Showing papers by "Rainu Kaushal published in 2014"

The patient-centered medical home, electronic health records, and quality of care.

Abstract: The patient-centered medical home (PCMH) model is being implemented widely, but its effects on quality of care are unclear. This longitudinal study of primary care physicians in a multipayer commun...

A Statewide Assessment of Electronic Health Record Adoption and Health Information Exchange among Nursing Homes

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

Association between use of a health information exchange system and hospital admissions

Abstract: Objective: Relevant patient information is frequently difficult to obtain in emergency department (ED) visits. Improved provider access to previously inaccessible patient information may improve the quality of care and reduce hospital admissions. Health information exchange (HIE) systems enable access to longitudinal, community-wide patient information at the point of care. However, the ability of HIE to avert admissions is not well demonstrated. We sought to determine if HIE system usage is correlated with a reduction in admissions via the ED. Methods: We identified 15,645 adults from New York State with an ED visit during a 6-month period, all of whom consented to have their information accessible in the HIE system, and were continuously enrolled in two area health plans. Using claims we determined if the ED encounter resulted in an admission. We used the HIE’s system log files to determine usage during the encounter. We determined the association between HIE system use and the likelihood of admission to the hospital from the ED and potential cost savings. Results: The HIE system was accessed during 2.4% of encounters. The odds of an admission were 30% lower when the system was accessed after controlling for confounding (odds ratio = 0.70; 95%C I= 0.52, 0.95). The annual savings in the sample was $357,000. Conclusion: These findings suggest that the use of an HIE system may reduce hospitalizations from the ED with resultant cost savings. This is an important outcome given the substantial financial investment in interventions designed to improve provider access to patient information in the US. Citation: Vest JR, Kern LM, Campion TR Jr, Silver MD, Kaushal R. Association between use of a health information exchange system and hospital admissions. Appl Clin Inf 2014; 5: 219–231 http://dx.doi.org/10.4338/ACI-2013-10-RA-0083

How could health information exchange better meet the needs of care practitioners

Abstract: Background: Health information exchange (HIE) has the potential to improve the quality of healthcare by enabling providers with better access to patient information from multiple sources at the point of care. However, HIE efforts have historically been difficult to establish in the US and the failure rates of organizations created to foster HIE have been high. Objectives: We sought to better understand how RHIO-based HIE systems were used in practice and the challenges care practitioners face using them. The objective of our study were to so investigate how HIE can better meet the needs of care practitioners. Methods: We performed a multiple-case study using qualitative methods in three communities in New York State. We conducted interviews onsite and by telephone with HIE users and non-users and observed the workflows of healthcare professionals at multiple healthcare organizations participating in a local HIE effort in New York State. Results: The empirical data analysis suggests that challenges still remain in increasing provider usage, optimizing HIE implementations and connecting HIE systems across geographic regions. Important determinants of system usage and perceived value includes users experienced level of available information and the fit of use for physician workflows. Conclusions: Challenges still remain in increasing provider adoption, optimizing HIE implementations, and demonstrating value. The inability to find information reduced usage of HIE. Healthcare organizations, HIE facilitating organizations, and states can help support HIE adoption by ensuring patient information is accessible to providers through increasing patient consents, fostering broader participation, and by ensuring systems are usable.

Health information exchange and the frequency of repeat medical imaging.

