association between Florida counties' public health outcomes and Meaningful Use achievement may have had less to do with using EHRs for reporting of clinical outcomes and more to do with using EHRs for coordination of care-a key measure of quality. The Florida Medicaid Promoting Interoperability Program which incentivized Medicaid providers towards achieving Meaningful Use, has demonstrated success regarding both rates of adoption and clinical outcomes. Because the Program ends in 2021, we support programs such as HealthyPeople 2030 Health IT which address the remaining half of Florida Medicaid providers who have not yet achieved Meaningful Use.

Public Health Innovation through Cloud Adoption: A Comparative Analysis of Drivers and Barriers in Japan, South Korea, and Singapore

Governments are increasingly using cloud computing to reduce cost, increase access, improve quality, and create innovations in healthcare. Existing literature is primarily based on successful examples from developed western countries, and there is a lack of similar evidence from Asia. With a population close to 4.5 billion people, Asia faces healthcare challenges that pose an immense burden on economic growth and policymaking. Cloud computing in healthcare can potentially help increase the quality of healthcare delivery and reduce the economic burden, enabling governments to address healthcare challenges effectively and within a short timeframe. Advanced Asian countries such as Japan, South Korea, and Singapore provide successful examples of how cloud computing can be used to develop nationwide databases of electronic health records; real-time health monitoring for the elderly population; genetic database to support advanced research and cancer treatment; telemedicine; and health cities that drive the economy through medical industry, tourism, and research. This article examines these countries and identifies the drivers and barriers of cloud adoption in healthcare and makes policy recommendations to enable successful public health innovations through cloud adoption.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring association between certified EHRs adoption and patient experience in U.S. psychiatric hospitals

OBJECTIVE

Certified Electronic Health Records (EHR) have been shown to improve the health service quality in some health settings, but there is scant evidence related to its adoption in psychiatric hospitals. This paper aimed to examine the relationship between certified EHR adoption and patient experience across psychiatric hospitals in the United States.

METHODS

A cross-sectional study design compared the difference in patient experience measures between psychiatric hospitals with and without certified EHR. Data were drawn from the American Hospital Association (AHA) Annual Survey Database and Hospital Compare datasets. Eleven publicly reported measures for patient experience from the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) were applied for analysis. Independent relationship of certified EHR adoption and patient experience was explored with multiple linear regression models adjusted for hospital organizational characteristics.

RESULTS

Positive associations were identified between certified EHR adoption and five patient perception measures-"recommend hospital" (β = 0.66, 95% CI = [0.16,1.16]; t = 2.68, p = 0.010), "overall hospital rating" (β = 0.39, 95% CI = [0.03,0.75]; t = 2.11, p = 0.035), "discharge information" (β = 0.45, 95% CI = [0.03,0.86]; t = 2.09, p = 0.037), "care transition" (β = 0.44, 95% CI = [0.14, 0.75]; t = 2.84, p = 0.005), and "responsiveness of hospital staff" (β = 0.47, 95% CI = [0.04, 0.90]; t = 2.13, p = 0.033).

CONCLUSION

Our results suggest the positive association between certified EHR adoption and patient experience. More studies are needed to explore impacts of certified EHR adoption and potential improvement in patient experience to quality of care.

Hospital Characteristics Associated with Certified EHR Adoption among US Psychiatric Hospitals

Objective

The aim of this study was to explore the relationship between hospital characteristics and certified electronic health record (EHR) adoption in psychiatric hospitals in the US.

Methods

Data were drawn from the American Hospital Association Annual Survey Database and the Centers for Medicare and Medicaid Services Hospital Compare data sets in 2016. Binary logistic regression analysis and χ² tests were performed to examine the relationship between certified EHR adoption and hospital characteristics.

Results

Of 1,059 psychiatric hospitals in the US, 502 (47.4%) have adopted certified EHR technology. Large hospitals (OR 2.29, 95% CI 1.52–3.44; p<0.001), not-for-profit hospitals (OR 1.74, 95% CI 1.22–2.49; p=0.008), and hospitals participating in a network (OR 1.78, 95% CI 1.34–2.37; p<0.001) were more likely to adopt certified EHRs. Hospitals in the northeast were less likely to implement certified EHRs compared to other regions. However, there was no significant association found between EHR utilization and system affiliation, urban location, teaching status, or participation of health-maintenance organizations and preferred provider organizations.

Conclusion

The study results suggested variations in EHR adoption according to hospital location, size, ownership, and network participation. This study fills a gap in previous work on certified EHR adoption that focused exclusively on general hospitals, but overlooked psychiatric hospitals. Future policies designed to influence the implementation of certified EHRs should take into consideration how hospital size, ownership, and network-affiliation status affect certified EHR adoption among psychiatric hospitals.

