Health Information Technology
Call for Papers
Barriers & Facilitators to Health Information
Adoption & Use
Chair: Robert Miller, University of California, San Francisco
Sunday, June 26 • 8:30 am – 10:00 am
●Managed Care and Physician Use of Information
Technology for Patient Care
Michael Furukawa, Ph.D., Jonathan Ketcham, Ph.D.
Presented By: Michael Furukawa, Ph.D., Assistant Professor,
School of Health Management and Policy, Arizona State
University, P.O. Box 874506, Tempe, AZ 85287-4506; Tel:
(480) 965-2363; Fax: (480) 965-6654; Email:
Michael.Furukawa@asu.edu
Research Objective: This study examines the impact of
managed care, practice organization and physician
demographics on physician use of information technology (IT)
for patient care in the U.S.
Study Design: We use data from the Community Tracking
Study Physician Survey, 2000-2001. The survey includes
information about managed care (capitation revenue,
competitive situation); practice organization (practice type,
size, ownership); physician demographics (age, gender,
specialty); and use of IT for patient care (guidelines,
formularies, reminders, patient notes, prescriptions, clinical
data exchange, patient e-mail). We estimate survey logistic
regressions of the likelihood of using each IT application and
survey negative binomial regressions of the count of IT
applications. Separate specifications are estimated for the full
population and limiting the sample to physician-owned
practices. Effects are tested both across markets using
controls for market size and Census region and within
markets using site fixed effects.
Population Studied: Nationally-representative sample of
12,604 physicians in the contiguous U.S. providing direct
patient care for at least 20 hours per week.
Principal Findings: We find wide variation in physician use of
IT for various patient care applications and the level of
computerization. Use of IT is highest for treatment guidelines
and exchange of clinical data with other physicians and lowest
for writing prescriptions and e-mail communication with
patients. On average, physicians use only 2 of the 7 IT
applications. Managed care, practice organization, and
physician demographics are all significant predictors of
physician use of IT. Greater capitation revenue and a more
competitive situation are strongly associated with greater use
of IT. These effects remain highly significant in specifications
testing across and within markets. Physicians in HMO and
Medical School practices are more likely to use IT than solo
physicians and partnerships. Physicians in larger and multispecialty practices are more likely to use IT. Ownership in the
practice and any hospital ownership interest are associated
with greater physician use of IT. Older and female physicians
are less likely to use IT. Physicians with Medical and Surgical
Specialties are more likely to use IT than Family Practice
physicians.
Conclusions: Physician use of IT varies widely by type of
practice and geographic area. Managed care, practice
organization and physician demographics explain some of this
variation. The effects of capitation and competition imply that
managed care and financial incentives play an important role
in IT diffusion. The effects of larger size and multi-specialty
practice suggest that economies of scale and scope are
important determinants of IT adoption. The effect of hospital
ownership interest implies that physician-hospital integration
may be an important IT diffusion network.
Implications for Policy, Delivery, or Practice: An important
policy question is whether financial incentives are an effective
catalyst for the diffusion of IT among physicians. Proponents
of pay-for-performance initiatives argue that tying IT to
reimbursement can spur IT adoption. This study’s finding of a
significant association between capitation and physician use
of IT offers some evidence supporting these contentions.
Primary Funding Source: No Funding
●Managing the Implementation of Health Information
Technology: Implications for Practice from Qualitative
Research
Michael Harrison, Ph.D., Carol Cain, Ph.D., Shilry Bar Lev,
MA, Nira Shalom, Ph.D.
Presented By: Michael Harrison, Ph.D., Senior Research
Scientist, Agency for Healthcare Research and Quality, 540
Gaither Road, Rockville, MD 20850; Tel: (301)427 1434; Fax:
(301) 427 1430; Email: mharriso@ahrq.gov
Research Objective: Synthesize results of qualitative research
on the implementation of electronic medical records (EMR)
and computerized physician order entry (CPOE) in hospitals.
Highlight common, yet often unanticipated, consequences of
interactions between health information technology (IT) and
socio-technical systems. Abstract lessons from these studies
that may contribute to better management of health IT
implementation.
Study Design: Present findings common to four
contemporary, independent, qualitative studies in hospitals at
different organizational levels. The studies, some of which are
unpublished, were conducted between 2002-2004. They
include an observational study of CPOE in an ICU in the
United States, a multi-method case study of EMR
implementation in an Israeli academic hospital; semistructured interviews focusing on major changes, including
health IT implementation, in two other Israeli hospitals; and
in-depth interviews on EMR use with staff in one of these
hospitals.
Population Studied: Between 26 and 150 individuals at each
site in all roles of the clinical organization, including
physicians, nurses, clinicians, managers, and computer
specialists.
Principal Findings: Occupational and organizational
differences among staff lead to divergence in attitudes toward
IT and variations in IT use. IT leads to unanticipated and
sometimes undesirable shifts in clinical work processes and
staff relations. Relatively minor variations in technology can
trigger large changes in work processes and staff
communication. Clinicians alter IT functions and processes
as they adapt technologies to their work routines and clinical
orientations. Adaptations occur for many reasons, including
convenience, clinical necessity, and the need to preserve
patient safety. These adaptations, along with the distinctive
background and local culture of adopting units, produce local
variations in health IT use, with ill-studied consequences.
Conclusions: In addition to traditional outcomes studies,
health IT research needs granular studies during and after
implementation. These highlight the two-way influences
between health IT and the hospitals’ socio-technical systems:
Practitioners adapt health IT to local conditions. Health IT, in
turn affects hospital operations, including workflow, power
dynamics, and workplace culture.
Implications for Policy, Delivery, or Practice: Periodic
assessments of HIT implementation and feedback from
hospital staff can help managers and policy makers more
effectively direct health IT dissemination. A mix of incentives
for adoption is needed to appeal to a broad range of staff
members. Adaptation (localization) of health IT is to be
expected. Recognizing the importance of localization can lead
to allowing some unit autonomy during implementation and
accepting local variations in usage. Awareness that health IT
can reshape staff relations may lead managers to track
emerging relations and adjust the technology to reduce
undesirable impacts. Health IT implementation should be
thought of as continuing, rather than as a discrete activity,
with ongoing assessment of how the technology is actually
used and the functions it serves.
Primary Funding Source: Harrison, Shalom and colleagues:
Israel National Institute for Health Policy and Health Services
Research and Mifal Hapayis; Bar-Lev: Bar Ilan University
Doctoral Fellowship; Cain: James Clark Stanford Graduate
Fellowship and National Library of Medicine (US). The views
expressed here are those of the authors and not the funding
agencies or the institutions with which they are or have been
affiliated.
●Computerized Prescription Systems in Public Mental
Health Agencies: Costs and Implementation Issues
Eri Kuno, Aileen Rothbard, Sc.D., Trevor Hadley, Ph.D.,
Cordula Holzer, M.D.
Presented By: Eri Kuno, 3535 Market Street, Room 3008,
Philadelphia, PA 19104; Tel: (215) 349-8709; Email:
kuno@mail.med.upenn.edu
Research Objective: Computerized prescription systems are
a promising technology that can reduce medication errors,
and improve efficiency and quality of prescribing. However,
few provider agencies utilize the benefits of information
technology to manage clinical care for patients with serious
mental illness in the community. The objective of this case
study is to inform decision makers about costs and
implementation issues associated with adding a computerized
prescription component to their existing information system.
Study Design: A computerized prescription system was
implemented in four community mental health agencies with
different information infrastructure as part of a larger study
looking at reducing racial disparities. The cost associated with
the system implementation was covered by the research grant.
Data necessary to estimate costs of technology and human
resources were gathered from the project financial report,
activity logs and training schedule. The costs of human
resources were estimated based on the metropolitan area
occupational wage estimates. In addition, the prescription
system utilization data was analyzed to describe the
implementation process.
Population Studied: Four not-for-profit specialty mental
health agencies, with 5 to 10 FTE psychiatrists, in an urban
setting comprised the study population.
Principal Findings: The prescribing system employed in the
project was a web-based system that charged monthly fees per
prescribing and non-prescribing user. The costs of upgrading
the computer system varied from $1,460 to $6,900,
depending on the size of the agency and the state of their
information infrastructure. The information system staff spent
for 116 hours ($3,248) for technical issues in implementation.
The training costs were about $4,500 per agency. The fees for
training and system activation support to the vendor were
divided by 4 agencies, costing $9,000 each. In addition, we
estimated that the costs of human resources devoted for the
pre-implementation decision-making process ranged from
$2,600 to $3,600. The actual utilization of the system was a
gradual process. Full implementation was accomplished in 6
to 9 months following the initial training. One year since the
initial training, the third agency reached 50% implementation,
and the last one just started to use the system because of the
holdup in upgrading its information system. The delay in
implementation was due to insufficient clinician buy-in and
inadequate pre-implementation workflow assessment.
Conclusions: The total initial costs ranged from $20,572 to
$27,549 per agency. Annual ongoing costs were expected to
range from $9,877 (5 FTE agency) to $14,677 (10 FTE agency).
To compensate psychiatrists’ time was one of major
incentives for the agencies to implement the computerized
prescription system.
Implications for Policy, Delivery, or Practice: The cost of
technology itself is not prohibiting for the initial
implementation as well as the ongoing support. Once the
computerized prescription writing becomes routine practice,
the system can be expanded to include other clinical
information. To provide an initial financial support to
implement a well-designed computerized prescription system
will be a valuable policy option, along with providing technical
assistance in implementation, considering long-range benefits
of the technology for monitoring and improving quality of care
for public sector clients.
Primary Funding Source: Pennsylvania Department of
Health
●Facilitating Physician Use of Information Technologies in
Clinical Practice
Ann Scheck McAlearney, Sc.D., MS, Deena Chisolm, Ph.D.
Presented By: Ann Scheck McAlearney, Sc.D., MS, Assistant
Professor, Health Services Management and Policy, The Ohio
State University, 1583 Perry Street, Atwell 246, Columbus, OH
43210; Tel: (614)292-0662; Fax: (614)438-6859; Email:
mcalearney.1@osu.edu
Research Objective: To better understand use and to identify
approaches to overcoming barriers to use of three information
technologies (IT) utilized in clinical practice: handheld
computers; computerized physician order entry (CPOE)
systems; and order sets within CPOE.
Study Design: A multidisciplinary team of investigators used
focus groups with physicians and interviews with clinical,
administrative, and information technology staff to gather
data at seven sites. Transcripts were coded using a
combination of deductive and inductive approaches to both
answer research questions and identify patterns and themes
that emerged in the data. Conceptual frameworks guiding our
research included theory in the areas of diffusion of
innovation, organizational change, and the social and
technical factors involved in acceptance of technology (models
of IT utilization).
Population Studied: Case study organizations included
academic medical centers, community hospital systems,
children’s hospitals, and independent practice associations.
Key informant interviews were held with 70 organizational
representatives and physicians. Focus groups included 71
physicians, and represented both users and non-users of the
various information technologies, across diverse clinical
specialties and practice settings.
Principal Findings: Three high-level themes emerged around
how to best facilitate physician adoption and use of these
three information technologies: usability and usefulness;
promotion; and training and support. Opportunities to
improve and extend physician use of these technologies
included providing retraining, offering one-on-one support on
a 24-hour basis, and providing forums for physicians to learn
from each other and other clinical change agents. Across
technologies, three major themes emerged related to
physicians’ concerns about their use: 1) reliability of the
technologies; 2) issues related to shifting workload from
others (e.g., unit clerks, nurses) to physicians themselves; and
3) dependency on information technologies to guide clinical
thinking. Several themes also emerged related to
organizations’ concerns about physicians’ IT use including: 1)
security concerns; 2) economic concerns; 3) technical
concerns, and 4) strategic concerns. Diffusion of innovation
theory was highly appropriate to evaluate factors related to the
voluntary use of handheld computers and order sets within
CPOE systems, especially with respect to the relative
advantage, compatibility, and perceived ease of use of the
technologies. In contrast, models of IT acceptance and
utilization were more useful to understand mandatory CPOE
system use. Using these models, technology complexity, job
fit, social factors, and facilitating conditions were reportedly all
important in improving users’ affect toward the systems, and
perspectives about long-term consequences of IT in clinical
practice.