Abstract: OBJECTIVES Medical imaging, which is expensive, is frequently repeated for the same patient within a relatively short period of time due to lack of access to previous images. Health information exchange (HIE) may reduce repeat imaging by facilitating provider access to prior images and reports. We sought to determine the effect of an HIE system on the occurrence of repeat imaging. STUDY DESIGN AND METHODS We conducted a cohort study of adult patients who consented to participate in a community-based HIE system in an 11-county region in New York. Using data from 2009-2010, we linked log files of provider HIE usage to administrative claims data from 2 commercial health plans. Using generalized estimation equations, we measured the association between HIE system access and repeat imaging within 90 days. RESULTS Of 196,314 patients in the cohort, 34,604 (18%) of patients had at least 1 imaging procedure, which was equivalent to a rate of 28.7 imaging procedures per 100 patients. Overall, 7.7% of images were repeated within 90 days. If the HIE system was accessed within the 90 days following an initial imaging procedure, imaging was significantly less likely to be repeated (5% repeated with HIE access vs 8% repeated without HIE access, P < .001). HIE system access reduced the adjusted odds of a repeat image by 25% (95% CI, 13%-35%). CONCLUSIONS Use of the HIE system to access previous patient information was associated with a reduction in repeated imaging.

The impact of interoperability of electronic health records on ambulatory physician practices: a discrete-event simulation study

Abstract: Background The effect of health information technology (HIT) on efficiency and workload among clinical and nonclinical staff has been debated, with conflicting evidence about whether electronic health records (EHRs) increase or decrease effort. None of this paper to date, however, examines the effect of interoperability quantitatively using discrete event simulation techniques. Objective To estimate the impact of EHR systems with various levels of interoperability on day-to-day tasks and operations of ambulatory physician offices. Methods Interviews and observations were used to collect workflow data from 12 adult primary and specialty practices. A discrete event simulation model was constructed to represent patient flows and clinical and administrative tasks of physicians and staff members. Results High levels of EHR interoperability were associated with reduced time spent by providers on four tasks: preparing lab reports, requesting lab orders, prescribing medications, and writing referrals. The implementation of an EHR was associated with less time spent by administrators but more time spent by physicians, compared with time spent at paper-based practices. In addition, the presence of EHRs and of interoperability did not significantly affect the time usage of registered nurses or the total visit time and waiting time of patients. Conclusion This paper suggests that the impact of using HIT on clinical and nonclinical staff work efficiency varies, however, overall it appears to improve time efficiency more for administrators than for physicians and nurses.

Rapid Growth in Use of Personal Health Records in New York, 2012–2013

Abstract: BACKGROUND Giving patients access to their own medical data may help improve communication and engage patients in healthcare. As a result, the federal electronic health record (EHR) incentive program requires providers to offer electronic data sharing with patients via personal health records (PHRs) or other technologies.

People with epilepsy who use multiple hospitals; prevalence and associated factors assessed via a health information exchange.

Abstract: Summary Objective Hospital crossover occurs when people seek care at multiple hospitals, creating information gaps for physicians at the time of care. Health information exchange (HIE) is technology that fills these gaps, by allowing otherwise unaffiliated physicians to share electronic medical information. However, the potential value of HIE is understudied, particularly for chronic neurologic conditions like epilepsy. We describe the prevalence and associated factors of hospital crossover among people with epilepsy, in order to understand the epidemiology of who may benefit from HIE. Methods We used a cross-sectional study design to examine the bivariate and multivariable association of demographics, comorbidity, and health service utilization variables with hospital crossover, among people with epilepsy. We identified 8,074 people with epilepsy from the International Classification of Diseases, Ninth Revision (ICD-9) codes, obtained from an HIE that linked seven hospitals in Manhattan, New York. We defined hospital crossover as care from more than one hospital in any setting (inpatient, outpatient, emergency, or radiology) over 2 years. Results Of 8,074 people with epilepsy, 1,770 (22%) engaged in hospital crossover over 2 years. Crossover was associated with younger age (children compared with adults, adjusted odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2–1.7), living near the hospitals (Manhattan vs. other boroughs of New York City, adjusted OR 1.6, 95% CI 1.4–1.8), more visits in the emergency, radiology, inpatient, and outpatient settings (p < 0.001 for each), and more head computerized tomography (CT) scans (p < 0.01). The diagnosis of “encephalopathy” was consistently associated with crossover in bivariate and multivariable analyses (adjusted OR 2.66, 95% CI 2.14–3.29), whereas the relationship between other comorbidities and crossover was less clear. Significance Hospital crossover is common among people with epilepsy, particularly among children, frequent users of medical services, and people living near the study hospitals. HIE should focus on these populations. Further research should investigate why hospital crossover occurs, how it affects care, and how HIE can most effectively mitigate the resultant fragmentation of medical records. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