Status of health information exchange: a comparison of six countries

Background

Health information exchange (HIE) is frequently cited as an important objective of health information technology investment because of its potential to improve quality, reduce cost, and increase patient satisfaction. In this paper we examine the status and practices of HIE in six countries, drawn from a range of higher and lower income regions.

Methods

For each of the countries represented – China, England, India, Scotland, Switzerland, and the United States – we describe the state of current practice of HIE with reference to two scenarios: transfer of care and referral. For each country we discuss national objectives, barriers and plans for further advancing clinical information exchange.

Results

The countries vary widely in levels of adoption of EHRs, availability of health information in electronic form suitable for HIE, and in the information technology infrastructure to be used for transmission. Common themes emerged, however, including an expectation that information will be exchanged rather than gathered anew, the need for incentives to promote information exchange, and concerns about data security and patient confidentiality.

Conclusions

Although the ability to transfer health information to where it is most needed is nearly always mentioned as an advantage of HIE adoption, there are wide differences in the degree to which this has been achieved to support the scenarios used in this study. Nevertheless, these differences indicate varying stages of progress along a comparable pathway, with similar barriers being identified in the countries described. In some cases, these have been partially surmounted while elsewhere work is needed. We reflect on contextual factors influencing the status and direction of HIE efforts in different global regions and their implications for progress.

Diffusion dynamics of electronic health records: A longitudinal observational study comparing data from hospitals in Germany and the United States

BACKGROUND

While aiming for the same goal of building a national eHealth Infrastructure, Germany and the United States pursued different strategic approaches - particularly regarding the role of promoting the adoption and usage of hospital Electronic Health Records (EHR).

OBJECTIVE

To measure and model the diffusion dynamics of EHRs in German hospital care and to contrast the results with the developments in the US.

MATERIALS AND METHODS

All acute care hospitals that were members of the German statutory health system were surveyed during the period 2007-2017 for EHR adoption. Bass models were computed based on the German data and the corresponding data of the American Hospital Association (AHA) from non-federal hospitals in order to model and explain the diffusion of innovation.

RESULTS

While the diffusion dynamics observed in the US resembled the typical s-shaped curve with high imitation effects (q = 0.583) but with a relatively low innovation effect (p = 0.025), EHR diffusion in Germany stagnated with adoption rates of approx. 50% (imitation effect q = -0.544) despite a higher innovation effect (p = 0.303).

DISCUSSION

These findings correlate with different governmental strategies in the US and Germany of financially supporting EHR adoption. Imitation only seems to work if there are financial incentives, e.g. those of the HITECH Act in the US. They are lacking in Germany, where the government left health IT adoption strategies solely to the free market and the consensus among all of the stakeholders.

CONCLUSION

Bass diffusion models proved to be useful for distinguishing the diffusion dynamics in German and US non-federal hospitals. When applying the Bass model, the imitation parameter needs a broader interpretation beyond the network effects, including driving forces such as incentives and regulations, as was demonstrated by this study.

Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy

Behavioral health care has been slow to take up robust efforts to improve patient safety. This lag is especially apparent in inpatient psychiatry, where there is risk for physical and psychological harm. Recent investigative journalism has provoked public concern about instances of alleged abuse, negligence, understaffing, sexual assault, inappropriate medication use, patient self-harm, poor sanitation, and inappropriate restraint and seclusion. However, empirical evidence describing the scope of unsafe experiences is limited. While evidence-based inpatient psychiatry requires care to be trauma-informed, market failures and a lack of payment alignment with patient-centered care leave patients vulnerable to harm. Existing regulatory mechanisms attempt to provide accountability; however, these mechanisms are imperfect. Furthermore, research is sparse. Few health services researchers study inpatient psychiatry, the issue has not been a priority among research funders, and data on inpatient psychiatry is excluded from national surveys of quality. Several policy levers could begin to address these deficiencies. These include aligning incentives with patient-centered care, building trauma-informed care into accreditation and monitoring, conducting trend analyses of critical incidents, and improving research capacity.

A National Assessment of Access to Technology Among Nursing Home Residents: A Secondary Analysis

Background

According to the National Center for Health Statistics, there are over 1.7 million nursing home residents in the United States. Nursing home residents and their family members have unique needs and stand to benefit from using technology empowering them to be more informed and engaged health care consumers. Although there is growing evidence for benefits of patient-facing technologies like electronic patient portals on patient engagement in acute and outpatient settings, little is known about use of this technology in nursing homes.

