Hospital adoption of electronic health record functions to support age-friendly care: results from a national survey

Facilitators and Barriers to Implementing the 4Ms Framework of Age-Friendly Health Systems: A Scoping Review

BACKGROUND

This scoping review explored the evidence in the peer-reviewed published journal literature to identify the facilitators and barriers to implementing the 4Ms Framework of Age-Friendly Health Systems in inpatient and outpatient clinical settings.

METHODS

Our search strategy focused on primary and secondary data sources that described the barriers and facilitators of incorporating the 4Ms Framework in clinical settings. We focused on older adults 65 years and older and followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-SCR).

RESULTS

The evidence analyses of the 19 identified articles revealed six facilitator themes and five barrier themes to implementing the 4Ms Framework of Age-Friendly Health Systems in inpatient and outpatient clinical settings. The most recurring facilitator theme was embedding the 4Ms Framework into routine clinical practice with clinical pathways and designated personnel. The most frequently reported barrier theme was the lack of clinicians' buy-in.

CONCLUSIONS

Future research may translate the findings of this scoping review into a facilitator and barrier checklist or a "reality-check" measure to monitor the progress of the journey of embracing the 4Ms Framework in outpatient or inpatient clinical settings. This study was not registered.

A Survey of Technology Abandonment in US Nursing Homes

OBJECTIVE

Adoption of health information technology (HIT) in nursing homes (NHs) improves quality of care. Although there is a robust body of research on HIT adoption, the closely related process of technology abandonment is not well understood. As NHs grow more reliant on HIT, problems of technology abandonment, defined as failure to scale up, spread, and sustain HIT need to be studied. Our objective is to describe HIT abandonment and its associations with organizational characteristics among a national sample of US NHs.

DESIGN

Longitudinal, retrospective analysis of data from 2 sources: HIT Maturity Survey and Staging model and public data from the Care Compare database.

SETTING AND PARTICIPANTS

Random sample of NHs (n = 299) representing each US state that completed the HIT maturity survey in 2 consecutive years: year 1 (Y1) was June 2019-August 2020 and year 2 (Y2) was June 2020-August 2021.

METHODS

The primary dependent variable was technology abandonment, operationalized by using total HIT maturity score, HIT maturity stage, and subscale scores within each dimension/domain. Independent variables were NH organizational characteristics including bed size, type of ownership, urbanicity, Centers for Medicare & Medicaid Services Five-Star Overall Rating and Staffing Rating.

RESULTS

Over the 2-year period, HIT abandonment occurred in 28% (n = 85) of NHs compared with 44% (n = 133) that experienced growth in HIT systems. HIT capabilities in resident care were abandoned most frequently. Using multivariable multinomial logistic regression, we found that large NHs (bed size greater than 120) were more likely to experience technology abandonment in administrative activities.

CONCLUSIONS AND IMPLICATIONS

Technology abandonment can increase strain on scarce resources and may impact administrators' ability to oversee clinical operations, especially in large NHs. This study contributes to the limited understanding of technology abandonment and can serve as a building block for others working to ensure limited resources are used effectively to improve care for NH residents.

Developing a Conceptual Framework for an Age-Friendly Health System: A Scoping Review

BACKGROUND

Population aging is usually associated with increased health care needs. Developing an age-friendly health system with special features, structure, and functions to meet the special needs of older people and improving their health status and quality of life is essential. This study aimed to develop a conceptual framework for an age-friendly health system, which would offer a conceptual basis for providing the best possible care for older people in health system to let them experience a successful, healthy, and active aging.

METHODS

A scoping review was used to design the conceptual framework based on Arksey and O'Malley's model, including six stages, with the final stage of using expert's opinions to improve and validate the initial framework. The health system model of Van Olmen, was selected as the baseline model for this framework. Then, by reviewing the available evidence, the characteristics of an age-friendly health system were extracted and incorporated in the baseline mode.