Conclusions: An organizational approach to IT support that
involves individualized attention to physician users, rather
than one-size-fits-all institution-wide implementation efforts
was an important facilitator promoting physician use of these
information technologies. Health care organizations
attempting to promote and support physician use of
information technologies must consider issues related to
security, economics, and information technology strategies
that may not be important concerns for physician users.
Implications for Policy, Delivery, or Practice: For
organizations interested in promoting clinical information
technology solutions, understanding physicians’ perspectives
about these barriers and opportunities to improve IT support
can be immediately applied.
Primary Funding Source: Center for Health Management
Research
●Keeping Pace with Technology: Information Technology
Use in Public Hospitals and Health Systems
Christina Moylan, MHS, Donna Sickler, MPH; Betsy Carrier,
MBA; Jennifer Cromwell
Presented By: Donna Sickler, MPH, Research Analyst,
National Association of Public Hospitals and Health Systems,
1301 Pennsylvania Avenue, NW, Suite 950, Washington, DC
20004, Tel: (202) 585-0100, Fax: (202) 585-0101, E-mail:
dsickler@naph.org
Research Objective: Public hospitals and health systems
provide an enormous volume of care to vulnerable, uninsured,
and diverse patient populations. Too often, these
organizations have few resources to invest in capital
improvements, including health information technology (HIT).
The primary objective of this research was to collect baseline
information on the use of electronic medical records (EMRs)
and related clinical applications in public hospitals and health
systems.
Study Design: Members of the National Association of Public
Hospitals and Health Systems (NAPH) were surveyed by
telephone and through the Internet. A 383-question survey
tool was used to collect information on the use of EMRs,
clinical data repositories (CDR), picture archival and
communication systems (PACS), radiology information
systems, laboratory management information systems,
inpatient and outpatient pharmacy management, digital
dictation and transcription, and clinical and patient access
systems in these facilities. Key informant interviews with
several NAPH members about the challenges and successes
in automating their hospitals were also conducted.
Population Studied: Over 100 NAPH members received the
survey. The response rate was 58 percent. These hospitals
represent a substantial percentage of the nations’ teaching
hospitals and care for a disproportionate share of uninsured
and chronically ill patients.
Principal Findings: Public hospitals consider HIT an area of
vital importance and many have made substantial progress in
automating their facilities. There is variation, however, with
regard to installation of the various HIT systems. They have
made significant progress in installing many of the
department-based clinical applications, such as in radiology or
laboratory departments. They appear to be lagging in
adopting more expensive technologies such as EMRs, CDRs,
and PACS compared with other facilities of similar size and
volume. We also found a low installation rate for technologies
that allow patients to access health information or e-mail their
physicians, similar to findings from other research on this
issue.
Conclusions: The public hospitals began HIT acquisition in
high use departmental areas, such as radiology or laboratory,
where vendor products were more established, required
capital investment was lower, and return on investment was
more immediate. The payer mix of these facilities – the high
volume of Medicaid and uninsured patients and few
commercial patients – is limiting the amount of operating
capital they have to invest in the needed but costlier systems,
such as EMRs.
Implications for Policy, Delivery or Practice: Although
public hospitals are making significant progress in automating
their facilities, capital investments are difficult given the
financial constraints that result from providing
uncompensated care to millions of uninsured and
underinsured patients. This situation warrants further
attention from policy makers given the goal to implement
EMRs nationwide within ten years. Public hospitals will
require special considerations and targeted funding to help
them keep pace with HIT investments being made in the rest
of the hospital industry. Considering the millions of patients
public hospitals treat every year, such targeted investment is
likely to yield valuable efficiencies and improvements in the
quality of care provided to our nation’s most vulnerable and
underserved citizens.
Primary Funding Source: National Association of Public
Hospitals and Health Systems
Call for Papers
Effects of HIT on Financial & Quality Performance
Chair: John Hsu, Kaiser Permanente
Monday, June 27 • 11:00 am – 12:30 pm
●Effects of Telehealth on the Self Management of Heart
Failure
Brendon Colaco, MBBS, MHA Kathryn Dansky, Ph.D., RN,
Kathryn Bowles, Ph.D., RN
Presented By: Brendon Colaco, MBBS, MHA, MS degree
student/Graduate Research Assistant, Health Policy and
Administration, Pennsylvania State University, S-254
Henderson, University Park, State College, PA 16801; Tel:
(814)863-9756; Fax: (814)863-0846; Email: bmc232@psu.edu
Research Objective: This study investigates the effects of
home care provided with telehealth on the self-management
of heart failure compared to traditional home care. This paper
presents preliminary findings on the relationship between the
use of a telehealth system and self management, including
patients’ (1) knowledge of heart failure, (2) behaviors
regarding symptom management, diet, medications, and
exercise, and (3) confidence to manage heart failure effectively.
Study Design: The design is a randomized, controlled field
study comparing the use of a home-based telehealth system
to traditional skilled home care in 10 Medicare-certified home
care agencies. Patients in both groups receive a 60 day
episode of home health services, as prescribed by their
personal physicians. Those assigned to the experimental
group receive skilled nurse home visits and use telehealth
technology to self monitor their blood pressure, pulse, blood
sugar, weight, and oxygen saturation. Patients in the control
group receive routine home care services only. Telephone
interviews to measure study outcomes are conducted by a
research assistant blinded to the study group with all patients
at baseline (admission), and 2 and 4 months later. Sections of
the Problem Rating Scale for Outcomes (PRSO) are used to
measure knowledge and behavior related to diet, medication
and symptom management, and activity. Patients’ confidence
levels regarding symptom management are measured with
the Self Care of Heart Failure Index (SCHF). Analyses include
descriptive statistics and repeated measures analyses of
variance.
Population Studied: Potential subjects are patients 55 and
older with congestive heart failure (CHF) as a primary or
secondary diagnosis admitted to 1 of 10 home health agencies
across the Commonwealth of Pennsylvania. Patients must be
able to speak conversational English, be cognitively intact and
have access to a telephone line in the home.
Principal Findings: This study is in progress with 230
patients currently enrolled. From the data currently available,
we found the following preliminary findings. The mean age of
the patients is 76 years; 59 % are female and 41% are male.
The percentage of patients in the telehealth and control group
is 47 and 52 respectively. Preliminary analysis shows a
difference between the self-management behaviors of the
control versus the telehealth group, indicating that telehealth
does improve behavior over time. This improvement is most
significant after 2 months. Patients in the telehealth group are
also more likely to attempt self-management initiatives, but
this effect is not sustained over time.
Conclusions: Our preliminary findings suggest that telehealth
improves behaviors regarding symptom management, diet,
medications, exercise and confidence to identify and address
heart failure symptoms.
Implications for Policy, Delivery, or Practice: The results of
the study will be useful in documenting the positive effects of
technology in home health settings. Further, it will develop
theoretical linkages between patient empowerment and
clinical outcomes through the use of technology. Results will
inform policy and aid development of disease management
models.
Primary Funding Source: RWJF
●Effect of Hospital IT Capabilities on Financial
Performance
Nir Menachemi, Ph.D., MPH, Jeffrey H. Burkhardt, Ph.D.,
FHFMA, Richard M. Shewchuk, Ph.D., Darrell E. Burke, Ph.D.,
Robert G. Brooks, M.D.
Presented By: Nir Menachemi, Ph.D., MPH, Assistant
Professor, Division of Health Affairs, FSU College of Medicine,
1115 West Call Street, Tallahassee, FL 32306; Tel: (850)6442362; Email: nir.menachemi@med.fsu.edu
Research Objective: Health IT has been linked to numerous
organizational and clinical benefits, but a true return on
investment (ROI) has been elusive. By taking a macro level
approach similar to researchers outside of healthcare, we
examined the relationship between overall IT utilization and
financial performance in hospitals.
Study Design: This unique project combined both primary
and secondary data. The two main sources of the data
include: (1) A hospital IT survey conducted in Florida between
May and October 2003; and (2) Florida hospital financial
statements and a case-mix index obtained from the Florida
Agency for Health Care Administration (AHCA) for the year
2003. Using the IT data collected, and previously devised
methods, we operationalized IT capabilities in three main
hospital functional areas; administrative, clinical, and
strategic. Regression analyses and differences in means tests
were then used to examine the relationship between these IT
capabilities and various financial indicators of overall and
operational financial performance. Specifically we examined
return on assets (ROA), cash flow ratio, operating margin,
total margin, net inpatient revenue, net patient revenue,
operating income, total income, hospital expenses, and total
expenses.
Population Studied: A total of 82 Florida hospitals were
analyzed in our study. This included the majority (84%) of
hospitals that participated in a previous hospital IT survey
conducted in Florida. Hospitals were excluded when financial
reports obtained from the state agency were not available or
reported along with an affiliated institution.
Principal Findings: Overall IT utilization, clinical IT
utilization, administrative IT utilization, and strategic IT
utilization were all positively and significantly related to
financial performance in hospitals. For each model, which
included one of the IT measure and a case mix index, Rsquared ranged from 0.26 to 0.45. In performance group
analysis, hospitals that had performed better financially had
also adopted more clinical, administrative, strategic, and
patient-safety related IT applications.
Conclusions: Hospitals in our dataset that have adopted
more clinical, administrative, or strategic IT applications seem
to perform better financially regardless of how we examined
financial outcomes.
Implications for Policy, Delivery, or Practice: Our findings
demonstrate that financial value is associated with IT
adoption in hospitals. Given that a true ROI is so difficult to
obtain for many individual hospital-wide IT systems, our data
can serve as a proxy for hospital leaders and policy makers
wanting to understand the potential financial effects of
investing in IT.
Primary Funding Source: Department of Health, State of
Florida
●The Value of Electronic Health Records in Solo/Small
Groups
Robert Miller, Ph.D., Ida Sim, M.D., Ph.D., Tiffany Martin, MA,
Chris Ganchoff, BA, Chris West, BA
Presented By: Robert Miller, Ph.D., Associate Professor of
Health Economics in Residence, Institute for Health & Aging,
University of California, San Francisco, 3333 California Street,
Suite 340, San Francisco, CA 94118; Tel: (415) 476-8568; Fax:
(415) 476-3915; Email: millerr@itsa.ucsf.edu
Research Objective: To determine the costs and benefits of
electronic health records (EHRs) in solo/small groups with
fewer than nine physicians. EHRs have the potential to
substantially improve quality, yet little is known about EHR
costs and benefits in solo/small groups, in which more than
two-thirds of all U.S. physicians work.
Study Design: We conducted case studies of 15 solo/small
group primary care practices that had been using an EHR for
one to three years, selecting cases from customer lists
provided by two leading vendors of EHR software. Among
other criteria, practices had to have full practices prior to
implementation (which eliminated new practices) and a stable
complement of billing providers (physicians, nurse
practitioners, physician assistants). We conducted semistructured interviews of EHR champions, structured surveys
of billing providers and observations of individual provider
EHR use, and reviewed contracts with vendors. Approximately
25% of practices that met our eligibility criteria agreed to
participate. Practices were compensated $1,400 (on average)
for provider and staff time.
Population Studied: Family medicine and internal medicine
solo/small group physician practices that were “early
adopters” of EHRs, and had used the EHRs from two vendors
for one to 3 years. Median practice size was four billing
providers.