Objective

The purpose of this study was to report findings from a secondary analysis of data from a national nursing home study of information technology (IT) adoption, called IT sophistication. We describe the extent to which nursing homes (n=815) allow residents or their representatives to access technology including electronic health records, patient portals, and health information-exchange systems as well as the ability of the residents or representatives to self-report data directly into the electronic health record.

Methods

We used descriptive statistics and regression techniques to explore relationships between information technology adoption (IT sophistication) and residents’ or their representatives’ access to technology. Covariates of location, bed size, and ownership were added to the model to understand their potential influence on the relationship between IT sophistication and resident access to technology.

Results

Findings revealed that resident access to technology was a significant predictor of the nursing home IT sophistication (P<.001). The inclusion of covariates—nursing home location, bed size, and ownership—with their interactions produced a nonsignificant effect in the model. Residents’ or their representatives’ use of electronic health records and personal health records were both significant predictors of overall IT sophistication (P<.001).

Conclusions

As nursing homes continue to progress in technological capabilities, it is important to understand how increasing IT sophistication can be leveraged to create opportunities to engage residents in their care. Understanding the impact of health information technology on outcomes and which technologies make a difference will help nursing home administrators make more informed decisions about adoption and implementation.

Key considerations when using health insurance claims data in advanced data analyses: an experience report

Health claims have become a popular source of data for healthcare analytics, with numerous applications ranging from disease burden estimation and policy evaluation to drug event detection and advanced predictive analytics. Independent of the application, a researcher utilising claims information will likely encounter challenges in using the data, which include dealing with several coding systems and coding irregularities. We highlight some of these challenges and approaches for successful analysis that may reduce implementation time and help in avoiding common pitfalls. We describe the experiences of a group of academic researchers in using an extensive seven-year repository of US medical and pharmaceutical claims data in a research study, and provide an overview of the challenges encountered with handling claims records for data analysis while sharing suggestions on how to address these challenges. To illustrate our experiences, we use the example of defining episodes of care for a bundled payment reimbursement system in the US context.

The Use of Health Information Exchange to Augment Patient Handoff in Long-Term Care: A Systematic Review

BACKGROUND

Legislation aimed at increasing the use of a health information exchange (HIE) in healthcare has excluded long-term care facilities, resulting in a vulnerable patient population that can benefit from the improvement of communication and reduction of waste.

OBJECTIVE

The purpose of this review is to provide a framework for future research by identifying themes in the long-term care information technology sector that could function to enable the adoption and use of HIE mechanisms for patient handoff between long-term care facilities and other levels of care to increase communication between providers, shorten length of stay, reduce 60-day readmissions, and increase patient safety.

METHODS

The authors conducted a systematic search of literature through CINAHL, PubMed, and Discovery Services for Texas A&M University Libraries. Search terms used were ("health information exchange" OR "healthcare information exchange" OR "HIE") AND ("long term care" OR "long-term care" OR "nursing home" OR "nursing facility" OR "skilled nursing facility" OR "SNF" OR "residential care" OR "assisted living"). Articles were eligible for selection if they were published between 2010 and 2017, published in English, and published in academic journals. All articles were reviewed by all reviewers and literature not relevant to the research objective was excluded.

RESULTS

Researchers selected and reviewed 22 articles for common themes. Results concluded that the largest facilitator and barrier to the adoption of HIE mechanisms is workflow integration/augmentation and the organizational structure/culture, respectively. Other identified facilitator themes were enhanced communication, increased effectiveness of care, and patient safety. The additional barriers were missing/incomplete data, inefficiency, and market conditions.

CONCLUSION

The long-term care industry has been left out of incentives from which the industry could have benefited tremendously. Organizations that are not utilizing health information technology mechanisms, such as electronic health records and HIEs, are at a disadvantage as insurers switch to capitated forms of payment that rely on reduced waste to generate a profit.

Data, Staff, and Money: Leadership Reflections on the Future of Public Health Informatics

CONTEXT

Health informatics can play a critical role in supporting local health departments' (LHDs') delivery of certain essential public health services and improving evidence base for decision support. However, LHDs' informatics capacities are below an optimum level. Efforts to build such capacities face ongoing challenges. Moreover, little is known about LHD leaders' desires for the future of public health informatics.

OBJECTIVES

Conduct a qualitative analysis of LHDs' future informatics plans, perceived barriers to accomplishing those plans, and potential impact of future advances in public health informatics on the work of the public health enterprise.

METHODS

This research presents findings from 49 in-depth key informant interviews with public health leaders and informatics professionals from LHDs, representing insights from across the United States. Interviewees were selected on the basis of the size of the population their LHD serves, as well as level of informatics capacity. Interviews were transcribed, verified, and double coded.

