Approaches and challenges to optimising primary care teams' electronic health record usage

Application of the Consolidated Framework for Implementation Research Model to Design and Implement an Optimization Methodology within an Ambulatory Setting

BACKGROUND

Following the implementation of a new electronic health record (EHR) system at Columbia University Irving Medical Center (CUIMC), the demands of the novel coronavirus disease 2019 (COVID-19) pandemic forced an abrupt reallocation of resources away from EHR adoption. To assist staff in focusing on techniques for improving EHR utilization, an optimization methodology was designed referencing the Consolidated Framework for Implementation Research (CFIR) approach.

METHODS

The study was performed using a methodology that comprised of two primary components as follows: (1) analysis of qualitative and quantitative data and (2) participation of frontline staff in project work groups. Working groups mapped out the current state of the identified workflows, designed and implemented interventions, monitored the effectiveness of each intervention, and scaled the proposed changes.

RESULTS

As a result of the optimization methodology, clinical and operational workflows improved in the pilot department. Operationally, the pilot department increased enrollment of patients in the virtual patient portal by 20%, increased schedule utilization by 25%, and reduced average check-in time by 19%. Clinically, the pilot department had a statistically significant increase in dictation and NoteWriter tool note composition from their baseline month to their observed month. Compared with the control department, the pilot department had a statistically significant increase in SmartTool and dictation note composition. The control department showed smaller increases, and in some cases a decline in performance, in these areas of operational and clinical workflows.

CONCLUSION

The CFIR framework helped design an optimization methodology by applying a set of constructs to support effective organizational optimization, accounting for inner and outer settings. Through this methodology, the inner setting was supported in leading the identification and execution of interventions targeted to impact the outer setting. The phase-1 data at CUIMC suggest this strategy is effective in identifying opportunities, implementing interventions and creating a scalable process for continued organizational optimization.

"I didn't know you could do that": A Pilot Assessment of EHR Optimization Training

BACKGROUND

Informatics tools within electronic health records (EHRs)-for example, data rosters and clinical reminders-can help disseminate care guidelines into clinical practice. Such tools' adoption varies widely, however, possibly because many primary care providers receive minimal training in even basic EHR functions.

OBJECTIVES

This mixed-methods evaluation of a pilot training program sought to identify factors to consider when providing EHR use optimization training in community health centers (CHCs) as a step toward supporting CHC providers' adoption of EHR tools.

METHODS

In spring 2018, we offered 10 CHCs a 2-day, 16-hour training in EHR use optimization, provided by clinician trainers, and customized to each CHC's needs. We surveyed trainees pre- and immediately post-training and again 3 months later. We conducted post-training interviews with selected clinic staff, and conducted a focus group with the trainers, to assess satisfaction with the training, and perceptions of how it impacted subsequent EHR use.

RESULTS

Six CHCs accepted and received the training; 122 clinic staff members registered to attend, and most who completed the post-training survey reported high satisfaction. Three months post-training, 80% of survey respondents said the training had changed their daily EHR use somewhat or significantly.

CONCLUSION

Factors to consider when planning EHR use optimization training in CHCs include: CHCs may face barriers to taking part in such training; it may be necessary to customize training to a given clinic's needs and to different trainees' clinic roles; identifying trainees' skill level a priori would help but is challenging; in-person training may be preferable; and inclusion of a practice coach may be helpful. Additional research is needed to identify how to provide such training most effectively.

Multidisciplinary Sprint Program Achieved Specialty-Specific EHR Optimization in 20 Clinics

OBJECTIVE

The objective of the study was to highlight and analyze the outcomes of software configuration requests received from Sprint, a comprehensive, clinic-centered electronic health record (EHR) optimization program.

METHODS

A retrospective review of 1,254 Sprint workbook requests identified (1) the responsible EHR team, (2) the clinical efficiency gained from the request, and (3) the EHR intervention conducted.

RESULTS

Requests were received from 407 clinicians and 538 staff over 31 weeks of Sprint. Sixty-nine percent of the requests were completed during the Sprint. Of all requests, 25% required net new build, 73% required technical investigation and/or solutions, and 2% of the requests were escalated to the vendor. The clinical specialty groups requested a higher percentage of items that earned them clinical review (16 vs. 10%) and documentation (29 vs. 23%) efficiencies compared with their primary care colleagues who requested slightly more order modifications (22 vs. 20%). Clinical efficiencies most commonly associated with workbook requests included documentation (28%), ordering (20%), in basket (17%), and clinical review (15%). Sprint user requests evaluated by ambulatory, hardware, security, and training teams comprised 80% of reported items.

DISCUSSION

Sprint requests were categorized as clean-up, break-fix, workflow investigation, or new build. On-site collaboration with clinical care teams permitted consensus-building, drove vetting, and iteration of EHR build, and led to goal-driven, usable workflows and EHR products.