Principal Findings: Median initial EHR costs were almost
$40,000 per provider; costs included productivity losses
during EHR implementation. On-going costs averaged about
20% of initial costs. Almost all providers used the EHR
routinely for documenting progress notes and ordering
prescriptions. A majority of practices reported significant
medical records and/or transcription savings, and most
practices gained revenue from higher levels of billing coding,
more captured billable services, and fewer denied claims. A
majority of practices likely would pay for their EHRs in under
three years, and most others in under five years. However,
practices reported substantial extra provider time costs (and
reduced provider personal time) for three to twelve months
following implementation for most practices. Only three
practices extensively used quality improvement capabilities for
chronic and preventive care (reminders, evidence-based
templates, lists of patients needing services, reports on
provider quality performance). Providers generally were
satisfied with the EHR software usefulness and ease-of-use
and would not return to paper records, but wanted more
training on how to use the EHRs more effectively.
Conclusions: EHRs are financially attractive for some
solo/small group physician practices, and financially
acceptable for most others; this assumes that the next layer of
physician EHR adopters is not radically dissimilar from early
adopters of EHRs. However, extra provider time costs were
substantial, and quality improvement activities were limited,
lowering the current value of EHRs in solo/small groups.
Implications for Policy, Delivery, or Practice: Substantial
time costs and limited quality improvement activities suggest
that purchasers and payers must provide financial incentives
to spur EHR adoption and use for QI, and should support
entities that provide additional support to practices to help
them use their EHRs more effectively.
Primary Funding Source: CWF
●Utilizing the Electronic Medical Record to Reduce
Inappropriate Medication Use
Alan White, Ph.D., Valerie Weber, M.D.
Presented By: Alan White, Ph.D., Senior Associate, Abt
Associates, 55 Wheeler Street, Cambridge, MA 02138; Tel:
(617) 349-2489; Fax: (617) 349-2675; Email:
alan_white@abtassoc.com
Research Objective: Falls are a common problem threatening
the independence of older individuals, and are associated with
significant morbidity and mortality. It is estimated that more
than 20 percent of elderly patients are taking medications that
may increase their risk of falls.
We evaluated how physicians would respond to an electronic
medical record (EMR) based intervention that notified them
about patients whose medications put them at increased risk
of falls, and how this intervention affected patient outcomes.
Study Design: Patients at-risk for falls were identified using
the EMR system. A pharmacist reviewed patient medications
and, using an EMR-based messaging function, notified the
primary care physician of the results. The message included a
patient-specific list of medications that the pharmacist
recommended that the physician review and a link to an
evidence-based guideline for fall prevention. The guideline
contained simple, practical ways that the physician could
reduce the risk of falls for their patients.
We evaluated impacts based on the change across time for
the intervention group and by comparing outcomes relative to
a comparison group. Patients were assigned to intervention or
comparison group by clinic. The study included 620
patients—413 in the intervention group and 207 in the
comparison group.
Population Studied: The study population was elderly (age
70+) with 4+ active medications including one or more
psychotropic medication and is from a largely rural part of
Pennsylvania.
Principal Findings: Almost all of the physicians read at least
some of the messages that they received as part of the study,
and most read all of the messages. About half of physicians
had reviewed the falls prevention guidelines and more than 40
percent indicated the messages led to medical management
changes, including, in some cases, medication changes.
The intervention group had lower utilization of psychotropic
medications and fewer new psychotropic medications than the
comparison group. These differences were larger for those
who were prescribed more psychotropic medications at
baseline. The intervention was also associated with a
reduction in the odds of a fall-- those in the intervention group
were only 0.38 times as likely to have one or more fall-related
diagnosis during as comparison group members, holding
other factors constant.
Conclusions: One reason for the success of the EMR
messages was likely that they contained personalized patientspecific information and were sent by a colleague with
expertise in the relevant subject matter. The study suggests a
potential role for pharmacists in reducing falls through
medication review and communication of their findings to
physicians. This approach may be an effective way to change
physician practices and impact patient outcomes related to
medication usage.
Implications for Policy, Delivery, or Practice: This type of
EMR-based program is a relatively inexpensive way to identify
patients at risk for falls. It may be possible to replicate it
without the use of an EMR through mailings or other forms of
communication between the pharmacist and the physician. A
similar approach could be used to target other inappropriate
medication patterns that may have other types of adverse
consequences.
Primary Funding Source: AHRQ
●Implementing Routine Outcome Assessment to Improve
Care for Mental Illness
Alexander Young, M.D., M.S.H.S., Matthew Chinman, Ph.D.,
Jim Mintz, Ph.D., Jennifer Magnabosco, Ph.D., Joe Hassell,
MA, Amy Cohen, Ph.D.
Presented By: Alexander Young, M.D., M.S.H.S., Associate
Professor, West LA VA, MIRECC, UCLA Neuropsychiatric
Institute, 11301 Wilshire Boulevard, 210A, Los Angeles, CA
90073; Tel: (310)268-3416; Fax: (310)268-4056; Email:
a1young@earthlink.net
Research Objective: The President’s New Freedom
Commission established national goals for mental health that
include improving access to effective, recovery-oriented
treatment services. Previously, implementing these services
has been very difficult. One major barrier has been a lack of
routine psychiatric outcome data. Using existing medical
records, it is often impossible to identify which patients would
benefit from specific services. Computerized patient selfassessment could routinely measure outcomes at minimal
cost. The objective of this project was to determine whether
such a system can accurately administer research-quality
outcome instruments to people with severe, persistent mental
illness; and to evaluate a pilot project to implement routine
outcome monitoring at mental health clinics.
Study Design: We developed an audio computer-assisted
patient self-assessment system (PAS) specifically to meet the
needs of people with cognitive impairments. Patients access
this internet-based system using a touch-screen monitor, and
complete a survey of symptoms, drug and alcohol use,
medication side-effects, and adherence. Accuracy of
assessment was evaluated in patients with schizophrenia or
bipolar disorder who completed duplicate surveys 20 minutes
apart: once face-to-face, and once using the computer.
Reliability was assessed with correlations, and bias with mode
x order repeated measures ANOVAs. The PAS was then
implemented at two large mental health clinics, one at a VA
medical center and one in a non-VA public system. Patients
use the PAS before their routine visits, a report is printed, and
the patient brings the report to their psychiatrist. Surveys,
interviews and focus groups have been conducted with
patients, clinicians, and managers to evaluate system
usability, usefulness, and its effect on treatment provision and
care organization.
Population Studied: 330 patients with schizophrenia,
schizoaffective disorder or bipolar disorder, and 8 physicians.
Principal Findings: Outcome scales assessed by
computerized and face-to-face interviews had similar internal
reliability, high correlations (r=.78-1.00), and similar means (at
p<.05). Most patients rated the PAS as easier, more
enjoyable, preferable and more private. 97-99% perfectly
answered questions about how to use it. Patients completed
the PAS faster. The PAS cost less than $2000 per kiosk and
was easily integrated into care processes at the clinics.
Patients reported that the PAS was easy to understand and
use, facilitated talking about feelings and difficulties, and
helped their psychiatrists understand them better.
Psychiatrists stated that PAS reports were easy to use, helped
cue them to ask about information they could otherwise
overlook, and allowed them to narrow their questioning and
thereby save time during short visits. The perceived value of
outcome information varied by clinician and domain, ranging
from somewhat to extremely valuable.
Conclusions: Computerized self-assessment is a reliable and
valid method for evaluating outcomes in people with mental
illness. It is relatively easy and affordable to implement and
sustain at typical mental health clinics.
Implications for Policy, Delivery, or Practice: Routine
patient self-assessment has the potential to support outcome
monitoring broadly. Controlled research is needed to evaluate
interventions that use this approach as part of efforts to
improve care.
Primary Funding Source: VA, NIMH
Related Posters
Poster Session B
Monday, June 27 • 6:15 pm – 7:30 pm
●Comparison of SNOMED-CT, LOINC, and ICD-CM
Coverage of Patient Safety Terms and Concepts.
Andrew Chang, JD, MPH, Gerard Castro, MPH, Anna Shearer,
MPH, Pavla Frazier, RN, MSN, MBA
Presented By: Andrew Chang, JD, MPH, Director-Center for
Patient Safety Research, Division of Research, Joint
Commission on Accreditation of Healthcare Organizations,
One Renaissance Boulevard, Oakbrook Terrace, IL 60181; Tel:
(630)792-5967; Fax: (630)792-4967; Email: achang@jcaho.org
Research Objective: To determine which clinical controlled
vocabulary had the best coverage of patient safety terms and
concepts found in the classification nodes of a standardized
patient safety taxonomy.
Study Design: This content coverage study entailed a
comparison of a corpus of terms and concepts found in the
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) Patient Safety Event Taxonomy
(PSET) with terms and concepts found in three controlled
medical vocabularies, International Classification of Diseases
(using ICD-9-CM and ICD-10), Logical Observation Identifier
Names and Codes (LOINC), and Systematized Nomenclature
for Medicine (SNOMED-CT). Patient safety terms in PSET
were decomposed into 160 single and compositional concepts
derived from five primary classifications: 1) Impact – the
outcome or effect of an incident; 2) Type – the perceptible or
visible process or structure that failed; 3) Domain – the
characteristics of the setting where an incident occurred and
the type of individuals involved; 4) Cause – the factors and
agents that lead to an incident; 5) Prevention and Mitigation –
the interventions to reduce the incidence and effects of
adverse outcomes, and branched to the quaternary level.
Concept and term searches were performed for each source
vocabulary using the UMLS Knowledge Source Server – a rich,
lexical, computer-based resource, with mappings to the three
vocabularies. Terms and concepts identified were evaluated
on a 4-point Likert scale where 1=matched or related concept
with identical term or root term, 2=matched or related concept
with different term, 3=different concept with identical term or
root term, and 4=no match. The overall degree of coverage of
patient safety terms and concepts provided by the
vocabularies was reported by tabulating the frequency of each
Likert item assigned to the 160 concepts.
Population Studied: All patients and providers affected by
adverse events in health care.
Principal Findings: LOINC had the most complete coverage
of the concepts present in PSET (Likert 1 & 2) (ICD-CM 63%;
LOINC 72%; SNOMED-CT 65%), but a combinatorial
vocabulary provided the most comprehensive coverage (ICDCM/LOINC/SNOMED-CT 93%). LOINC covered 59%(95) and
SNOMED-CT covered 58%(92) of single and compositional
concepts completely (Likert 1 only). Coverage was best for
concepts found in the Domain and Type classifications,
describing health delivery settings, provider and patient
characteristics, and patient management factors. Missing
concepts were largely related to the assessment of harm,
clinical performance, and human errors. SNOMED-CT had
9%(15) and LOINC had only 2%(3) unmatched concepts and
terms, whereas ICD-CM had 26%(41). Individually, ICD-10
had slightly better coverage than ICD-9 (ICD-10, 59%; ICD-9
57%).
Conclusions: Results suggest that no single medical
vocabulary can sufficiently represent the patient safety domain
completely. The overall coverage of the concepts in patient
safety was good. LOINC and SNOMED-CT have a
compositional nature and a richer taxonomy to construct postcoordinated patient safety codes. Consistency and
comparability across data sets requires annotation with
controlled vocabularies and, further, metadata standards for
data representation.
Implications for Policy, Delivery, or Practice: Interoperable
and future-proof health information systems will require
standard vocabularies to represent patient safety data
consistently, thereby facilitating clinical decision support,
research, and efficient care delivery.