RESULTS

Using the electronic searching, initially 12 316 documents were identified, of which 140 studies were selected and included in this review study. The relevant data were extracted from the 140 studies by two reviewers independently. Most studies were conducted in 2016-2020, and mostly were from United States (33.6%). To have an age-friendly health system, interventions and changes should be performed in functions, components and objectives of health systems. This system aims to provide evidence-based care through trained workforces and involves older people and their families in health policy-makings. Its consequences include better health acre for older people, with fewer healthcare-related harms, greater care satisfaction and increased use of cost-effective health services.

CONCLUSION

To meet the needs of older people, health systems should make interventions in their functions for better performance. In line with these changes, other parts of society should work in harmony and set the health of older people as a top priority to ensure they can have a successful aging.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

Barriers to and recommendations for integrating the age-friendly 4-Ms framework into electronic health records

BACKGROUND

The Institute for Healthcare Improvement's 4-Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4-Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4-Ms.

METHODS

Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media.

RESULTS

Sixty-six respondents from all geographic segments of the U.S. (n = 62) and non-U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4-Ms, and creating age-specific best practice alerts.

CONCLUSIONS

The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4-Ms in EHRs.

Prevalence and Predictors of Ambulatory Care Physicians' Documentation of Mobility Limitations in Older Adults

OBJECTIVE

To determine how often physicians document mobility limitations in visits with older adults, and which patient, physician, and practice characteristics associate with documented mobility limitations.

DESIGN

We completed a cross-sectional analysis of National Ambulatory Medical Care Surveys, years 2012-2016. Multivariate analyses were conducted to identify patient, physician, and practice-level factors associated with mobility limitation documentation.

SETTING

Ambulatory care visits.

PARTICIPANTS

We analyzed visits with adults 65 years and older. Final sample size represented 1.3 billion weighted visits.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

We defined the presence/absence of a mobility limitation by whether any International Classification of Diseases (ICD)-9 or ICD-10 code related to mobility limitations, injury codes, or the patient's "reasons for visit" were documented in the visits.

RESULTS

The overall prevalence of mobility limitation documentation was 2.4%. The most common codes were falls-related. Patient-level factors more likely to be associated with mobility limitation documentation were visits by individuals over 85 years of age, relative to 65-69 years, (odds ratio 2.32, 95% confidence interval 1.76-3.07]; with a comorbid diagnosis of arthritis (odds ratio 1.35, 1.18-2.01); and with a comorbid diagnosis of cerebrovascular disease (odds ratio 1.60, 1.13-2.26). Patient-level factors less likely to be associated with mobility limitation documentation were visits by men (odds ratio 0.80, 0.64-0.99); individuals with a cancer diagnosis (odds ratio 0.76, 0.58-0.99); and by individuals seeking care for a chronic problem (relative to a new problem [odds ratio 0.36, 0.29-0.44]). Physician-level factors associated with an increased likelihood of mobility limitation documentation were visits to neurologists (odds ratios 4.48, 2.41-8.32) and orthopedists (odds ratio 2.67, 1.49-4.79) compared with primary care physicians. At the practice-level, mobility documentation varied based on the percentage of practice revenue from Medicare.

CONCLUSIONS

Mobility limitations are under-documented and may be primarily captured when changes in function are overt.

Patient Portals to Support Care Partner Engagement in Adolescent and Adult Populations: A Scoping Review

IMPORTANCE

Family and other unpaid care partners may bridge accessibility challenges in interacting with the patient portal, but the extent and nature of this involvement is not well understood.

OBJECTIVE

To inform an emerging research agenda directed at more purposeful inclusion of care partners within the context of digital health equity by (1) quantifying care partners' uptake and use of the patient portal in adolescent and adult patients, (2) identifying factors involving care partners' portal use across domains of the System Engineering Initiative for Patient Safety model, and (3) assessing evidence of perceived or actual outcomes of care partners' portal use.

