Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians

The Impact of Delivery Reform on Health Information Exchange with Behavioral Health Providers: Results from a National Representative Survey of Ambulatory Physicians

Health information exchange (HIE) is an effective way to coordinate care, but HIE between health and behavioral health providers is limited. Recent delivery reform models, including the Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) prioritize interprofessional collaboration, but little is known about their impact on behavioral health HIE. This study explores whether delivery reform participation affects behavioral health HIE among ambulatory health providers using pooled 2015-2019 data from the National Electronic Health Record Survey, a nationally representative survey of ambulatory physicians' technology use (n = 8,703). The independent variable in this analysis was provider participation in ACO, PCMH, Hybrid ACO-PCMH, or standard care. The dependent variable was HIE with behavioral health providers. Chi square analysis estimated unweighted rates of behavioral health HIE across reform models. Logistic regression estimated the impact of delivery reform participation on rates of behavioral health HIE. Unweighted estimates indicated that Hybrid ACO-PCMH providers had the highest rates of HIE (n = 330, 33%). In the fully adjust model, rates of HIE were higher among ACO (AOR = 2.66, p < .01), PCMH (AOR = 4.73, p < .001) and Hybrid ACO-PCMH participants (AOR = 5.55, p < .001) compared to standard care, but they did not significantly vary between delivery models. Physicians infrequently engage in HIE with behavioral health providers. Compared to standard care, higher rates of HIE were found across all models of delivery reform. More work is needed to identify common elements of delivery reform models that are most effective in supporting this behavior.

Implementation of Patient Safety Structures and Processes in the Patient-Centered Medical Home

ABSTRACT

Although most patient-clinician interactions occur in ambulatory care, little research has addressed measuring ambulatory patient safety or how primary care redesign such as the patient-centered medical home (PCMH) addresses patient safety. Our objectives were to identify PCMH standards relevant to patient safety, construct a measure of patient safety activity implementation, and examine differences in adoptions of these activities by practice and community characteristics. Using a consensus process, we selected elements among a widely adopted, nationally representative PCMH program representing activities that, according to a physician panel, represented patient safety overall and in four domains (diagnosis, treatment delays, medications, and communication and coordination) and generated a score for each. We then evaluated this score among 5,007 practices with the highest PCMH recognition level. Implementation of patient safety activities varied; the few military practices (2.4%) had the highest, and community clinics the lowest, patient safety score, both overall (82.0 and 72.0, respectively, p < .001) and across specific domains. Other practice and community characteristics were not associated with the patient safety score. Understanding better what factors are associated with implementation of patient safety activities may be a key step in improving ambulatory patient safety.

Technology-facilitated care coordination in rural areas: What is needed?

BACKGROUND

Health is poorer in rural areas and a major challenge is care coordination for complex chronic conditions. The HITECH and 21^st Century Cure Acts emphasize health information exchange which underpins activities required to improve care coordination.

OBJECTIVE AND METHODS

Using semi-structured interviews and surveys, we examined how providers experience electronic health information exchange during care coordination since these Acts were implemented, with a focus on rural settings where health disparities exist. We used a purposive sample that included primary care, acute care hospitals, and community health services in the United States.

FINDINGS

We identified seven themes related to care coordination and information exchange: 'insufficient trust of data'; 'please respond'; 'just fax it'; 'care plans'; 'needle in the haystack'; 're-documentation'; and 'rural reality'. These gaps were magnified when information exchange was required between unaffiliated electronic health records (EHRs) about shared patients, which was more pronounced in rural settings.

CONCLUSION

Policy and incentive modifications are likely needed to overcome the observed health information technology (HIT) shortcomings. Rural settings in the United States accentuate problems that can be addressed through international medical informatics policy makers and the implementation and evaluation of interoperable HIT systems.

Closing the Loop on Electronic Referrals: A Quality Improvement Initiative Using the Care Coordination Model

Primary care providers refer nearly one-third of their patients to specialty care services. Despite provider recommendations, approximately 1 in 4 referrals are never completed. Incomplete referral rates are higher among vulnerable and medically underserved individuals. Sixty-seven percent of federally qualified community health centers report difficulty obtaining specialty care appointments and incomplete referral rates as high as 73%. Effective electronic referral processes can improve health outcomes, reduce waste, and mitigate risks. Using the Care Coordination Model as its framework, this quality improvement initiative implemented evidence-based interventions aimed at improving patient support and organizational accountability for electronic referrals.

Promoting access to health information

Purpose

Describe the design of a health information and technology educational intervention that promotes health information sharing and technology use for older adult African Americans to support access to health information. The paper aims to discuss this issue.

Design/methodology/approach

The study team developed a novel method to design the intervention. It drew upon three approaches: intergenerational technology transfer, participatory design and community-based participatory research.

Findings

Older adult African Americans (55+) with diabetes and young adults (18–54) connected to them via familial or naturally occurring social networks designed the intervention, which was conducted in the two study sites in Michigan, USA. In total, 29 participants helped design the intervention. Four themes emerged concerning factors that promote intergenerational information exchange in the context of technology and health. First, focus on one technology skill. Second, working together in small groups is preferred. Third, patience is essential. Last, physical capabilities (i.e., eyesight, operating on relatively small screens) and literacy levels should be considered.

Originality/value

This novel method of having participants from the sample population select the health information materials and technology exercises serves as a guide for implementing health information and education interventions aimed at technology use to support self-management for vulnerable patient populations.