Consumer Perspectives on Personal Health Records: A 4-Community Study

Abstract: Objectives To characterize consumer attitudes toward personal health records (PHRs) in 4 diverse communities across New York state (NYS). Study design Combined analysis from four separate cross-sectional studies. Methods We analyzed pooled data from surveys separately administered to 4 NYS communities. Results from individual communities have been previously published. However, pooling the data allowed us to conduct multivariable regression analyses that identified key factors associated with potential usage among a broad group of consumers. Results We received responses from 701 consumers. A majority (74%) of respondents (n = 494) reported that they would use a PHR and the majority wanted a broad array of functionalities available. We found that potential PHR use was significantly associated with Internet use at least monthly (odds ratio [OR] = 5.8, 95% confidence interval [CI] = 3.3-10.2), a belief that PHRs may improve the security of health information (OR = 2.6, 95% CI = 1.5-4.7), and a belief that PHRs may improve quality of care (OR = 4.1, 95% CI = 2.6-6.6). Conclusions As federal initiatives aim to improve healthcare, which includes making care more patient centered, PHRs will likely play an increasing role. Our results provide critical information to inform policy efforts, suggesting that PHRs must offer a broad range of patient-centered functionalities while maintaining high privacy and security standards to narrow the gap between reported interest and actual use. Ensuring widespread access to and frequent use of the internet among consumers will also be critical to avoid creating healthcare disparities through PHR use.

Risk factors for unexplained medication discrepancies during transitions in care.

Abstract: Background and objectives Unexplained discrepancies between patient reported- and physician-prescribed medication regimens are an important source of potential harm to patients after hospital discharge. However, there are limited data available identifying risk factors associated with discrepancies in medications. Our objective was to describe the epidemiology of unexplained medication discrepancies and identify patient risk factors for these discrepancies. Methods This prospective observational study is part of a larger study conducted from August 2009 to February 2011 in an academic hospital and affiliated office practices. We compared medication lists from hospital discharge, the first ambulatory visit, and patient self-report. Medication lists were gathered from the inpatient and outpatient electronic health records. Demographic and health-related predictor variables were collected through an inpatient survey and chart review. Results Among 100 patients, 291 unexplained medication discrepancies were identified (31%, n=930). Of these, 98 had high potential for harm (34%). Omitted medications were the most common type of unexplained discrepancy (72%, n=210). In multivariable analysis, having more than five outpatient visits during the previous year and having less than high school education independently predicted a higher number of unexplained discrepancies. Having Medicaid insurance and receiving care from a third-year resident during the first follow-up visit were protective. Conclusions Unexplained medication discrepancies are common at the first ambulatory visit post-hospital discharge and underscore the need to maintain accurate medication lists across the continuum of care. Individual-level characteristics may potentially be used to identify patients who need special attention for their medication management.

A Case Report in Health Information Exchange for Inter-organizational Patient Transfers