RESULTS

Major barriers to doing more with informatics included staff capacity and training, financial constraints, dependency on state health agency, and small LHD size/lack of regionalization. When asked about the role of leadership in expanding informatics, interviewees said that leaders could make it a priority through (1) learning more about informatics and (2) creating appropriate budgets for integrated information systems. Local health department leaders said that they desired data that were timely and geographically specific. In addition, LHD leaders said that they desired greater access to clinical data, especially around chronic disease indicators.

CONCLUSIONS

Local health department leadership desires to have timely or even real-time data. Local health departments have a great potential to benefit from informatics, particularly electronic health records in advancing their administrative practices and service delivery, but financial and human capital represents the largest barrier. Interoperability of public health systems is highly desirable but hardly achievable in the presence of such barriers.

Implementation of Electronic Health Records in US Nursing Homes

While electronic health records have emerged as promising tools to help improve quality of care, nursing homes have lagged behind in implementation. This study assessed electronic health records implementation, associated facility characteristics, and potential impact on quality indicators in nursing homes. Using national Centers for Medicare & Medicaid Services and survey data for nursing homes, a cross-sectional analysis was conducted to identify variations between nursing homes that had and had not implemented electronic health records. A difference-in-differences analysis was used to estimate the longitudinal effect of electronic health records on commonly used quality indicators. Data from 927 nursing homes were examined, 49.1% of which had implemented electronic health records. Nursing homes with electronic health records were more likely to be nonprofit/government owned (P = .04) and had a lower percentage of Medicaid residents (P = .02) and higher certified nursing assistant and registered nurse staffing levels (P = .002 and .02, respectively). Difference-in-differences analysis showed greater quality improvements after implementation for five long-stay and two short-stay quality measures (P = .001 and .01, respectively) compared with those who did not implement electronic health records. Implementation rates in nursing homes are low compared with other settings, and better-resourced facilities are more likely to have implemented electronic health records. Consistent with other settings, electronic health records implementation improves quality in nursing homes, but further research is needed to better understand the mechanism for improvement and how it can best be supported.

Leveraging Electronic Health Record Implementation to Facilitate Clinical and Operational Quality Improvement in an Ambulatory Surgical Clinic

The implementation of electronic health records is a challenging, complex process requiring significant resources. The temptation is to convert a paper process into electronic format. This strategy fosters a familiar product to the users but is fraught with pitfalls. We chose to utilize the opportunity of the implementation of an enterprise-wide ambulatory electronic health record to foster an overreaching clinical and operational improvement project in a multispecialty surgical ambulatory clinic practice. We interrogated every aspect of the practice: clinic design, scheduling, physical space, staffing, and clinical and operational workflows. We present here the results of a 3-year process improvement.

Clinical Data Systems to Support Public Health Practice: A National Survey of Software and Storage Systems Among Local Health Departments

CONTEXT

Numerous software and data storage systems are employed by local health departments (LHDs) to manage clinical and nonclinical data needs. Leveraging electronic systems may yield improvements in public health practice. However, information is lacking regarding current usage patterns among LHDs.

OBJECTIVE

To analyze clinical and nonclinical data storage and software types by LHDs.

DESIGN

Data came from the 2015 Informatics Capacity and Needs Assessment Survey, conducted by Georgia Southern University in collaboration with the National Association of County and City Health Officials.

PARTICIPANTS

A total of 324 LHDs from all 50 states completed the survey (response rate: 50%).

MAIN OUTCOME MEASURES

Outcome measures included LHD's primary clinical service data system, nonclinical data system(s) used, and plans to adopt electronic clinical data system (if not already in use). Predictors of interest included jurisdiction size and governance type, and other informatics capacities within the LHD. Bivariate analyses were performed using χ and t tests.

RESULTS

Up to 38.4% of LHDs reported using an electronic health record (EHR). Usage was common especially among LHDs that provide primary care and/or dental services. LHDs serving smaller populations and those with state-level governance were both less likely to use an EHR. Paper records were a common data storage approach for both clinical data (28.9%) and nonclinical data (59.4%). Among LHDs without an EHR, 84.7% reported implementation plans.

CONCLUSIONS

Our findings suggest that LHDs are increasingly using EHRs as a clinical data storage solution and that more LHDs are likely to adopt EHRs in the foreseeable future. Yet use of paper records remains common. Correlates of electronic system usage emerged across a range of factors. Program- or system-specific needs may be barriers or facilitators to EHR adoption. Policy makers can tailor resources to address barriers specific to LHD size, governance, service portfolio, existing informatics capabilities, and other pertinent characteristics.