Primary Funding Source: AHRQ
●Use of a Touch Screen Patient-Entered Data System to
Improve Efficiency of New Patient Registration in an
Ambulatory Care Clinic
Deena Chisolm, Ph.D., Robynn Young, MEd, Kendra Heck,
MPH
Presented By: Deena Chisolm, Ph.D., Clinical Assistant
Professor, Pediatrics, The Ohio State University, 700
Children's Drive, Room J1414, Columbus, OH 43205; Tel:
(614) 722-6030; Fax: (614) 722-3544; Email: chisolmd@ccri.net
Research Objective: Ever increasing time pressures on
physicians in community-based clinics require that practices
identify new approaches to streamlining patient intake and
care processes. The objective of this project is to assess to
implementation of a touch screen patient-entered data system
for completion of intake paperwork required for new patients
in a community-based behavioral health care clinic.
Study Design: This study was conducted using an
intervention/control design in two behavioral health clinics in
the Central Ohio area operated by Columbus Children's
Hospital. The intervention clinic, located in a Northwestern
suburb of Columbus, implemented the EnterVue computer
system developed by Flipside Media. The EnterVue kiosk was
programmed to capture all information traditionally captured
on new patient intake forms. Researchers observed the intake
process at this site to determine the amount of time taken by
patients or parents to complete the entry screens and the
amount of time taken by staff to orient users to the system
and answer questions. After all required information was
completed, printed and signed, research staff conducted a
brief satisfaction interview with the patient or parent
measuring ease of use, perceived privacy, and general
satisfaction. The interview also assessed the patient’s
computer proficiency. At the control clinic, located in a
Northeastern suburb of Columbus, intake was conducted in
the usual manner. Research staff used the same observation
protocol as in the intervention clinic to measure paperworkassociated time for the patient and the staff.
Population Studied: The study group was a convenience
sample of new patient intakes in the study clinics between
June and December of 2004. Analysis included 25 individuals
at the intervention clinic and 22 individuals at the control
clinic.
Principal Findings: Overwhelmingly, patients at the
intervention clinic found the system easy to use and were
highly satisfied with the experience. This positive response
was consistent across levels of computer experience. Impact
on process efficiency was less clear. The average time for
paperwork completion was slightly longer in the intervention
group (mean=27.2) than in the control group (mean=22.8).
This differential was largely driven by the added time needed
for the computer-entered forms to be printed and signed by
the patient and/or parent. Excluding the printing and signing
time, the completion time in the intervention group fell to an
average of 14.3 minutes.
Conclusions: Touch screen electronic patient-entered data
collection tool are well received within a pediatric behavioral
health population, even when users have limited computer
experience. However, improvements in process efficiency are
not guaranteed. This is particularly true when some
components of the process (i.e. signatures) must remain
manual.
Implications for Policy, Delivery, or Practice: As physician
practices make important financial decisions regarding the
purchase of technologies to improve administrative
processes, they must consider issues of patient acceptance,
staff acceptance, and actual potential for improvement. Some
well-accepted and conceptually exciting applications may have
limited financial return on investment because of limitations
in the underlying process.
Primary Funding Source: Institutional Research Funds
●Evaluating an Intervention to Improve the Quality of Care
for Schizophrenia
Amy Cohen, Ph.D., Alexander Young, M.D., MSHS, Jim Mintz,
Ph.D.
Presented By: Amy Cohen, Ph.D., Psychologist, Mental Illness
Research, Education, and Clinical Center (MIRECC), Greater
Los Angeles VA Healthcare Center, 11301 Wilshire Boulevard
(210A), Los Angeles, CA 90073; Tel: (310) 478-3711 x40770;
Fax: (310) 268-4056; Email: ancohen@ucla.edu
Research Objective: Schizophrenia occurs in about 1% of the
population and accounts for 2.5% of all healthcare
expenditures. Practice guidelines have been promulgated, yet
patients often do not receive effective treatments. Principals
of collaborative care and chronic disease management have
been used to improve care for chronic disorders. The VA
EQUIP project (“Enhancing Quality Utilization in Psychosis”)
applied these principals to schizophrenia.
Study Design: EQUIP was a randomized, controlled trial of a
collaborative care model at two medical centers. Psychiatrists
were randomized to the intervention or usual care. Interviews
were conducted with patients and clinicians before and after
the intervention, and data obtained from medical records.
The intervention focused on proactive care, caregiver
involvement, and treatment response to patients’ needs. An
informatics system, called the “Medical Informatics Network
Tool” (MINT), was developed to support the project. MINT
includes an internet browser interface for data entry and
management, and PC-based applications that interact with
providers and the VA electronic medical record. At each site, a
nurse briefly assessed symptoms, side effects and other
problems before each psychiatrist visit. These “psychiatric
vital signs” were entered into a secure database using a web
browser. When the psychiatrist subsequently opened the
patient’s medical record, MINT displayed a “PopUp” window.
This provided assessment data, one-click access to guidelines,
and a messaging system for team communication. Clinicians
used MINT reports to identify patients who were not receiving
necessary services. Managers used reports to monitor
performance and identify pervasive problems that required
reorganization of services.
Population Studied: 68 psychiatrists, 8 other clinicians, and
375 patients with schizophrenia were enrolled.
Principal Findings: The care model was sustained for 15
months. Clinician use of MINT was steady throughout
implementation. PopUps were displayed more than 3,000
times, and viewed by psychiatrists for a median duration of 7
seconds. Providers stated that the intervention provided
important new information about their patients, especially in
psychosocial domains, and allowed them to monitor needs
and treatment of their patients. Providers reported that team
communication was substantially enhanced regarding
patients, facilitating provision of appropriate services. The
intervention’s effect on medication prescribing varied by
psychiatrist and site. MINT identified treatment refractory
patients which led to the establishment of a clozapine clinic at
one site. MINT identified a pervasive problem with weight
gain which led to the establishment of wellness programs at
both sites. Provision of caregiver services did not increase.
Conclusions: It has not generally been possible to manage
the quality of care for schizophrenia, and multiple barriers
exist to improving care. MINT established an infrastructure
that allowed clinicians and managers to monitor and improve
care.
Implications for Policy, Delivery, or Practice: Informatics
systems can be useful in a variety of chronic illnesses. At the
patient level, these systems can identify specific clinical
problems that need to be addresed. At the provider level, they
identify when a provider should consider new treatment
strategies. At the practice level, they identify pervasive
problems that require changes in the organization of care.
Primary Funding Source: VA
●IT Adoption and Quality of Care by Physicians who Treat
Children in Florida
Donna Ettel, Ph.D., Lisa Simpson, MB, BCh, MPH, Nir
Menachemi, Ph.D.
Presented By: Donna Ettel, Ph.D., Research Associate,
Division of Child health outcomes, USF, 601 4th Street South,
CRI 1008, Saint Petersburg, FL 33601; Tel: (727)553-3673; Fax:
(727)553-3666; Email: dettel@hsc.usf.edu
Research Objective: To increase our understanding of IT
diffusion into child health provider settings through a
comprehensive, survey-based needs assessment of the
current state of IT utilization and adoption intentions among
practicing child health providers in Florida. Nationally, it is not
known to what extent physicians serving children have
adopted various IT applications to improve care. Providers
serving children are faced with a unique set of challenges
which could plausibly result in even slower adoption ot IT in
their practices, however, there is minimal information in the
literature about the nature and scope of IT diffusion in peditric
settings.
Study Design: The survey was developed as part of a larger
study of physician IT use across all populations in Florida.
Additional questions relevant to children's health care IT and
quality were adapted from an instrument previously used to
assess IT use nationally which will support comparisons to
national benchmarks. Three mailings are being conducted
betwwn February and March 2005 and all data will be analyzed
by May 2005. The IT dependent variables are the physician
use of email, PDAs, and electronic health records (E.H.R).
Use of numerous dimensions of EHR is assessed (e.g. lists,
order entry, scheduling, clinical decision support). In
addition, quality related variables include physician's prior
involvement in quality collaboratives, physician perception of
the role of IT in improving quality, physician experiences with
process failures which are likely to be ameliorated by adopting
IT, and whether physician reimbursements are linked to
quality or IT dimensions. The independent variables include
physician characteristics (age, race/ethnicity, years in practice,
specialty, practice setting), practice characteristics (size, type,
payor mix, patient age mix) and perceived barriers
(productivity, finacial, techinical and patient related barriers).
Analysis will include descriptive, univariate analyses of
variance to identify significant trends.
Population Studied: This study is limited to physicians
(MD/DO) with an active Florida medical license practicing
throughout the state of Florida who by virtue of virtue of their
practice treat children. This study specifically examined all
family physicians, pediatricians, and pediatric specialist in
Florida (n=5856). Data is extracted from a larger survey of
physicians in Florida (n~15,000).
Principal Findings: Data will be presented and include the
current state of IT utilization and adoption intentions amond
child health providers (including email, PDAs and electronic
health records) and barriers to implementation.
Conclusions: Forthcoming
Implications for Policy, Delivery, or Practice: This
information will be the first of its kind in the area of child
health and will assist policymakers and other key stakeholders
in Florida- and nationally- in identifying, designing and
implementing strategies to promote the adoption of electronic
health records and other information technology in children's
health settings.
●A Survey of Quality Enhancing Health Technologies:
Methodological Challenges
Cheryl Fahlman, BSP, MBA, Ph.D., Bonnie Blanchfield, Ph.D.,
Mary Pittman, Ph.D.
Presented By: Cheryl Fahlman, B.S.P., M.B.A., Ph.D., Senior
Research Associate, Health Research and Educational Trust,
325 7th Street NW, Washington, DC 20004; Tel: (202)6262365; Fax: (202)626-2689; Email: cfahlman@aha.org
Research Objective: The primary aim of this survey was to
identify and understand hospital capital investment priorities
and strategies in the current era of patient safety and quality
improvement. This session will describe some of the
methodological challenges faced during the administration of
the survey and policy implications of the findings.
Study Design: This was a mail survey released at the
beginning of September 2004 to all hospital members of the
American Hospital Association (n=4896). Respondents had
the opportunity to respond through a secured website or on
paper. We then analyzed the relationship between hospital
characteristics, technologies implemented, those planned for
implementation within the next three years, and funding
mechanisms.
Population Studied: Four hundred and eighteen acute care
hospitals completed the survey by November 30, 2004.
Principal Findings: The survey was sent to all hospital CEO’s,
but was designed to be completed by the hospital leader or a
small team, most knowledgeable about investment strategies
for twenty different technologies. The primary challenge we
faced was identifying the correct person within the hospital to
complete the survey. We sent the survey to the hospital CEO
with instructions to give it to the appropriate person(s). We
found a wide variety in the departments designated to
complete the survey. Although an advisory committee
provided input and the survey was pilot tested, many hospitals
found the survey long and had difficultly identifying
appropriate data sources. For each technology implemented
or planned for the next year, between 11 and 16 questions were
asked. For hospitals with many technologies, it represented a
significant amount of work to complete the survey. In order to
increase the response rate we extended the survey deadline to
November 30, 2004. We sent weekly email reminders to
those CEO’s for whom we had an email address. For those
institutions for which we did not have email addresses, we
conducted a telephone follow-up. We promoted the survey
through the State Hospital Associations and the National
Alliance for Health Information Technology.
Conclusions: Even though we used a variety of outreach
methods, we did not achieve a high response rate. Although
our response rate is relatively low, we had the second largest
survey of hospitals and capital spending ever completed in the
United States. By far, this survey contains information that is
more detailed on what technologies hospitals are looking at,
funding sources, why hospitals are investing, and factors
considered during the investment process.
Implications for Policy, Delivery, or Practice: The goal for
any survey is 50% or greater response rate. With the many
challenges we faced this did not happen. However, given the
distribution of the responses and the valuable nature of the
information obtained from our survey, even with the
challenges we faced, it was necessary to do.