CONCLUSION

This program evaluation demonstrates the process by which optimization can occur and the products that result when we adhere to optimization principles in health care organizations.

Optimizing the electronic health record: An inpatient sprint addresses provider burnout and improves electronic health record satisfaction

OBJECTIVE

We sought reduce electronic health record (EHR) burden on inpatient clinicians with a 2-week EHR optimization sprint.

MATERIALS AND METHODS

A team led by physician informaticists worked with 19 advanced practice providers (APPs) in 1 specialty unit. Over 2 weeks, the team delivered 21 EHR changes, and provided 39 one-on-one training sessions to APPs, with an average of 2.8 hours per provider. We measured Net Promoter Score, thriving metrics, and time spent in the EHR based on user log data.

RESULTS

Of the 19 APPs, 18 completed 2 or more sessions. The EHR Net Promoter Score increased from 6 to 60 postsprint (1.0; 95% confidence interval, 0.3-1.8; P = .01). The NPS for the Sprint itself was 93, a very high rating. The 3-axis emotional thriving, emotional recovery, and emotional exhaustion metrics did not show a significant change. By user log data, time spent in the EHR did not show a significant decrease; however, 40% of the APPs responded that they spent less time in the EHR.

CONCLUSIONS

This inpatient sprint improved satisfaction with the EHR.

Pharmacists' Perspectives on the Use of My Health Record

(1) Background: My Health Record (MHR) is a relatively new nationwide Australian digital health record system accessible by patients and a range of healthcare professionals. Pharmacists will be key contributors and users of the MHR system, yet little is known about the perceived barriers and benefits of use. (2) Objective: To explore pharmacists' perspectives related to potential benefits and barriers associated with use of MHR. (3) Methods: An online survey was developed and face-validated. The survey was advertised to Australian pharmacists on pharmacy professional bodies' websites. This was a cross-sectional study using an anonymous questionnaire. Descriptive statistics were used to describe the distribution of the data. Chi-square, Kendall's tau coefficient (tau-c) and Kruskal-Wallis tests were used to examine the relationships where appropriate. (4) Results: A total of 63 pharmacists completed the survey. The majority of respondents worked in a metropolitan area (74%), and the most common workplace setting was community pharmacy (65%). Perceived benefits identified by responders include that the use of MHR would help with continuity of care (90%), and that it would improve the safety (71%) and quality (75%) of care they provided. Importantly, more than half of pharmacists surveyed agreed that MHR could reduce medication errors during dispensing (57%) and could improve professional relationships with patients (57%) and general practitioners (59%). Potential barriers identified by pharmacists included patients' concerns about privacy (81%), pharmacists' own concern about privacy (46%), lack of training, access to and confidence in using the system. Sixty six percent of respondents had concerns about the accuracy of information contained within MHR, particularly among hospital and general practice pharmacists (p = 0.016) and almost half (44%) had concerns about the security of information in the system, mainly pharmacists working at general practice and providing medication review services (p = 0.007). Overall satisfaction with MHR varied, with 48% satisfied, 33% neither satisfied nor dissatisfied, and 19% dissatisfied, with a higher satisfaction rate among younger pharmacists (p = 0.032). (5) Conclusions: Pharmacists considered that the MHR offered key potential benefits, notably improving the safety and quality of care provided. To optimize the use of MHR, there is a need to improve privacy and data security measures, and to ensure adequate provision of user support and education surrounding the ability to integrate use of MHR with existing workflows and software.

Performance payment challenges for family physician program

CONTEXT

Payment mechanisms are one of the effective tools for achieving optimal results in health system. Pay for performance (P4P) is one of the best programs to enhance the quality of health services through financial incentives. Considering of implementing family physician program in Iran and the P4P system, it is essential to address the challenges of implementing P4P system in the family physician program.

AIMS

This study aimed to investigate the challenges of implementation of P4P system in family physician program.

SETTINGS AND DESIGN

The qualitative study was carried out at areas covered by Iran University of Medical Sciences in Tehran, Iran.

MATERIALS AND METHODS

The semi-structured interview was conducted on 32 key informants in 2019. The sampling method was determined based on purposeful sampling. The topic guide of interviews was experiences in implementing of family physician program and challenges of implementing P4P system. Participants had least 5-year experience in the family physician program.

STATISTICAL ANALYSIS USED

A framework analysis was used to analyze the data using the software MAXQDA 10.

RESULTS

The current study identified 7 themes, 14 subthemes, and 46 items related to the challenges to successful implementation of P4P systems in the family physician program including family physicians' workload, family physician training, promoting family physician program, paying to the family physician team, assessment and monitoring systems, information management, and the level of authority of family physicians.