"Striving for Excellence": Minimum Data Set Coordinators' Perceptions of Their Role in the Nursing Home

The purpose of the current study was to explore how Minimum Data Set (MDS) coordinators perceive their role and the assessment process. Eleven MDS coordinators from 10 geographically dispersed nursing homes (NHs) were interviewed between May and September 2013. Four broad themes emerged from content analysis: (a) information gathering, (b) interdisciplinary coordination, (c) role challenges, and (d) resources. The first two themes referred to key components and competencies in the MDS coordinators' role, the third theme dealt with certain challenges inherent in the role, and the fourth theme highlighted resources that helped address these challenges. The current study provides insight into how MDS coordinators perceive their role, as well as some of the challenges they face to successfully enact that role. The current findings can help inform NH management staff, such as directors of nursing and NH administrators, and policy makers, on how best to support MDS coordinators' work to enable efficient and accurate resident assessment processes.

In emergency departments, radiologists' access to EHRs may influence interpretations and medical management

The adoption of electronic health records (EHRs) that meet federal meaningful-use standards is a major US national policy priority. Policy makers recognize the potential of electronic communication in delivering high-quality health care, particularly in an environment of expanding remote access to medical care and the ever-increasing need to transmit health care records across institutions. To demonstrate this principle, we sought to estimate the significance of EHR access in emergent neuroradiologic interpretations. Three neuroradiologists conducted a prospective expert-rater analysis of 2,000 consecutive head computed tomography (CT) exams ordered by emergency department (ED) physicians. For each head CT exam, the neuroradiologists compared medical information generated by ED physicians to information generated by the interpreting radiologists who had access to additional EHR-derived patient data. In 6.1 percent of the head CT exams, the neuroradiologists reached consensus--meaning two out of three agreed--that the additional clinical data derived from the EHR was "very likely" to influence radiological interpretations and that the lack of that data would have adversely affected medical management in those patients. Health care providers must recognize the value of implementing EHRs and foster their widespread adoption.

Adoption factors associated with electronic health record among long-term care facilities: a systematic review

OBJECTIVES

The Health Information Technology for Economic and Clinical Health (HITECH) Act created incentives for adopting electronic health records (EHRs) for some healthcare organisations, but long-term care (LTC) facilities are excluded from those incentives. There are realisable benefits of EHR adoption in LTC facilities; however, there is limited research about this topic. The purpose of this systematic literature review is to identify EHR adoption factors for LTC facilities that are ineligible for the HITECH Act incentives.

SETTING

We conducted systematic searches of Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete via Ebson B. Stephens Company (EBSCO Host), Google Scholar and the university library search engine to collect data about EHR adoption factors in LTC facilities since 2009.

PARTICIPANTS

Search results were filtered by date range, full text, English language and academic journals (n=22).

INTERVENTIONS

Multiple members of the research team read each article to confirm applicability and study conclusions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Researchers identified common themes across the literature: specifically facilitators and barriers to adoption of the EHR in LTC.

RESULTS

Results identify facilitators and barriers associated with EHR adoption in LTC facilities. The most common facilitators include access to information and error reduction. The most prevalent barriers include initial costs, user perceptions and implementation problems.

CONCLUSIONS

Similarities span the system selection phases and implementation process; of those, cost was the most common mentioned. These commonalities should help leaders in LTC facilities align strategic decisions to EHR adoption. This review may be useful for decision-makers attempting successful EHR adoption, policymakers trying to increase adoption rates without expanding incentives and vendors that produce EHRs.

Meaningful Use Status and Participation in Health Information Exchange Among New York State Hospitals: A Longitudinal Assessment

BACKGROUND

Billions of dollars is being utilized to promote electronic health record (EHR) adoption and electronic health information exchange (HIE). Monitoring trends over time is critical to understanding the success of policies initiatives. New York State is a leader in state-based initiatives promoting health information technology (HIT), and its experiences can provide valuable lessons to inform ongoing state and federal efforts.

METHODS

All hospitals in New York State were previously surveyed in 2009 to determine rates of EHR adoption, preparedness to meet meaningful use criteria, and participation in HIE. A follow-up survey was conducted from November 2012 through February 2013 to evaluate progress over time.

RESULTS

Responses were received from 129 of 210 hospitals (61% response rate). Some 98% of responding hospitals (n = 126) had implemented or begun implementing an EHR-greater than a fourfold increase in three years. Nearly three-quarters had already attested to Stage 1 meaningful use for Medicaid (74.8%, n = 86) and Medicare (70.8%, n = 85), although only 10.7% (n = 13) anticipated it would be easy to achieve Stage 2 meaningful use. Seventy-nine percent of respondents (n = 92) reported exchanging electronic patient-level clinical data with other partners, and 89.9% (n = 116) reported participation in regional arrangements to share data. Lack of architecture and cost remain major barriers to achieving robust HIE.