Recommendations for increasing response in future surveys
would include eliminating some of the questions, consider the
formatting issues when an on-line survey is printed out for
completion, conducting a second mailing rather than only
email and telephone reminders, and increasing overall
awareness of the survey through a variety of channels.
Primary Funding Source: No Funding Source
●Valuing Integrated Public Health Information Systems
S. Nicole Fehrenbach, MPP, Ph.D. Candidate, Ellen Amore,
MPH, Amy Zimmerman, MPH, Anita Renehan-White, MPH,
Terry Hastings
Presented By: S. Nicole Fehrenbach, MPP, Ph.D. Candidate,
Assistant Director, Public Health Informatics Institute, 750
Commerce Drive, Decatur, GA 30030; Tel: (404)687-5622; Fax:
(800)-765-7520; Email: nfehenbach@taskforce.org
Research Objective: To develop and test an evaluation
framework for integrating public health information systems.
The framework focused on the integration of newborn
screening laboratory systems with child health program
information systems within state health departments. State
health departments are responsible for assuring the timely
screening of all newborns within its jurisdiction to prevent
adverse health outcomes.
Study Design: Based upon Delone and McLean’s Model of
Information Success, this study incorporated public health
values into an established information system model,
empirically tested the model through content analysis of
integration proposals and a case study of state public health
agencies. Case study methods included semi-structured
interviews and archival research. A modified pre-post design
was used for the case study because the integration ‘went live’
in March 2004. As a result, data prior to the integration could
be obtained and analyzed and compared with post-integration
data.
Population Studied: The sample for the content analysis
comprised 16 public health agency funded data integration
proposals to HRSA/MCHB to support Genetic Services
Branch Special Projects of Regional and National Significance.
The integration proposals were analyzed by benefit to staff,
organization, newborn population, and community. The case
was selected because of its unique fully operational status
among the sample.
Principal Findings: The Delone and McLean model can be
expanded to incorporate public health values as a meaningful
framework for assessing the value of integrated information
systems. The original domains of the model (system quality,
information quality, use, users satisfaction, individual impact
and organizational impact) are applicable to the public health
agency experience. Additional domains of epidemiology use,
communication and reporting use, and community health
outcomes have high relevance to public health and had
substantial evidence as themes in the content analysis and
case study findings. The content analysis results emphasized
individual and population health outcomes. Economic costs
and benefits were notably absent from the documents. Case
study results were consistent with the content analysis
findings and expanded the value realization into additional
domains. Significant benefit is derived among staff and within
the organization, including increased efficiency in completing
job tasks, improved assurance of screening, rapid
identification of newborns lost to follow-up, improved tracking
and surveillance, and improved complex relationships with
public health partners in health care delivery.
Conclusions: Public health departments pursuing integration
strategies have a need to articulate the associated value of
integrating information from disparate systems. Established
value dimensions in public health have focused on individual
and community health outcomes and not examined the
system of value generation from the architectural and data
levels to user and performance levels. As this study shows,
information system value is broadly realized at individual,
organizational and community levels in ways not previously
recognized. Such a framework can be applied in other areas of
public health informatics.
Implications for Policy, Delivery, or Practice: The framework
will help to inform public health program and information
systems decision-making as public health departments strive
to comply with federal health informatics policies promoting
integration of information systems. It also advances
evaluation capabilities within the field of public health
informatics.
Primary Funding Source: Association of Public Health
Laboratories
●Maine Health Care Claims Data Bank: Selected Case
Studies Using a New Health Services Research Resource
Karl Finison, MA
Presented By: Karl Finison, MA, Director of Research,
Research, Maine Health Information Center, PO Box 360,
Manchester, ME 04351; Tel: (207)623-2555; Fax: (207)6227086; Email: kfinison@mhic.org
Research Objective: Creation of a new statewide, all-payer
administrative claims data bank.
Study Design: In 2001 the Maine Legislature and Governor
King approved LD 1304, An Act to Create the Maine Health
Data Processing Center, establishing what is believed to be
the nation’s first comprehensive statewide Health Care Claims
Data Bank. Under a partnership between the Maine Health
Data Organization (MHDO) and the Maine Health
Information Center (MHIC), the Maine Health Data
Processing Center (MHDPC) was formed collect
administrative eligibility, medical, pharmacy, and dental
claims from all payers providing insurance to Maine residents.
Population Studied: The new Data Bank 2003 eligibility and
claims data are described along with the methods used to
extract important sub-populations from the data.
Principal Findings: We briefly report selected results from the
first three client-specific studies completed using the new
data. The first study reports the incidence, utilization, and
cost for persons with chronic obstructive pulmonary disease
and asthma for a public health client. The second study
reports on the occurrence of mental health conditions and use
of medications in children and teens for a child advocacy
group. The third study reports statewide cost rates and
geographical variance in emergency department utilization for
a Maine employer client.
Conclusions: States can build all-payer claims data banks to
report on the utilization and cost of health services.
Implications for Policy, Delivery, or Practice: A statewide
all-payer claims data bank can be used to make informed
decisions about health care services use and cost.
Primary Funding Source: State
●The Adoption of IT to Share Clinical Data Among
Providers: How Does It Vary Across Communities?
Joy Grossman, Ph.D., Thomas Bodenheimer, M.D.
types of incentives and policies are mostly likely to be effective
in speeding adoption.
Primary Funding Source: RWJF
Presented By: Joy Grossman, Ph.D., Senior Health
Researcher, Center for Studying Health System Change, 600
Maryland Avenue SW, Suite 501, Washington, DC 20024; Tel:
(202)484-3298; Fax: (202)484-9258; Email:
jgrossman@hschange.org
Research Objective: To assess the extent of the adoption of
IT to share clinical data among providers, how adoption varies
across communities and what factors help explain the
differences.
Study Design: Qualitative analysis of site visit interviews with
health care executives in 12 communities as part of the Center
for Studying Health System Change’s fifth round of site visits
conducted between January and June 2005. (Eleven of the 12
site visits will be completed and results available for analysis
before the Research Meeting.)
Population Studied: Hospitals, physician groups, safety net
providers, health plans and local health IT organizations and
experts in 12 nationally representative metropolitan areas
across the country.
Principal Findings: Preliminary findings suggest that there is
wide variation in clinical data sharing in the 12 communities
but that most communities have not yet addressed this need
in any broad way. A small number of sites are actively
engaged in community-wide collaborative efforts to share
data; in another small group of sites, the large hospital
systems have efforts underway to share some clinical data
among affiliated hospitals and in some cases physicians, while
in most others, the efforts are more diffuse, with select
providers engaged in much more limited activities that lag
behind the adoption of other types of clinical IT. In most
sites, physician groups are less likely than hospitals to be
focusing on clinical data sharing. Similarly, there is variation
in the role that non-provider organizations, such as health
plans, purchasers and local policy makers, are playing in
helping to promote adoption, with active participation in only
a few sites. The site visits will further explore exactly what type
of clinical data sharing is occurring, which parties are
sponsoring these efforts, the barriers and facilitators to
adoption and the implications for policy.
Conclusions: Efforts to share clinical data among providers
are just beginning in the “average” market and the barriers to
adoption, such as cost and complexity of implementation, that
apply to other types of IT adoption are likely as formidable for
clinical data exchange, if not more so. A key question for
study will be the extent to which the market and organizational
factors that have facilitated early adoption are unique to active
communities or hold promise for other communities as well.
Implications for Policy, Delivery, or Practice: Clinical data
sharing is one of the most promising ways IT has the potential
to improve the quality and efficiency of health care delivery.
Recently, policymakers have focused efforts on developing
community-wide health information exchanges. However,
much of the limited research on IT adoption focuses on
adoption within provider organizations. This research will
provide policymakers with a much needed baseline on the
limited extent to which information sharing among providers
is occuring; an assessment of how far communities have to go
to see widespread adoption, as well as insights into what
●Mail-order Pharmacy Use Encouraged by Electronic
Messaging
Nancy Hardie, MPH, MS, Adam Bock, M.D., Philip Denucci,
PharmD
Presented By: Nancy Hardie, MPH, MS, Senior Research
Analyst, Health Research Group, Definity Health, 1600 Utica
Avenue, Suite 900, St. Louis Park, MN 55416; Tel: (952) 2775500; Fax: (952) 277-5502; Email:
nancy.hardie@definityhealth.com
Research Objective: This study estimated the influence of
electronic messaging (e-mail) on the utilization of mail-order
prescription drug services over a 5 month period (April 1
through September 1, 2004). We hypothesized that health
plan members who opened an individualized web-based email documenting the cost savings of long-term disease
specific drug(s) via a pharmacy benefit managed mail-order
pharmacy had a significantly higher likelihood of ordering one
or more mail-order prescriptions than members who did not
open such an e-mail.
Study Design: A follow-up study of a consumer directed
health plan (CDHP) was implemented to compare mail-order
pharmacy utilization between members who use CDHP webbased e-mail services and those who do not. The cohort
consisted of CDHP members (Definity Health) who received
at least one cost saving e-mail messages on Definity Health’s
consumer web-site (N=44,428) between January 1 and March
31, 2004. An individualized e-mail message was posted on a
consumer directed health plan’s secure web-site
(www.definityhealth.com) to any member whose pharmacy
claims indicated at least one filled prescription for a long-term
disease-specific condition from January 1 to March 31, 2004.
Messages were posted to the website by March 31, 2004. This
e-mail message informed study members of mail-order and
retail pharmacy costs for their specific medication(s). Webbased data were used to determine if each study member read
their individualized cost-reducing message over a six month
follow-up period. Study members who opened these cost
saving e-mail messages (n=6,616) were compared to those
who did not open their individualized messages (n=37,812).
Pharmacy use (mail-order pharmacy / retail pharmacy) was
reviewed from claims and web-based data following the
message. The number and rate of study members in each email group (received e-mail / e-mail not opened) during the
study period was determined as was their actual and
calculated cost savings. The cohort was followed for the
entire study period; incomplete data over the follow-up period
were too infrequent to affect statistical testing.
Population Studied: Members of this CDHP may access
personalized web-based messages on the plan’s website that
are designed to inform them of cost saving opportunities and
personally relevant advice on health behavior. Each cohort
member’s inclusion criteria were 1. An adult Definity Health
member (a CDHP), and 2. Filled at least 1 prescription for
disease-specific chronic conditions from January 1 through
March 31, 2004. These criteria were used to include members
most likely to benefit from mail-order pharmacy services as
they required medication(s) for long-term use. CDHP
members fitting these criteria were selected from pharmacy
claims data.
Principal Findings: Electronic messages on the CDHP website informed 6,616 members (15% of the cohort) of the cost
saving benefits of mail-order pharmacy. The proportion of
mail-order pharmacy users among e-mail readers was over
twice that of those not reading their CDHP web-site e-mail (p
< 0.01). The probability that members who read cost reducing
e-mail messages and filled prescription(s) via mail-order
pharmacy was over two times that of their non-reading
counterparts (Relative Risk: 2.14, 95% CI: 2.06-2.24). Among
those who received at least one drug message, the cost
savings attributable to mail-order utilization was 53%.
Conclusions: Electronic messages influence the use of mailorder pharmacy and in so doing reduce prescription drug
costs for CDHP members who receive long-term drug therapy
for chronic conditions. Encouraging mail-order pharmacy via
electronic messages does reduce pharmacy costs.
Conclusions: Electronic messages influence the use of mailorder pharmacy and in so doing reduce prescription drug
costs for CDHP members who receive long-term drug therapy
for chronic conditions. Encouraging mail-order pharmacy via
electronic messages does reduce pharmacy costs.