CONCLUSION

The study results demonstrated notable challenges for successful implementation of P4P system which can helpful to managers and policymakers.

Impact of health information technology optimization on clinical quality performance in health centers: A national cross-sectional study

Background

Delivery of preventive care and chronic disease management are key components of a high functioning primary care practice. Health Centers (HCs) funded by the Health Resources and Services Administration (HRSA) have been delivering affordable and accessible primary health care to patients in underserved communities for over fifty years. This study examines the association between health center organization’s health information technology (IT) optimization and clinical quality performance.

Methods and findings

Using 2016 Uniform Data System (UDS) data, we performed bivariate and multivariate analyses to study the association of Meaningful Use (MU) attestation as a proxy for health IT optimization, patient centered medical home (PCMH) recognition status, and practice size on performance of twelve electronically specified clinical quality measures (eCQMs). Bivariate analysis demonstrated performance of eleven out of the twelve preventive and chronic care eCQMs was higher among HCs attesting to MU Stage 2 or above. Multivariate analysis demonstrated that Stage 2 MU or above, PCMH status, and larger practice size were positively associated with performance on cancer screening, smoking cessation counseling and pediatric weight assessment and counseling eCQMs.

Conclusions

Organizational advancement in MU stages has led to improved quality of care that augments HCs patient care capacity for disease prevention, health promotion, and chronic care management. However, rapid technological advancement in health care acts as a potential source of disparity, as considerable resources needed to optimize the electronic health record (EHR) and to undertake PCMH transformation are found more commonly among larger HCs practices. Smaller practices may lack the financial, human and educational assets to implement and to maintain EHR technology. Accordingly, targeted approaches to support small HCs practices in leveraging economies of scale for health IT optimization, clinical decision support, and clinical workflow enhancements are critical for practices to thrive in the dynamic value-based payment environment.

Physician champions' perspectives and practices on electronic health records implementation: challenges and strategies

Objective

Physician champions are “boots on the ground” physician leaders who facilitate the implementation of, and transition to, new health information technology (HIT) systems within an organization. They are commonly cited as key personnel in HIT implementations, yet little research has focused on their practices and perspectives.

Materials and Methods

We addressed this research gap through a qualitative study of physician champions that aimed to capture their challenges and strategies during a large-scale HIT implementation. Email interviews were conducted with 45 physician champions from diverse clinical areas 5 months after a new electronic health record (EHR) system went live in a large academic medical center. We adopted a grounded theory approach to analyze the data.

Results

Our physician champion participants reported multiple challenges, including insufficient training, limited at-the-elbow support, unreliable communication with leadership and the EHR vendor, as well as flawed system design. To overcome these challenges, physician champions developed their own personalized training programs in a simulated context or in the live environment, sought and obtained more at-the-elbow support both internally and externally, and adapted their departmental sociotechnical context to make the system work better.

Discussion and Conclusions

This study identified the challenges physician champions faced and the strategies they developed to overcome these challenges. Our findings suggest factors that are crucial to the successful involvement of physician champions in HIT implementations, including the availability of instrumental (eg, reward for efforts), emotional (eg, mechanisms for expressing frustrations), and peer support; ongoing engagement with the champions; and appropriate training and customization planning.

Narrative Review for Exploring Barriers to Readiness of Electronic Health Record Implementation in Primary Health Care

Objectives

The aim of this study is to explore the enabling factors associated with readiness in Electronic Health Record (EHR) implementation and to identify the barriers related to readiness regarding the situation of primary health cares in developed and developing countries.

Methods

A narrative review of open-source literature was conducted using the ProQuest, ScienceDirect, MEDLINE, and PMC databases to identify the enabling factors and barriers to EHR readiness. The keywords applied were 'electronic health record', 'readiness', 'primary health care', and 'primary care'.

Results

Some barriers were found that may affect readiness, specifically individual barriers and organizational barriers. In developing countries, organizational barriers such as a lack of skilled manpower, insufficient senior management, and a lack of interaction among team members were the common barriers, while in developed countries individual barriers such as unfamiliarity with new systems and a lack of time to use computers were frequently found as barriers to readiness.

Conclusions

This study summarized the enabling factors and barriers with regard to EHR readiness in developed and developing countries.

Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach

Background

Health systems in the United States are increasingly required to become leaders in quality to compete successfully in a value-conscious purchasing market. Doing so involves developing effective clinical teams using approaches like the clinical microsystems framework. However, there has been limited assessment of this approach within United States primary care settings.