DISCUSSION

Although much progress has been made since 2009, careful attention must be paid to helping hospitals meet the stricter Stage 2 meaningful use requirements and to supporting robust HIE to help fulfill HIT's promise of achieving higher-quality, lower-cost health care.

Factors associated with adoption of health information technology: a conceptual model based on a systematic review

BACKGROUND

The Health Information Technology for Economic and Clinical Health Act (HITECH) allocated $19.2 billion to incentivize adoption of the electronic health record (EHR). Since 2009, Meaningful Use Criteria have dominated information technology (IT) strategy. Health care organizations have struggled to meet expectations and avoid penalties to reimbursements from the Center for Medicare and Medicaid Services (CMS). Organizational theories attempt to explain factors that influence organizational change, and many theories address changes in organizational strategy. However, due to the complexities of the health care industry, existing organizational theories fall short of demonstrating association with significant health care IT implementations. There is no organizational theory for health care that identifies, groups, and analyzes both internal and external factors of influence for large health care IT implementations like adoption of the EHR.

OBJECTIVE

The purpose of this systematic review is to identify a full-spectrum of both internal organizational and external environmental factors associated with the adoption of health information technology (HIT), specifically the EHR. The result is a conceptual model that is commensurate with the complexity of with the health care sector.

METHODS

We performed a systematic literature search in PubMed (restricted to English), EBSCO Host, and Google Scholar for both empirical studies and theory-based writing from 1993-2013 that demonstrated association between influential factors and three modes of HIT: EHR, electronic medical record (EMR), and computerized provider order entry (CPOE). We also looked at published books on organizational theories. We made notes and noted trends on adoption factors. These factors were grouped as adoption factors associated with various versions of EHR adoption.

RESULTS

The resulting conceptual model summarizes the diversity of independent variables (IVs) and dependent variables (DVs) used in articles, editorials, books, as well as quantitative and qualitative studies (n=83). As of 2009, only 16.30% (815/4999) of nonfederal, acute-care hospitals had adopted a fully interoperable EHR. From the 83 articles reviewed in this study, 16/83 (19%) identified internal organizational factors and 9/83 (11%) identified external environmental factors associated with adoption of the EHR, EMR, or CPOE. The conceptual model for EHR adoption associates each variable with the work that identified it.

CONCLUSIONS

Commonalities exist in the literature for internal organizational and external environmental factors associated with the adoption of the EHR and/or CPOE. The conceptual model for EHR adoption associates internal and external factors, specific to the health care industry, associated with adoption of the EHR. It becomes apparent that these factors have some level of association, but the association is not consistently calculated individually or in combination. To better understand effective adoption strategies, empirical studies should be performed from this conceptual model to quantify the positive or negative effect of each factor.

Measuring agreement between decision support reminders: the cloud vs. the local expert

BACKGROUND

A cloud-based clinical decision support system (CDSS) was implemented to remotely provide evidence-based guideline reminders in support of preventative health. Following implementation, we measured the agreement between preventive care reminders generated by an existing, local CDSS and the new, cloud-based CDSS operating on the same patient visit data.

METHODS

Electronic health record data for the same set of patients seen in primary care were sent to both the cloud-based web service and local CDSS. The clinical reminders returned by both services were captured for analysis. Cohen's Kappa coefficient was calculated to compare the two sets of reminders. Kappa statistics were further adjusted for prevalence and bias due to the potential effects of bias in the CDS logic and prevalence in the relative small sample of patients.

RESULTS

The cloud-based CDSS generated 965 clinical reminders for 405 patient visits over 3 months. The local CDSS returned 889 reminders for the same patient visit data. When adjusted for prevalence and bias, observed agreement varied by reminder from 0.33 (95% CI 0.24 - 0.42) to 0.99 (95% CI 0.97 - 1.00) and demonstrated almost perfect agreement for 7 of the 11 reminders.

CONCLUSIONS

Preventive care reminders delivered by two disparate CDS systems show substantial agreement. Subtle differences in rule logic and terminology mapping appear to account for much of the discordance. Cloud-based CDSS therefore show promise, opening the door for future development and implementation in support of health care providers with limited resources for knowledge management of complex logic and rules.

Rational use of electronic health records for diabetes population management

Population management is increasingly invoked as an approach to improve the quality and value of diabetes care. Recent emphasis is driven by increased focus on both costs and measures of care as the US moves from fee for service to payment models in which providers are responsible for costs incurred, and outcomes achieved, for their entire patient population. The capacity of electronic health records (EHRs) to create patient registries, apply analytic tools, and facilitate provider- and patient-level interventions has allowed rapid evolution in the scope of population management initiatives. However, findings on the efficacy of these efforts for diabetes are mixed, and work remains to achieve the full potential of an-EHR based population approach. Here we seek to clarify definitions and key domains, provide an overview of evidence for EHR-based diabetes population management, and recommend future directions for applying the considerable power of EHRs to diabetes care and prevention.