Implications for Policy, Delivery, or Practice: Electronic
messages used by consumer directed health plans provide a
convenient media which offers information that directly affects
consumer behavior. This media provides new opportunities
for consumers to receive personalized health care
information, make choices and reduce health costs.
Primary Funding Source: Definity Health
●Computerized Solutions Drive Efficiency in Healthcare
Brian Jacobs, M.D.
Presented By: Brian Jacobs, M.D., Associate Professor,
Project Director, Integrating Clinical Information Systems
(ICIS), Pediatric Intermediate Care Unit, Fellowship Director,
Division of Critical Care Medicine, Cincinnati Children’s
Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH
45229-; Tel: (513)636-4200; Email: Brian.Jacobs@cchmc.org
Research Objective: An integral part of Cincinnati Children’s
Hospital Medical Center (CCHMC)’s vision to be the leader in
improving child health was the redesign of its care delivery
process. With a strong belief in implementing healthcare
information technology (IT) solutions, CCHMC focused on
the ability to have all physician orders submitted via a
computerized order entry process. CCHMC administrators
believed that such a system would improve patient care,
reduce turnaround time for tests and results, and ultimately
better align clinician’s workflow. Additional objectives
included: optimizing patient safety, maximizing regulatory
compliance, and enhancing provider, patient and family
satisfaction.
Study Design: The overall initiative was titled Integrating
Clinical Information Systems (ICIS). In order to ensure that
this process would work, the team evaluated process
improvements by adapting the principles of six sigma.
Implementation of the new IT solution was the result of 20
percent technology innovation and 80 percent process
reengineering. Through partnering with Siemens Medical
Solutions, CCHMC was able to develop a computerized entry
system that enabled all healthcare professionals within their
facility to communicate clearly and reduce variance in care. At
CCHMC, physicians drove the design of the order entry
system and a nursing team led the development of the clinical
documentation component.
Population Studied: CPOE and clinical documentation were
implemented throughout the 373-bed pediatric hospital within
8 months. General populations using the solutions are
physicians and nurses.
Principal Findings: The computerized systems have had a
dramatic impact at CCHMC. Clinical outcome improvements
at CCHMC include:
· elimination of transcription errors in medication orders · a
35% reduction in medication errors ·a 52% improvement in
medication turnaround times ·a 24% reduction in verbal
orders for controlled substances ·100% compliance with pain
assessment documentation requirements defined by state
regulatory agencies. In addition, the information that
physicians and nurses enter to a patient’s chart is monitored
against regulations/protocols within the system to monitor for
any errors. The facility has also seen increased patient
comfort/satisfaction because they know that their information
is kept on an electronic system with built-in checks and
balances. The success of the project earned CCHMC the 2003
Nicholas E. Davies Award of Excellence for Healthcare
Organizations.
Conclusions: Physician involvement in the development of
computerized solutions will enhance the acceptance of the
program because the system will meet the needs of the
medical staff. In addition, CCHMC was able to achieve several
of its objectives from patient safety to physician workflow
improvements.
Implications for Policy, Delivery, or Practice: The program
at CCHMC demonstrates that information based solutions
can be utilized in the hospital environment. In addition, the
success at CCHMC supports that belief that the physicians
and nurses can adapt to new solutions within their workplace.
Finally, CCHMC’s success is another example to support
using healthcare IT solutions for better patient care, efficiency
and workflow effectiveness.
Primary Funding Source: No Funding Source
●A Resource-based Perspective on IT Capability in Health
Care Organizations
Naresh Khatri, Ph.D.
Presented By: Naresh Khatri, Ph.D., Assistant Professor,
Health Management and Informatics, University of Missouri Columbia, 302 Clark Hall, Columbia, MO 65211; Tel: 573-8842510; Fax: 573-882-6158; Email: KhatriN@health.missouri.edu
Research Objective: This paper performs an extensive review
of literature, identifies mechanisms through which IT can
provide sustainable competitive advantage firms, and builds a
comprehensive, five-dimensional conception of IT capability
for health care organizations.
Study Design: In the first part, an extensive review of research
literature on the resource-based view was conducted. This
review included articles from general management literature
as well as health care management literature. In the second
part, based on the review of literature, a comprehensive
conception of IT capability was developed.
Population Studied: Review of articles on IT in general
management and health care management journals and
databases to date.
Principal Findings: Most of the early work on IT, in the form
of conceptual models, anecdotal evidence, and case studies
was uniformly positive about the contribution of IT to
organizational performance. However, emerging empirical
evidence has shown that there is no significant direct
connection between IT and performance. The literature on the
resource-based view suggests two possible avenues in which
IT can be a source of competitive advantage to organizations
indirectly: (1) by embedding or ‘fusing’ IT with other intangible
organizational resources and processes and (2) by developing
an IT capability in the organization.
In the absence of internal IT capabilities, health care
organizations have relied heavily on the fragmented IT vendor
market in which vendors do not offer an open architecture,
and are unwilling to offer electronic interfaces that would
make their “closed” systems compatible with those of other
vendors. Health care systems are hamstrung as a result,
because they have implemented so many different
technologies and databases that information stays in silos.
Health systems can meet this challenge by developing internal
IT capabilities that would allow them to seamlessly integrate
clinical IT components and develop innovative uses of IT. IT
capability consists of five dimensions: (1) professionally
competent CIO and enlightened top management, (2)
elevated status of IT in the organization, (3) trusting
relationships between IT managers and line managers, (4) IT
human resources, (5) IT infrastructure.
Conclusions: The empirical evidence shows no direct
connection between IT and firm performance. Thus,
‘throwing’ IT resources into the organizational mix with the
hope of improving bottom line performance is not prudent.
The literature on the resource-based view suggests that
internal IT capability is critical for strategic management of IT
in health care organizations.
Implications for Policy, Delivery, or Practice: The role of
CIO in developing IT capability of an organization is
important. Thus, health care organizations need to make sure
that they fill this critical position with a professionally
competent individual. Moreover, the CIO needs to have the
same status as other top management team members.
IT is fundamental to information-intensive and knowledgebased health care organizations. Thus, outsourcing of IT,
other than unimportant, peripheral activities, is likely to be
counterproductive because outsourcing of critical IT tasks
depletes an organization’s capacity to manage its IT
strategically. By relying on outsourcing, an organization
remains dependent on vendors and, as a result, would never
be able to develop internal IT capability.
Primary Funding Source: No Funding Source
●Critical Incidents in the Creation of a Clinical Information
System Linking Mothers and Newborns in Los Angeles
area Hospitals
Lisa Korst, M.D., Ph.D., Michele D. Kipke, Ph.D., Istvan Seri,
M.D., Ph.D., Bruce Fielding,T. Murphy Goodwin, M.D.
Presented By: Lisa Korst, M.D., Ph.D., Associate Professor,
Pediatrics, USC Keck School of Medicine, 4650 Sunset
Boulevard, MS #30, Los Angeles, CA 90027; Tel: (323)
671.7623; Fax: (323)906-8043; Email: LKORST@chla.usc.edu
Research Objective: In 2003, Childrens Hospital Los Angeles
(CHLA) embarked on a 2 year Research Partnership with First
5 LA, a philanthropic organization committed to early
childhood health and development programs for pregnant
women and young children up to 5 years old. One arm of this
Partnership addressed the feasibility of creating an interhospital clinical information system: 1) to link data from
mothers and babies within hospitals; 2) to link these same
data across hospitals; 3) to link these data among families,
and therefore 4) generating longitudinal datasets to monitor
health status and outcomes of at-risk mothers and children.
Study Design: Eight project milestones were defined and
evaluated. The successful achievement of a milestone was
judged on a five-point scale that was based on working
through its “critical incidents,” or “sticking points.”
Population Studied: Our efforts began with LAC+USC
Women’s and Children’s Hospital and CHLA, combining
clinical and administrative hospital data from deliveries in
2002 and 2003 with data from newborns transferred to CHLA,
thus tracking complete episodes of care for these children. We
have begun efforts at a third local community hospital where
we now have approval to add their patients, and where we will
then track those newborns that are transferred to CHLA.
Principal Findings: The 4 linkage objectives were achieved,
although progress varied within each milestone:
AGREEMENTS: Execute all key agreements (contracts and
human subjects’ research proposals) within a timely manner.
Score 3/5: Milestone achievement unrealistic, scaled back and
achieved. DESIGN: Design a multi-hospital information
system that can accomplish the data linkage Aims described
above. Score 5/5: Achieve the letter and intention of the
milestone. OPERATIONS: Provide smooth conduct of the
project with respect to handling objectives, maintaining
communications, anticipating timelines and working with
budgets. Score 3/5: Milestone achievement unrealistic, scaled
back and achieved. DEVELOPMENT: Create a working
product. Score 4/5: Achieved the milestone, but experienced
critical incidents (got stuck). IMPLEMENTATION: Import all
relevant data into the system, and/or install software as
necessary for use at LAC and CHLA. Score 2/5: Strong
progress toward milestone achieved. EXPANSION:
Implement the basic system in two additional hospitals.
Score 2/5: Strong progress toward milestone achieved.
GOVERNANCE: Develop a working organization to share
data. Score 2/5: Strong progress toward milestone achieved.
SUSTAINABILITY: Design and create a self-funding strategy.
Score 2/5: Strong progress toward milestone achieved
Conclusions: Although current policy structures are not
optimal, data regarding individuals were aggregated from
different sources, both within and across hospitals.
Longitudinal data regarding high-risk families were also
aggregated and tracked.
Implications for Policy, Delivery, or Practice: Critical
incidents appear to be the rule within each milestone, and
most of these incidents require attention, creativity, and
resources to develop workarounds and get “unstuck.” The
capacity to address these incidents varies across
organizations.
Primary Funding Source: First 5 LA
●Assessing Accuracy of Record Linkage Between
Administrative Data and Vital Statistics
Bing Li, MA, Hude Quan. Ph.D., Andrew Fong, MSc,
Mingshan Lu, Ph.D.
Presented By: Bing Li, MA, Research Associate, Institute of
Health Economics, 223 Edgemont Estates Drive NW, Calgary,
T3A 2M4; Tel: (403) 944-3120; Fax: (403) 944-8950; Email:
LIB@UCALGARY.CA
Research Objective: Record linkage techniques are widely
used in health services research to obtain comprehensive
information and conduct more revealing analyses. Accuracy of
record linkage is essential for such studies to obtain valid
results. Therefore, we conducted this study to assess the
linkage rate and accuracy using the deterministic linkage
approach among three commonly used Canadian
administrative databases namely the population registry, inhospital discharge data set and vital statistic registry.
Study Design: Three combinations of four personal identifiers
(i.e. surname, first name, gender, and date of birth) were used
to determine the optimal combination. The accuracy of linkage
was assessed using a unique personal health number
available in all three databases.
Population Studied: We included residents of a Canadian
health region during fiscal years 1998/99 and 2001/02. Infants
with age less than one year old were excluded because
identifying variables such as names are often missing or
inaccurate.
Principal Findings: Among the three combinations, the
combination of surname, gender, and date of birth identifiers
had the optimal linkage rate of 88% and accuracy rate of 96%
between the population registry and vital statistic registry in
2001 and linkage rate of 93.1% and accuracy rate of 97.8%
between the in-hospital discharge data and vital statistic
registry in 2001 respectively. Adding the first name to the
three identifiers above increased the accuracy rate less than
0.9%, but decreased linkage rate almost 10%. The linkage and
accuracy rates improved in recent years and increased with
age but did not vary by gender.
Conclusions: Our findings suggest that the deterministic
record linkage method using the combination of surname,
gender and date of birth appears to be optimal and to
accurately link over 80% of records. However, the accurate
linkage rate depends on type of database and quality of
information.