EVIDENCE REVIEW

Following Arksey and O'Malley's methodologic framework, a scoping review of manuscripts published February 1 and March 22, 2022, was conducted by hand and a systematic search of PubMed, PsycInfo, Embase, and Web of Science. The search yielded 278 articles; 125 were selected for full-text review and 41 were included.

FINDINGS

Few adult patient portal accounts had 1 or more formally registered care partners (<3% in 7 of 7 articles), but care partners commonly used the portal (8 of 13 contributing articles reported >30% use). Care partners less often authored portal messages with their own identity credentials (<3% of portal messages in 3 of 3 articles) than with patient credentials (20%-60% of portal messages in 3 of 5 articles). Facilitators of care partner portal use included markers of patient vulnerability (13 articles), care partner characteristics (15 articles; being female, family, and competent in health system navigation), and task-based factors pertaining to ease of information access and care coordination. Environmental (26 articles) and process factors (19 articles, eg, organizational portal registration procedures, protection of privacy, and functionality) were identified as influential to care partner portal use, but findings were nuanced and precluded reporting on effects. Care partner portal use was identified as contributing to both patient and care partner insight into patient health (9 articles), activation (7 articles), continuity of care (8 articles), and convenience (6 articles).

CONCLUSIONS AND RELEVANCE

In this scoping review, care partners were found to be infrequently registered for the patient portal and more often engaged in portal use with patient identity credentials. Formally registering care partners for the portal was identified as conferring potential benefits for patients, care partners, and care quality.

Management and organization construction status and development suggestions of aged-friendly medical institutions in mainland China

The increasing number of regions have begun to construct age‐friendly medical institutions to further promote the “successful aging” of the elderly in mainland China. This study deeply analyzes the development status of age‐friendly medical institutions abroad and describes the policies, research, evaluation, and certification of different countries. This study focuses on the current construction status of age‐friendly medical institutions in mainland China. With the issuing of several national policies, mainland China has established a top‐down system for the construction of age‐friendly medical institutions, which has been gradually implemented in the actions of medical institutions. On the whole, the goal and evaluation standard are clear and the action is rapid. However, it also faces many challenges and problems. This study puts forward various suggestions for the construction of age‐friendly medical institutions, such as increasing manpower and financial investment and carrying out evidence‐based research. In particular, we should pay attention to promoting a bottom‐up construction system, understand the actual needs of the elderly, pay attention to the personal experience of the elderly, and fully mobilize the active and full participation of the whole society.

Progress toward Digital Transformation in an Evolving Post-acute Landscape

Digitization has been a central pillar of structural investments to promote organizational capacity for transformation, and yet skilled nursing facilities (SNFs) and other post-acute providers have been excluded and/or delayed in benefitting from the past decade of substantial public and private sector investment in information technology (IT). These settings have limited internal capacity and resources to invest in digital capabilities on their own, propagating a limited infrastructure that may only further sideline SNFs and their role in an ever-evolving healthcare landscape that needs to be focused on age-friendly, high-value care. Meaningful progress will require continuous refinement of supportive policy, financial investment, and scalable organizational best practices specific to the SNF context. In this essay, we lay out an action agenda to move from age-agnostic to age-friendly digital transformation. Key to the value proposition of these efforts is a focus on interoperability- the seamless exchange of electronic health information across settings that is critical for care coordination and for providers to have the information they need to make safe and appropriate care decisions. Interoperability is not synonymous with digital transformation, but a foundational building block for its potential. We characterize the current state of digitization in SNFs in the context of key health IT policy advancements over the past decade, identifying ongoing and emergent policy work where the digitization needs of SNFs and other post-acute settings can be better addressed. We also discuss accompanying implementation considerations and strategies for optimally translating policy efforts into impactful practice change across an ever-evolving post-acute landscape. Acting on these insights at the policy and practice level provides cautious optimism that nursing home care – and care for older adults across the care continuum – may benefit more equitably from the promise of future digitization.