Health information exchange, system size and information silos

There are many technology platforms that bring benefits only when users share data. In healthcare, this is a key policy issue, because of the potential cost savings and quality improvements from 'big data' in the form of sharing electronic patient data across medical providers. Indeed, one criterion used for federal subsidies for healthcare information technology is whether the software has the capability to share data. We find empirically that larger hospital systems are more likely to exchange electronic patient information internally, but are less likely to exchange patient information externally with other hospitals. This pattern is driven by instances where there may be a commercial cost to sharing data with other hospitals. Our results suggest that the common strategy of using 'marquee' large users to kick-start a platform technology has an important drawback of potentially creating information silos. This suggests that federal subsidies for health data technologies based on 'meaningful use' criteria, that are based simply on the capability to share data rather than actual sharing of data, may be misplaced.

A statewide assessment of electronic health record adoption and health information exchange among nursing homes

OBJECTIVE

To determine rates of electronic health record (EHR) adoption and health information exchange (HIE) among New York State (NYS) nursing homes.

DATA SOURCES/STUDY SETTING

Primary data collected from a novel survey administered between November 2011 and March 2012 to all NYS nursing homes.

STUDY DESIGN

We used a cross-sectional study design to assess level of EHR implementation, automation of key functionalities, participation in HIE, and barriers to adoption.

DATA COLLECTION/EXTRACTION METHODS

We used descriptive statistics to characterize rates of EHR adoption and participation in HIE and logistic regression to identify nursing home characteristics associated with EHR adoption and HIE.

PRINCIPAL FINDINGS

We received responses from 375 of 632 nursing homes (59.3 percent). Of respondents, almost one in five (n=66, 18.0 percent) reported having a fully implemented and operational EHR and a majority (n=192, 54.4 percent) reported electronically exchanging information. Nursing homes with 100-159 beds were significantly less likely than other facilities to have implemented or be in the process of implementing an EHR (p=.011).

CONCLUSIONS

Our findings present an important systematic look at EHR adoption and HIE by NYS nursing homes. Although the nursing home sector has been reported to lag in health information technology adoption, our results are encouraging. However, they suggest much room for growth and highlight the need for targeted initiatives to achieve more widespread adoption in this important health care sector.

Business Benefits or Incentive Maximization? Impacts of the Medicare EHR Incentive Program at Acute Care Hospitals

This study investigates the influence of the Medicare EHR Incentive Program on EHR adoption at acute care hospitals and the impact of EHR adoption on operational and financial efficiency/effectiveness. It finds that even before joining the incentive program, adopter hospitals had more efficient and effective Medicare operations than those of non-adopters. Adopters were also financially more efficient. After joining the program, adopter hospitals treated significantly more Medicare patients by shortening their stay durations, relative to their own non-Medicare patients and also to patients at non-adopter hospitals, even as their overall capacity utilization remained relatively unchanged. The study concludes that many of these hospitals had implemented EHR even before the initiation of the incentive program. It further infers that they joined this program with opportunistic intentions of tapping into incentive payouts which they maximized by taking on more Medicare patients. These findings give credence to critics of the program who have questioned its utility and alleged that it serves only to reward existing users of EHR technologies.

Electronic health records and US public health: current realities and future promise

Electronic health records (EHRs) could contribute to improving population health in the United States. Realizing this potential will require understanding what EHRs can realistically offer to efforts to improve population health, the requirements for obtaining useful information from EHRs, and a plan for addressing these requirements. Potential contributions of EHRs to improving population health include better understanding of the level and distribution of disease, function, and well-being within populations. Requirements are improved population coverage of EHRs, standardized EHR content and reporting methods, and adequate legal authority for using EHRs, particularly for population health. A collaborative national effort to address the most pressing prerequisites for and barriers to the use of EHRs for improving population health is needed to realize the EHR's potential.

Operational health information exchanges show substantial growth, but long-term funding remains a concern

Policy makers are actively promoting the electronic exchange of health information to improve the quality and efficiency of health care. We conducted a national survey of organizations facilitating health information exchange, to assess national progress. We found that 30 percent of hospitals and 10 percent of ambulatory practices now participate in one of the 119 operational health information exchange efforts across the United States, substantial growth from prior surveys. However, we also found that 74 percent of health information exchange efforts report struggling to develop a sustainable business model. Our findings suggest that despite progress, there is a substantial risk that many current efforts to promote health information exchange will fail when public funds supporting these initiatives are depleted.