Implications for Policy, Delivery, or Practice: The linkage
and accuracy rates might be increased taking the strategy of
first matching records using unique identifiers, then matching
remaining records using a combination of surname, gender
and date of birth.
Primary Funding Source: No Funding Source
●Waiver or Alteration of Consent for Clinical Research
Benjamin Littenberg, M.D., Charles D. MacLean, MDCM
Presented By: Benjamin Littenberg, M.D., Professor of
Medicine, General Internal Medicine, University of Vermont,
371 Pearl Street, Burlington, VT 05401; Tel: (802)847-8268;
Fax: (802)847-0319; Email: benjamin.littenberg@uvm.edu
Research Objective: Federal laws and regulations, including
the Health Insurance Portability and Accountability Act of
1996 (HIPAA) and the “Common Rule” governing human
subjects protection, generally require that all research subjects
provide consent. These provisions, intended primarily to
protect individuals, have been described as significant barriers
to the use of clinical registries and other population-based
tools for health care research. However, the regulations do
allow for the waiver or alteration of usual consent procedures
when the research meets certain criteria: “(1) The research
involves no more than minimal risk to the subjects; (2) The
waiver or alteration will not adversely affect the rights and
welfare of the subjects; (3) The research could not practicably
be carried out without the waiver or alteration; and (4)
Whenever appropriate, the subjects will be provided with
additional pertinent information after participation.”
Nonetheless, waivers and alterations are rarely used in health
care research. Our objective is to describe the successful use
of an altered consent process in community-based research.
Study Design: The Vermont Diabetes Information System
collects laboratory data and patient identifiers from 13
hospitals around the region for a controlled trial of a quality
improvement intervention. Randomization occurs at the
practice level. Potential subjects (adults with diabetes) are
identified by laboratory data and mailed a letter describing the
study. They are asked to call a toll-free number (or their
provider’s office) to withdraw from the study. If they do not
withdraw in ten working days, they are enrolled.
Population Studied: 7,758 adults with diabetes receiving
Primary Care in Vermont or nearby New York or New
Hampshire.
Principal Findings: Thorough legal review by the University’s
Institutional Review Board, the National Institutes of Health,
and legal representatives for the state-wide Quality
Improvement Organization, hospital laboratories, and
practices confirmed that the design meets all federal and state
laws and regulations. Two-hundred-ten recipients requested
withdrawal. An additional 31 patients called for more
information but remained in the study. The overall
participation rate was 97.3% (7548/7758).
Conclusions: HIPAA and other federal regulations raise
challenges to the use of clinical registries in research, but
alterations to the consent process are useful tools that allow
low risk research to proceed under the new laws.
Implications for Policy, Delivery, or Practice: It is possible
to enroll a broad and representative population under current
law while maintaining appropriate protections for research
subjects.
Primary Funding Source: NIH - NIDDK
●Using Qualitative Observations to Inform a Quantitative
Survey Design in Human Factors Research
Armine Lulejian, MPH, Emily Patterson, Ph.D., Jason Saleem,
Ph.D., Laura Militello, MS, Steven Asch, M.D., MPH
Presented By: Armine Lulejian, MPH, Project Director,
Veteran's Administration Greater Los Angeles Healthcare
System, 11301 Wilshire Boulevard, Los Angeles, CA 90073; Tel:
(310)478-3711x48568; Email: armine.lulejian@med.va.gov
Research Objective: Computerized clinical reminders (CRs)
are widely used in the Veteran’s Healthcare Administration
(VA) to improve provider adherence to preventive care
guidelines. Analysis of human factors, the study and
interaction of humans and decision support systems in
complex environments, is essential in understanding factors
involved in the utilization of CRs. The main goal of this
research was to identify the prevalence of barriers and
facilitators to the use of CRs across the VA. Qualitative
observations were used to construct a reliable and valid
quantitative survey to measure factors that influence the
interaction of physicians and decision support systems.
Study Design: Data collection from ethnographic observation
involved trained observers who captured (1) observable
activities and verbalizations, and (2) self-reported data from
users. Semi-structured interviews were used to capture
information about use and effectiveness, as well as perceived
barriers and facilitators. Additionally, debrief interviews were
conducted with participants to increase data validity. Results
were used to inform the design of the quantitative instrument,
physician survey, and to collect information on use,
effectiveness, barriers and facilitators of CRs.
Population Studied: Observations were conducted in the
primary care clinics at four geographically dispersed facilities
in the VA during regular operating hours. A convenience
sample of attending physicians, fellows, and residents were
observed. Providers were observed prior to, during, and after
the patient encounter as they interacted with the electronic
medical record and the CRs. Every CR that was not used,
used, or appeared to be difficult to use was noted.
Additionally, factors that facilitated or hindered CR use were
identified.
Principal Findings: Analysis of data from the qualitative
observations resulted in the identification of five major
components that informed the design of the quantitative
instrument to collect data on CRs. We identified several major
human factors regarding CR use which included (1)
organizational, (2) design, (3) provider, (4) contextual, and (5)
software related factors. Subcomponents of these human
factors were further identified. For instance, organizational
factors include training and workload; design factors include
usefulness and usability; and provider factors include provider
demographics and computer expertise. Each subcomponent
was used to construct survey items for future quantitative data
collection.
Conclusions: This study examined factors involving the
translation of human factors knowledge and expertise to
construct a survey which examines the use and effectiveness
of CRs, as well as identify barriers and facilitators to CR
utilization. Qualitative findings from the observational study
informed the design of a survey.
Implications for Policy, Delivery, or Practice: It is expected
that using qualitative findings to inform quantitative research
in human factors studies will yield quantitative metrics from a
representative sample on issues that can directly apply to
policy, as well as software development. Furthermore, this
approach will facilitate the adoption and effective use of
clinical reminders to improve patient care.
Primary Funding Source: VA
●Cancer Survivors Health Information Seeking Behaviors
Deborah K. Mayer, RN, Ph.D.(c), FAAN
Presented By: Deborah K. Mayer, RN, Ph.D.(c), FAAN,
Program Manager, Institute for Clinical Research and Health
Policy Studies, Tufts-New England Medical Center, 750
Washington Street #345, Boston, MA 02111; Tel: (508)2725482; Fax: (617)636-6280; Email: dmayer@tufts-nemc.org
Research Objective: Interactive health communications holds
promise in delivering tailored programs to affect beliefs,
knowledge and behaviors regarding health promotion, cancer
risk reduction and screening practices. The total number of
cancer survivors in the US is now reaching 10 million or 3.5%
of the population. This group may have unique health
communication preferences based on their cancer
experiences. The purpose of this study is to describe the
cancer information seeking behaviors and preferences of
cancer survivors (Ca+) and compare them to those without a
personal or family history of cancer (Ca-).
Study Design: This is a cross sectional, descriptive,
correlational study using the National Cancer Institute’s 2003
Health Information National Trends Survey (HINTS)
database. HINTS provide a large (n=6369) randomly selected
national telephone survey sample of the US population of
which 12% are cancer survivors.
Population Studied: The cancer survivors (n= 756) were
predominantly Caucasian (83.4%), 60 years old (s.d.16.1),
married (51.8%), female (70%), had > high school education
(55.4%), were employed (62.2%), had > good health status
(68.8%), and had health insurance (94%). The most common
cancers were skin (n=143), breast (n=119), and cervical (n=94).
Ca- respondents were significantly different in age, gender,
race, health status and insurance.
Principal Findings: The three most common sources of
cancer information for Ca+ were the Internet (46.5%), health
care providers (22%), and books (14.7%). Both groups used
the Internet to find cancer information (Ca+ 51.9% and Ca59.4%) and found it very/somewhat useful (91.9%). Benefits
included convenience (44%), amount of information (24%),
and immediacy of access (16%). Barriers included too
complicated (48.3%), not interested (40.4%), and costs
(36%). While there were significant differences between Ca+
and Ca- groups in actual and preferred sources of information,
both groups preferred and trusted information from health
care providers first and the Internet second. Cancer survivors
were more confident they could find cancer information
(68.6%) compared to the Ca- group (59.1%).
Conclusions: Cancer survivors’ information seeking behaviors
and preferences are different from those who have not had a
cancer experience. Understanding the needs and behaviors of
cancer survivors will be the first step toward developing more
effective interactive health communication programs targeted
and tailored to this growing population as a means of
improving or maintaining their health.
Implications for Policy, Delivery, or Practice: Over the last
decade, health communications have expanded from the
more traditional print, video, and one-to-one interactions to
include new multimedia technologies such as interactive CDROMs, Internet sites, kiosks, tailored print and smart phone
interventions. Developing tailored health communications to
address the unique needs of the growing population of cancer
survivors may be more effective if delivered through preferred
channels.
Primary Funding Source: American Cancer Society
●EHR and other IT Adoption by Ambulatory Physicians in
Florida
Nir Menachemi, Ph.D., Lisa Simpson, MB, BCh, MPH, Donna
Lee Ettel, Ph.D.
Presented By: Nir Menachemi, Ph.D., Assistant Professor,
College of Medicine, Florida State University, Tallahassee, FL
32306; Email: nir.menachemi@med.fsu.edu
Research Objective: To increase our understanding of IT
diffusion into ambulatory physician practice settings through a
comprehensive, survey-based needs assessment of the
current state of IT utilization and adoption intentions among
practicing physicians in Florida.
Study Design: A physician survey was developed and piloted.
Three waves are being conducted between February 2005 and
March 2005 and all data will be analyzed by May 2005. The
dependent variables are the physician use of email, PDAs, and
electronic health records (EHR). With whom email is used and
for what purpose will be examined. Use of numerous
dimensions of EHR is assessed (e.g. lists, order entry,
scheduling, clinical decision support). The independent
variables include physician characteristics (age, race/ethnicity,
years in practice, specialty, practice setting), practice
characteristics (size, type, payor mix, patient age mix) and
perceived barriers (productivity, financial, technical and
patient related barriers). Analysis will include descriptive,
univariate analyses of variance to identify significant trends.
Population Studied: This study is limited to physicians
(MD/DO) with an active Florida medical license practicing
throughout the state of Florida. All primary care physicians
(n=12,147) defined as family practice, general internal
medicine, obstetrics, and general pediatrics were included.
Additionally, a 25% sample (n=2,380) of medical and surgical
subspecialists, dermatologists, and psychiatrists was included.
Radiologists, emergency physicians and pathologists were
excluded because they typically do not practice in the
ambulatory setting.
Principal Findings: EHR and other IT adoption trends will be
presented. Factors related to the adoption of these
technologies will be identified. Specifically, physician
characteristics, practice characteristics, and perceived barriers
will be examined.
Conclusions: Data findings will be presented and include the
current state of IT utilization an adoption intentions among
physicians (including email, PDAs, and EHR) and barriers to
implementation. Factors associated wtih increased use of
specific technologies will be examined including physician
demographics, practice characteristics and perceived barriers.
Implications for Policy, Delivery, or Practice: This
information will assist policymakers and other key
stakeholders in Florida in identifying, designing and
implementing strategies to promote the adoption of electronic
health records and other information technology in the
ambulatory setting in Florida.
●Culture, Quality, and the Electronic Health Record
Cindy Nowinski, M.D., Ph.D., Susan M. Becker, RN, BSN,
Katherine S. Reynolds, RN, Elizabeth A. Hahn, MA, Jennifer L.
Beaumont, MS, Carol Ann Caprini, BA
Presented By: Cindy Nowinski, M.D., Ph.D., Director of
Education, Center on Outcomes Research and Education,
Evanston Northwestern Healthcare, 1001 University Place,
Suite 100, Evanston, IL 60201; Tel: (847) 570-1707; Fax: (847)
733-5338; Email: cnowinski@enh.org
Research Objective: To evaluate changes in organizational
culture and quality of care over time, in order to better
understand the relationships between conversion to an
Electronic Health Record (EHR), organizational culture, quality
improvement, and quality of care.