Methods

This paper describes the implementation, mixed-methods evaluation results, and lessons learned from instituting a Microsystems approach across 6 years with 58 primary care teams at a large Midwestern academic health care system. The evaluation consisted of a longitudinal survey augmented by interviews and focus groups. Structured facilitated longitudinal discussions with leadership captured ongoing lessons learned. Quantitative analysis employed ordinal logistic regression and compared aggregate responses at 6-months and 12-months to those at the baseline period. Qualitative analysis used an immersion/crystallization approach.

Results

Survey results (N = 204) indicated improved perceptions of: organizational support, team effectiveness and cohesion, meeting and quality improvement skills, and team communication. Thematic challenges from the qualitative data included: lack of time and coverage for participation, need for technical/technology support, perceived devaluation of improvement work, difficulty aggregating or spreading learnings, tensions between team and clinic level change, a part-time workforce, team instability and difficulties incorporating a data driven improvement approach.

Conclusions

These findings suggest that a microsystems approach is valuable for building team relationships and quality improvement skills but is challenged in a large, diverse academic primary care context. They additionally suggest that primary care transformation will require purposeful changes implemented across the micro to macro-level including but not only focused on quality improvement training for microsystem teams.

Understanding optimisation processes of electronic health records (EHRs) in select leading hospitals: a qualitative study

Background

Little is known about optimisation of electronic health records (EHRs) systems in the hospital setting while adoption of EHR systems continues in the United States.

Objective

To understand optimisation processes of EHR systems undertaken in leading healthcare organisations in the United States.

Methods

Informed by a grounded theory approach, a qualitative study was undertaken that involved 11 in-depth interviews and a focus group with the EHR experts from the high performing healthcare organisations across the United States.

Results

The study describes EHR optimisation processes characterised by prioritising exponentially increasing requests with predominant focus on improving efficiency of EHR, building optimisation teams or advisory groups and standardisation. The study discusses 16 types of optimisation that interdependently produced 16 results along with identifying 11 barriers and 20 facilitators to optimisation.

Conclusions

The study describes overall experiences of optimising EHRs in select high performing healthcare organisations in the US. The findings highlight the importance of optimising the EHR after, and even before, go-live and dedicating resources exclusively for optimisation.

Building the learning health system: Describing an organizational infrastructure to support continuous learning

INTRODUCTION

Academic health centers are reorganizing in response to dramatic changes in the health-care environment. To improve value, they and other health systems must become a learning health system, specifically one that has the capacity to understand performance across the continuum of care and use that information to achieve continuous improvements in efficiency and effectiveness. While learning health system concepts have been well described, the practical steps to create such a system are not well defined. Establishing the necessary infrastructure is particularly challenging at academic health centers due to their tripartite missions and complex organizational structures.

METHODS

Using an evidence-based framework, this article describes a series of organizational-level interventions implemented at an academic health center to create the structures and processes to support the functions of a learning health system.

RESULTS

Following implementation of changes from 2008 to 2013, system-level performance improved in multiple domains: patient satisfaction, population health screenings, improvement education, and patient engagement.

CONCLUSIONS

This experience can be applied to health systems that wrestle with making system-level change when existing cultures, structures, and processes vary. Using an evidence -based framework is useful when developing the structures and processes that support the functions of a learning health system.

Building the learning health system: Describing an organizational infrastructure to support continuous learning

INTRODUCTION

Academic health centers are reorganizing in response to dramatic changes in the health-care environment. To improve value, they and other health systems must become a learning health system, specifically one that has the capacity to understand performance across the continuum of care and use that information to achieve continuous improvements in efficiency and effectiveness. While learning health system concepts have been well described, the practical steps to create such a system are not well defined. Establishing the necessary infrastructure is particularly challenging at academic health centers due to their tripartite missions and complex organizational structures.

METHODS

Using an evidence-based framework, this article describes a series of organizational-level interventions implemented at an academic health center to create the structures and processes to support the functions of a learning health system.

RESULTS

Following implementation of changes from 2008 to 2013, system-level performance improved in multiple domains: patient satisfaction, population health screenings, improvement education, and patient engagement.

CONCLUSIONS

This experience can be applied to health systems that wrestle with making system-level change when existing cultures, structures, and processes vary. Using an evidence -based framework is useful when developing the structures and processes that support the functions of a learning health system.

Stepping Up to the Plate: An Agenda for Research and Policy Action on Electronic Medical Records in Canadian Primary Healthcare

Building on a previous study, which identified gaps in primary healthcare electronic medical record (emr) research and knowledge, a one-day conference was held to facilitate a strategic discussion of these issues. This paper offers a multi-faceted research agenda and suggestions for policy actions as a way forward in bridging the gaps. one facet focuses on the need for research. The second facet focuses on harnessing the knowledge of primary healthcare emr stakeholders. finally, the third facet focuses on policy actions. this paper offers consensus-based suggestions with a view to improving the overall primary healthcare emr landscape in canada.