Abstract: Objective: To provide a case report of barriers and promoters to implementing a health information exchange (HIE) tool that supports patient transfers between hospitals and skilled nursing facilities. Methods: A multi-disciplinary team conducted semi-structured telephone and in-person interviews in a purposive sample of HIE organizational informants and providers in New York City who implemented HIE to share patient transfer information. The researchers conducted grounded theory analysis to identify themes of barriers and promoters and took steps to improve the trustworthiness of the results including vetting from a knowledgeable study participant. Results: Between May and October 2011, researchers recruited 18 participants: informaticians, healthcare administrators, software engineers, and providers from a skilled nursing facility. Subjects perceived the HIE tool’s development a success in that it brought together stakeholders who had traditionally not partnered for informatics work, and that they could successfully share patient transfer information between a hospital and a skilled nursing facility. Perceived barriers included lack of hospital stakeholder buy-in and misalignment with clinical workflows that inhibited use of HIE-based patient transfer data. Participants described barriers and promoters in themes related to organizational, technical, and user-oriented issues. The investigation revealed that stakeholders could develop and implement health information technology that technically enables clinicians in both hospitals and skilled nursing facilities to exchange real-time information in support of patient transfers. User level barriers, particularly in the emergency department, should give pause to developers and implementers who plan to use HIE in support of patient transfers. Conclusions: Participants’ experiences demonstrate how stakeholders may succeed in developing and piloting an electronic transfer form that relies on HIE to aggregate, communicate, and display relevant patient transfer data across health care organizations. Their experiences also provide insights for others seeking to develop HIE applications to improve patient transfers between emergency departments and skilled nursing facilities.

Public and private sector roles in health information technology policy: Insights from the implementation and operation of exchange efforts in the United States

Abstract: Objectives In the US, the federal and state governments are supporting interoperable health information technology (HIT) and health information exchange (HIE) through policy interventions and financial investments. However, private healthcare organizations and partnerships have also been active in establishing exchange activities, promoting interoperability, and developing technologies. This combination of influence from different actors has resulted in a rapidly changing healthcare environment. In this context, we sought insights into the optimal roles for the public and private sectors in HIT/HIE policy development and implementation. Methods We leveraged the concurrency of federal and New York State initiatives to spur HIT/HIE adoption by interviewing HIT experts ( n =17). Interviewees represented federal and state government agencies, healthcare providers, and exchange organizations. A semi-structured interview guide with open-ended questions covered the domains of organization, value, privacy, security, and evaluation. We analyzed transcripts using a general inductive and comparative approach. Results Interviewees assigned roles for standard setting and funding to the federal government and suggested states were better positioned to offer implementation support. Interviewees forwarded a public–private partnership model as a potential solution to the limitations facing the private and public sectors. Conclusions HIT/HIE policy is a complex issue involving standards, privacy, funding and implementation. When New York State began funding HIT, significant federal intervention did not exist. Since the launch of New York State's program and the subsequent federal Meaningful Use criteria, interviewees expressed distinct but complementary roles for both state and federal governments and saw an avenue to include the private sector through public–private partnerships.

Expert panel evaluation of health information technology effects on adverse events.

Abstract: Rationale, aims and objectives Adverse events (AEs) among hospitalized patients occur frequently and result in significant sequelae. Federal policy is incentivizing health information technology (HIT) use, although research demonstrating safety benefits from HIT is mixed. Our objective was to evaluate the potential effects of HIT on reducing 21 different inpatient AEs. Identifying AEs most likely to be reduced by HIT can inform the design of future studies evaluating its effectiveness. Methods We conducted a modified Delphi panel of national experts in HIT and safety. We conducted a focused literature review to inform the experts. Using a novel framework, experts rated each AE as ‘definitely reduced by health IT,’ ‘possibly reduced by health IT’ and ‘not likely to be reduced by health IT’. Results From our panel discussion, experts identified six AEs as ‘definitely reduced by health IT’: (1) adverse drug events (ADEs) associated with digoxin; (2) ADE associated with IV heparin; (3) ADE associated with hypoglycaemic agents; (4) ADE associated with low molecular weight heparin and factor Xa inhibitor; (5) contrast nephropathy associated with catheter angiography; and (6) ADE hospital-acquired antibiotic-associated Clostridium difficile. Conclusions Understanding the effects of HIT on patient outcomes will be essential to ensuring that the significant federal investment results in anticipated improvements. This study serves as an important early step in helping with the design of future work evaluating level of HIT infrastructure and rates of inpatient AEs.

Introduction and commentary for special issue on health information technology.