Study Design: This four year observational study is being
conducted at a non-profit, integrated healthcare system that
includes three hospitals, an employed physician group, and
several outpatient clinics. The study examines organizational
culture, continuous quality improvement (CQI)
implementation, and quality of care prior to conversion to an
EHR (Baseline) and at 12, 24, and 36 months thereafter.
Baseline and 12 month (Time 2) data have been collected,
with Time 3 data to be obtained in March 2005.
Organizational culture and CQI implementation are assessed
with a standardized survey. Quality of care is evaluated via
seven routinely collected quality indicators. Results were
analyzed at the network level and, to investigate differing
culture and CQI patterns for subgroups within the
organization, scores of five smaller groups (Hospitals A–C,
and Groups D–E) were also compared. Culture and CQI
scores were analyzed using a mixed model approach,
including time point, group, and the interaction between time
and group as fixed effects; and staff members as random
effects. Quality indicators at Baseline and Time 2 were
compared using chi-square tests. Preliminary examination of
the relationships between the EHR, culture, and quality
improvement were conducted by correlating changes in
culture dimensions with change in quality at the three acute
care facilities.
Population Studied: Baseline surveys were sent to all
employees (including physicians) holding managerial level
positions or higher. The study population was subsequently
enlarged (Time 2) to include non-employed members of the
Professional Staff. Six hundred twenty-one people completed
the Baseline (54% response rate) and 471 completed the Time
2 survey (38% response rate).
Principal Findings: At baseline, the organization
demonstrated a predominantly hierarchical and rational
culture, with a level of CQI maturity consistent with that of
similar healthcare systems. Subgroups differed significantly in
their cultural profiles and degree of CQI implementation.
After the EHR conversion, the organization became more
hierarchical and less group oriented but CQI maturity
remained stable. Subgroups showed several significant
changes in culture and CQI maturity from Baseline to Time 2.
At the network level, six of seven quality indicators remained
stable, and one decreased. Each hospital decreased on at
least one indicator. Several strong correlations between
changes in culture scores and changes in quality indicators at
the three hospitals suggest that a more structured cultural
environment is associated with improvement in quality
indicators that rely on standardized processes.
Conclusions: Conversion to an EHR is associated with at
least short-term changes in organizational culture and quality
of care. The extent and nature of these changes can vary for
organizational subgroups. Furthermore, the impact of the
EHR on some quality indicators may be mediated by the
underlying culture.
Implications for Policy, Delivery, or Practice: Maximizing
the benefits of an EHR may require attention to the cultural
environment within which it is introduced and implemented.
Primary Funding Source: No Funding Source
●Impact of Patient-Centered Decision-Support on Quality
of Asthma Care in the Emergency Department
Stephen Porter, M.D., MPH, MSc, Peter Forbes, MSc, Henry
Feldman, Ph.D, Donald Goldmann, M.D.
Presented By: Stephen Porter, M.D., MPH, MSc, Assistant
Professor, Division of Emergency Medicine, Children's
Hospital Boston, 300 Longwood Avenue, Boston, MA 02115;
Tel: (617)355-6624; Fax: (617)730-0335; Email:
stephen.porter@childrens.harvard.edu
Research Objective: Communication barriers and underrecognition of chronic severity limit emergency department
(ED) providers' ability to improve disease management for
asthmatic patients. The asthma kiosk, a novel patient-driven
decision support tool, provides clinicians with tailored
recommendations for guideline-based treatment. We evaluate
the impact of the asthma kiosk on measures of quality during
ED care, specifically, parent-reported satisfaction with
communication and provider compliance with guidelineendorsed processes of care.
Study Design: An intervention trial was conducted at a single
tertiary care pediatric ED. Parents used the kiosk to report
children's symptoms, current medications and unmet needs.
During baseline, no output from the kiosk was shared and
usual care proceeded. During intervention, the output was
shared with ED clinicians. Subjects completed a telephone
follow-up interview one week after discharge. Primary
outcomes were: 1) prescription of controller medication to
patients not on controllers whose disease severity met
persistent criteria, and, 2) mean problem ratings for domains
of information-sharing and partnership.
Population Studied: Eligible subjects were English or
Spanish-speaking parents of children age 1–12 years
presenting to the ED with a respiratory complaint and history
of asthma.
Principal Findings: Over 5 months, 1090 parent-child dyads
were screened and 430 were eligible. 286/430 (66.5%) parents
enrolled in the trial. The kiosk generated severity
classifications for 264/286 (92.3%) of children. 131 subjects
enrolled during baseline, 13 during a run-in phase, and 142
during intervention. Baseline subjects were older (mean age
5.3 yr) compared to intervention (4.4 yr) but did not differ on
chronic severity, current use of controllers, or race. During the
intervention phase, providers gave a significantly higher
proportion of inhaled corticosteroid to eligible patients
compared to baseline (9/50 versus 2/43, p<0.05). Between
baseline and intervention, the reported number of partnership
problems rose from 1.4 +/- 1.7 (mean+/- SD) to 1.8 +/- 1.4
(p<0.05); the number of information problems was
unchanged. When ED providers acted on kiosk data, reports
of information problems were fewer (0.6 +/- 0.8) than when
no action was taken (1.1 +/- 1.1), p=0.06.
Conclusions: The asthma kiosk successfully produced
actionable output during ED care. The technology intervention
demonstrated modest and variable impact on quality.
Implications for Policy, Delivery, or Practice: Patientgenerated action plans, created through use of the kiosk,
provide a useful metric to judge the quality of ED care at the
process level. Patients' perception of partnership with clinical
providers may be adversely influenced by the use of a
technology product.
Primary Funding Source: AHRQ, Charles H. Hood
Foundation
●Profile Reports To Promote Quality Cancer Care
Andrew Stewart, MA, E. Greer Gay, Ph.D., John Ayanian, M.D.,
Joseph Lipscomb, Ph.D., Lina Patel-Parekh, MHA, David P
Winchester, M.D.
Presented By: Andrew Stewart, MA, Senior Manager National Cancer Data Base, Cancer, American College of
Surgeons, 633 North Saint Clair Street, Chicago, IL 60611; Tel:
(312)202-5285; Fax: (312)-202-5009; Email: astewart@facs.org
Research Objective: The Commission on Cancer (CoC) has
developed a web-based “Cancer Program Practice Profile
Report” to provide over 1,400 local providers with
comparative information to assess their local utilization of
adjuvant chemotherapy (ACT) following the resection of Stage
III cancers of the colon. The project is examining best ways to
promote accepted practice at the local level. These reports
identify cancer programs that are concordant or nonconcordant with nationally accepted guidelines specific to
treatment of Stage III cancer.
Study Design: A set of Profile Reports designed by the CoC
identifies cancer programs that are concordant or nonconcordant with nationally accepted guidelines specific to
treatment of Stage III cancer. These web-based “Cancer
Program Practice Profile Reports” are targeted to over 1,400
CoC approved cancer programs across the United States.
They display historical patterns of reported treatment of Stage
III colon cancer, using information routinely captured by
hospital based cancer registries and reported to the National
Cancer Data Base (NCDB). The reports also provide
comparisons of practices between similar types of cancer
programs nationally, regionally and at state level. These
Practice Profile Reports also include a web-based data
reconciliation tool allowing cancer programs to modify
information previously reported to the NCDB. Cancer
programs will address the issue of treatment data
completeness as part of their use of these reports.
Population Studied: The Profile Reports are based on over
11,000 Stage III colon cancer patients diagnosed between
1998 and 2002. All patients were surgically resected and
tissue was patholgically examimed at over 1,400 cancer
programs in the United States.
Principal Findings: Data reported to the NCDB as recently as
2002 indicate, in aggregate, that just over 60% of Stage III
patients receive recommended therapy. Since the early 1990s,
it has been recognized that appropriate care of Stage III colon
cancers includes the administration of ACT. More recently,
organizations such as the National Comprehensive Cancer
Network (NCCN) have disseminated treatment guidelines for
the management of a broad range of cancers, including Stage
III colon disease.
Conclusions: Based on findings indicating almost 40% noncompliance with standard of care, this project is examining
best ways the CoC can promote accepted practice at the local
level. Cancer programs will also be able to close the “data
gap” that is commonly believed to exist in cancer registry
treatment data.
Implications for Policy, Delivery, or Practice: Exposure to
these Profile Reports will spur local practitioners to review
their processes of care and promote better communication
between individual providers and centralized data repositories
and significantly contribute to the assessment of care
provided to cancer patients.
Primary Funding Source: No Funding Source
●Patterns of Computer-Use by Rural Primary Care
Physicians: The Relative Importance of Physician
Attributes vs. Medical Group Attributes in Physicians'
Hands-on Use of Computers
Timothy Weddle, BSE, MBA, MA
Presented By: Timothy Weddle, BSE, MBA, MA, Graduate
Student, Sociology, Loyola University Chicago, 6525 North
Sheridan Road, Damen Hall 9th Floor, Chicago, IL 60626; Tel:
(312) 508-0533; Email: tweddle@luc.edu
Research Objective: There is considerable variability in how
physicians incorporate computers into their practice of
medicine with some physicians taking full advantage of
computers while other physicians use computers little or not
at all. This study looks at measures of association related to
physicians’ use or non-use of computers. The study focused
on rural primary care physicians (PCPs) in a variety of medical
group settings.
Study Design: A survey was conducted by mail and by
interview with PCPs who practiced in 20 rural counties. The
survey included questions about physicians’ background with
computers, their medical group affiliations, their uses of
computers, and support provided to them by support staff.
The 15-county mail survey obtained 129 responses, a 70%
response rate. The 5-county interview requests resulted in 26
interviews, a 33% participation rate. The data were analyzed
using a four-step methodology to identify shared patterns of
computer use among these physicians. Steps 1, 2, and 3 used
data from the 15 mail survey counties to build a prediction
model, holding out data from the 5 interview counties. The
cases from the 5 interview counties were used in Step 4. Step 1
used Factor Analysis to identify common cause uses of
computers. Step 2 performed Cluster Analysis to identify
common patterns of computer use. Step 3 built a Polytomous
Logit Regression model to predict physicians’ membership in
the clusters identified in Step 2. Step 4 used the cases from
the 5 interview counties to test the ability of the model to
predict physicians' membership in computer-use
communities.
Population Studied: The target population included PCPs
(family practice, general practice, internal medicine, pediatrics,
and OB/ GYNE) who practiced in 20 mid-west rural counties.
Principal Findings: Physicians’ computer uses were divided
among 3 common computer-use patterns that I called
“computer-use communities.” The “Medical Reference
Computer-use Community” consisted of physicians who used
computers solely to search for disease specific information
from journals or medical specialty web sites. The “Open Loop
Computer-use Community” used computers to look-up
patients’ test results or physicians’ notes about patients to
prepare for their patient encounters in addition to searching
web sites. The “Closed Loop Computer-use Community” used
computers to document their progress notes in addition to
the uses exhibited by the Open Loop Computer-use
Community physicians.
Conclusions: Physician’s computer use was a function of
their group practice setting rather than an attribute associated
with individual physicians.
Implications for Policy, Delivery, or Practice: The results of
this study are of interest to policy makers and organizations
that are interested in establishing communities of computer
use where physicians input information into EMRs. This study
reveals that enlisting physicians to input information into
EMRs involves the transitioning of medical groups rather than
motivating individual physicians. This study is also of use to
policy researchers because the construct of “computer use
communities” is a new and useful way to make sense of data
related to physicians’ computer use.
Primary Funding Source: Self-Funded Dissertation Project