A pilot study of distributed knowledge management and clinical decision support in the cloud

OBJECTIVE

Implement and perform pilot testing of web-based clinical decision support services using a novel framework for creating and managing clinical knowledge in a distributed fashion using the cloud. The pilot sought to (1) develop and test connectivity to an external clinical decision support (CDS) service, (2) assess the exchange of data to and knowledge from the external CDS service, and (3) capture lessons to guide expansion to more practice sites and users.

MATERIALS AND METHODS

The Clinical Decision Support Consortium created a repository of shared CDS knowledge for managing hypertension, diabetes, and coronary artery disease in a community cloud hosted by Partners HealthCare. A limited data set for primary care patients at a separate health system was securely transmitted to a CDS rules engine hosted in the cloud. Preventive care reminders triggered by the limited data set were returned for display to clinician end users for review and display. During a pilot study, we (1) monitored connectivity and system performance, (2) studied the exchange of data and decision support reminders between the two health systems, and (3) captured lessons.

RESULTS

During the six month pilot study, there were 1339 patient encounters in which information was successfully exchanged. Preventive care reminders were displayed during 57% of patient visits, most often reminding physicians to monitor blood pressure for hypertensive patients (29%) and order eye exams for patients with diabetes (28%). Lessons learned were grouped into five themes: performance, governance, semantic interoperability, ongoing adjustments, and usability.

DISCUSSION

Remote, asynchronous cloud-based decision support performed reasonably well, although issues concerning governance, semantic interoperability, and usability remain key challenges for successful adoption and use of cloud-based CDS that will require collaboration between biomedical informatics and computer science disciplines.

CONCLUSION

Decision support in the cloud is feasible and may be a reasonable path toward achieving better support of clinical decision-making across the widest range of health care providers.

Understanding electronic medical record adoption in the United States: communication and sociocultural perspectives

Background

This paper adopts a communication and sociocultural perspective to analyze the factors behind the lag in electronic medical record (EMR) adoption in the United States. Much of the extant research on this topic has emphasized economic factors, particularly, lack of economic incentives, as the primary cause of the delay in EMR adoption. This prompted the Health Information Technology on Economic and Clinical Health Act that allow financial incentives through the Centers of Medicare and Medicaid Services for many health care organizations planning to adopt EMR. However, financial incentives alone have not solved the problem; many new innovations do not diffuse even when offered for free. Thus, this paper underlines the need to consider communication and sociocultural factors to develop a better understanding of the impediments of EMR adoption.

Objective

The objective of this paper was to develop a holistic understanding of EMR adoption by identifying and analyzing the impact of communication and sociocultural factors that operate at 3 levels: macro (environmental), meso (organizational), and micro (individual).

Methods

We use the systems approach to focus on the 3 levels (macro, meso, and micro) and developed propositions at each level drawing on the communication and sociocultural perspectives.

Results

Our analysis resulted in 10 propositions that connect communication and sociocultural aspects with EMR adoption.

Conclusions

This paper brings perspectives from the social sciences that have largely been missing in the extant literature of health information technology (HIT) adoption. In doing so, it implies how communication and sociocultural factors may complement (and in some instances, reinforce) the impact of economic factors on HIT adoption.

The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology

The environment in which the field of cardiology finds itself has been rapidly changing. This supplement, an expansion of a report created for the Board of Trustees, is intended to provide a timely snapshot of the socio-economic, political, and scientific aspects of this environment as it applies to practice both in the United States and internationally. This publication should assist healthcare professionals looking for the most recent statistics on cardiovascular disease and the risk factors that contribute to it, drug and device trends affecting the industry, and how the practice of cardiology is changing in the United States.

Hospital IT Sophistication Profiles and Patient Safety Outcomes

Information technology (IT) sophistication of acute care hospitals in Texas was measured to explore the relationships between IT infrastructure and patient outcomes using Donabedian’s framework. The sample was acute care hospitals (n=175) with an IT profile using HIMSS, demographic and operations data. Three dimensions of hospital IT sophistication were measured and related to patient care outcomes using the AHRQ Patient Safety Indicators (PSI). Significant relationships (p < 0.05) using linear regression were found between hospital IT sophistication and three PSI measures. A review of similar studies during the same time period in Iowa, Georgia, and Florida compares findings from two instruments used to profile hospital IT infrastructure. This study adds to and confirms findings of positive relationships between IT sophistication of hospitals and patient care outcomes using the AHRQ safety indicators. Discussion of the conceptual model and the IT sophistication construct provides a theoretical framework for this line of research.