Abstract: In 2009, as part of the so-called Stimulus Act, the federal government made a large investment in health information technology (health IT), designating up to $30 billion in incentive payments to providers to adopt and “meaningfully use” certified electronic health record (EHR) systems. The EHR Incentive Program’s inclusion in this legislation—also known as the American Recovery and Reinvestment Act (ARRA)—was apt (111th Congress of the United States 2009). Not only could health IT funding stimulate economic activity but it could also help modernize the health care system, lay the foundation for new health care delivery and payment models, and promote a learning health care environment.

Improving immunization data management: an editorial on the potential of Electronic Health Records.

Abstract: Immunizations are critical for maintaining individual and population health. Yet ensuring that complete immunization histories are available at the point of care is challenging. Currently, immunization information systems (IIS) are used to aggregate data at a regional level, although their value is often limited by incomplete data. The Electronic Health Record (EHR) Incentive Program, which is an unprecedented federal initiative promoting EHR use, is linking financial payments in part to demonstrating ability to transmit EHR data directly to IIS and thus has potential to change immunization data management on a large scale. We believe that EHRs are critical for allowing more complete and timely immunization data capture and will offer many benefits. To achieve these benefits, however, it will be necessary to engage the EHR vendor community in developing EHRs that allow for comprehensive immunization data capture and policy makers to incentivize bidirectional, real-time exchange between IIS and EHRs.

Applications of health information exchange information to public health practice.

Abstract: Increased information availability, timeliness, and comprehensiveness through health information exchange (HIE) can support public health practice. The potential benefits to disease monitoring, disaster response, and other public health activities served as an important justification for the US’ investments in HIE. After several years of HIE implementation and funding, we sought to determine if any of the anticipated benefits of exchange participation were accruing to state and local public health practitioners participating in five different exchanges. Using qualitative interviews and template analyses, we identified public health efforts and activities that were improved by participation in HIE. HIE supported public health activities consistent with expectations in the literature. However, no single department realized all the potential benefits of HIE identified. These findings suggest ways to improve HIE usage in public health.

Information retrieval pathways for health information exchange in multiple care settings.

Abstract: Objectives To determine which health information exchange (HIE) technologies and information retrieval pathways healthcare professionals relied on to meet their information needs in the context of laboratory test results, radiological images and reports, and medication histories. Study design Primary data was collected over a 2-month period across 3 emergency departments, 7 primary care practices, and 2 public health clinics in New York state. Methods Qualitative research methods were used to collect and analyze data from semi-structured interviews and participant observation. Results The study reveals that healthcare professionals used a complex combination of information retrieval pathways for HIE to obtain clinical information from external organizations. The choice for each approach was setting- and information-specific, but was also highly dynamic across users and their information needs. Conclusions Our findings about the complex nature of information sharing in healthcare provide insights for informatics professionals about the usage of information; indicate the need for managerial support within each organization; and suggest approaches to improve systems for organizations and agencies working to expand HIE adoption.

Characterising the effect of interoperability on healthcare work: a novel framework

Abstract: Successful design and implementation of interoperable health IT requires an understanding of specific technological capabilities of systems, as well as how these systems impact clinical workflow. Several existing frameworks classify interoperability levels, but none focus on the impact on clinical work, particularly at the task level. A synthesis of existing interoperability frameworks from select interoperability frameworks in the literature about both medical and non-medical systems is presented and a new, 7-level framework in order to characterise the effect of varying levels of interoperability on the users’ work based upon qualitative data collected in a field study of the use of health information exchange in 12 ambulatory practices is proposed. The lowest level describes paper-based tasks completed with no access to electronic information from other institutions; the highest level describes interoperable systems in which data elements from other institutions are integrated into the patient's record...

Adoption of clinical data exchange in community settings: a comparison of two approaches.

Abstract: Adoption of electronic clinical data exchange (CDE) across disparate healthcare organizations remains low in community settings despite demonstrated benefits. To expand CDE in communities, New York State funded sixteen community-based organizations to implement point-to-point directed exchange (n=8) and multi-site query-based health information exchange (HIE) (n=8). We conducted a cross-sectional study to compare adoption of directed exchange versus query-based HIE. From 2008 to 2011, 66% (n=1,747) of providers targeted for directed exchange and 21% (n=5,427) of providers targeted for query-based HIE adopted CDE. Funding per provider adoptee was almost two times greater for directed exchange (median (interquartile range): $25,535 ($17,391-$42,240)) than query-based HIE ($14,649 ($9,897-$28,078)), although the difference was not statistically significant. Because its infrastructure can cover larger populations using similar levels of public funding, query-based HIE may scale more broadly than directed exchange. To our knowledge, this is among the first studies to compare directed exchange versus query-based HIE.

State funding for health information technology and selected ambulatory healthcare quality measures.

Abstract: Background: Previous studies on the effects of health information technology (health IT) on ambulatory quality have had mixed results New York State has invested heavily in health IT throughout the State, creating a unique opportunity to assess effects on health care quality across multiple communities Objective: To determine any association between primary care providers’ receipt of funding from New York State’s Healthcare Efficiency and Affordability Law for New Yorkers Program (HEAL NY) and ambulatory quality of care Methods: A statewide, longitudinal cohort study of primary care physicians in New York State was conducted Data regarding which primary care physicians received funding through the HEAL NY program (Phase 5 or Phase 10) in 2008 or 2009 were obtained from the New York State Department of Health Health care quality in 2010 was measured using claims data that had been aggregated across 7 commercial health plans across the state Physicians were divided into 2 groups, based on receipt of HEAL funding (yes/no) Any association was measured between study group and each of 7 quality measures, all of which appear in the Stage 1 federal Meaningful Use program Negative binomial regression was used, adjusting for provider gender and specialty Results: The study included 3,988 primary care providers, of whom 863 (22%) had received HEAL NY funding The HEAL-funded physicians provided higher quality of care on 5 of the 7 measures: breast cancer screening, eye exams in patients with diabetes, nephropathy screening in patients with diabetes, influenza vaccination and pneumococcal vaccination (p<00001 for all adjusted comparisons) The HEAL-funded group provided higher quality of care by an absolute 2 to 6 percentage points per measure for those 5 measures Conclusion: Primary care physicians who received state funding for health IT provided higher quality of care than those who did not receive such funding

Effect of a state‐based incentive programme on the use of electronic health records

Abstract: Rationale, aims and objectives In 2004, New York passed the Health Care Efficiency and Affordability Law for New Yorkers (HEAL NY) Capital Grants Program, which was the largest state-based investment in health information technology adoption in the United States. We sought to evaluate the effects of this programme on electronic health records (EHR) usage. Methods We undertook a case-control study of health care providers who had signed up with a regional extension centre, some of whom had also received HEAL funding through programmes intended to support EHR adoption. The outcome of interest was achievement of Medicare or Medicaid Meaningful Use and the primary exposure was any link to HEAL NY funding. The association between Meaningful Use status and independent variables was measured using logistic regression models. Results Meaningful Users were more likely to have had a history of HEAL NY funding (OR = 1.83; 95% CI = 1.59, 2.09). Also, achievement of Meaningful Use was associated with having an EHR before 2011 (OR = 1.64; 95% CI = 146, 1.83). Among those with EHRs prior to 2011, the odds of achieving Meaningful Use were statistically higher if coupled with HEAL NY funding (OR = 3.12; 95% CI = 2.50, 3.90). Conclusion Achieving Meaningful Use was associated with a history of HEAL NY funding. However, it was the combination of HEAL NY funding and historic usage of EHRs that was associated with the largest increase in the odds that the provider was a Meaningful User. These findings indicate that state-based incentive programmes can support the effective usage of health information technologies.