Characteristics of Future Models of Integrated Outpatient Care

Replacement of fee-for-service with capitation arrangements, forces physicians and institutions to minimize health care costs, while maintaining high-quality care. In this report we described how patients and their families (or caregivers) can work with members of the medical care team to achieve these twin goals of maintaining-and perhaps improving-high-quality care and minimizing costs. We described how increased self-management enables patients and their families/caregivers to provide electronic patient-reported outcomes (i.e., symptoms, events) (ePROs), as frequently as the patient or the medical care team consider appropriate. These capabilities also allow ongoing assessments of physiological measurements/phenomena (mHealth). Remote surveillance of these communications allows longer intervals between (fewer) patient visits to the medical-care team, when this is appropriate, or earlier interventions, when it is appropriate. Systems are now available that alert medical care providers to situations when interventions might be needed.

A Clinical Care Monitoring and Data Collection Tool (H3 Tracker) to Assess Uptake and Engagement in Mental Health Care Services in a Community-Based Pediatric Integrated Care Model: Longitudinal Cohort Study

BACKGROUND

National recommendations for pediatric integrated care models include improved capacity for care coordination and communication across primary care and specialty mental health providers using technology, yet few practical, short-term solutions are available for low-resource, community-based pediatric integrated care clinics.

OBJECTIVE

The goal of the paper is to describe the development and features of a Web-based tool designed for program evaluation and clinician monitoring of embedded pediatric mental health care using a community-partnered approach. In addition, a longitudinal study design was used to assess the implementation of the tool in program evaluation, including clinical monitoring and data collection.

METHODS

Biweekly meetings of the partnered evaluation team (clinic, academic, and funding partners) were convened over the course of 12 months to specify tool features using a participatory framework, followed by usability testing and further refinement during implementation.

RESULTS

A data collection tool was developed to collect clinic population characteristics as well as collect and display patient mental health outcomes and clinical care services from 277 eligible caregiver/child participants. Despite outreach, there was little uptake of the tool by either the behavioral health team or primary care provider.

CONCLUSIONS

Development of the H3 Tracker (Healthy Minds, Healthy Children, Healthy Chicago Tracker) in two community-based pediatric clinics with embedded mental health teams serving predominantly minority children is feasible and promising for on-site program evaluation data collection. Future research is needed to understand ways to improve clinic integration and examine whether promotion of primary care/mental health communication drives sustained use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02699814; https://clinicaltrials.gov/ct2/show/NCT02699814 (Archived by WebCite at http://www.webcitation.org/772pV5rWW).

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

Background

The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.

Objectives

To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.

Design

Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.

Data sources

Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.

Results

The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.

Limitations

The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.

Conclusions

Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.

Study registration

This study is registered as PROSPERO CRD42016038900.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

"The Doctor Needs to Know": Acceptability of Smartphone Location Tracking for Care Coordination

Background

Care coordination can be highly challenging to carry out. When care is fragmented across health systems and providers, there is an increased likelihood of hospital readmissions and wasteful health care spending. During and after care transitions, smartphones have the potential to bolster information transfer and care coordination. However, little research has examined patients’ perceptions of using smartphones to coordinate care.

Objective

This study’s primary objective was to explore patient acceptability of a smartphone app that could facilitate care coordination in a safety net setting. Our secondary objective was to identify how clinicians and other members of primary care teams could use this app to coordinate care.

Methods

This qualitative study was conducted at a federally qualified health center in metropolitan Chicago, IL. We conducted four focus groups (two in English, two in Spanish) with high-risk adults who owned a smartphone and received services from an organizational care management program. We also conducted structured interviews with clinicians and a group interview with care managers. Focus groups elicited patients’ perceptions of a smartphone app designed to: (1) identify emergency department (ED) visits and inpatient stays using real-time location data; (2) send automated notifications (ie, alerts) to users’ phones, asking whether they were a patient in the hospital; and (3) send automated messages to primary care teams to notify them about patients’ confirmed ED visits and inpatient stays. Focus group transcripts were coded based on emergent themes. Clinicians and care managers were asked about messages they would like to receive from the app.

Results

Five main themes emerged in patient focus group discussions. First, participants expressed a high degree of willingness to use the proposed app during inpatient stays. Second, participants expressed varying degrees of willingness to use the app during ED visits, particularly for low acuity ED visits. Third, participants stated their willingness to have their location tracked by the proposed app due to its perceived benefits. Fourth, the most frequently mentioned barriers to acceptability were inconveniences such as “false alarm” notifications and smartphone battery drainage. Finally, there was some tension between how to maximize usability without unnecessarily increasing user burden. Both clinicians and care managers expressed interest in receiving messages from the app at the time of hospital arrival and at discharge. Clinicians were particularly interested in conducting outreach during ED visits and inpatient stays, while care managers expressed more interest in coordinating postdischarge care.

Conclusions

High-risk primary care patients in a safety net setting reported a willingness to utilize smartphone location tracking technology to facilitate care coordination. Further research is needed on the development and implementation of new smartphone-based approaches to care coordination.

Effects of Hospital Systems on Medical Home Transformation in Primary Care Residency Training Practices

Most primary care residency training practices have close financial and administrative relationships with teaching hospitals and health systems. Many residency practices have begun integrating the core principles of the patient-centered medical home (PCMH) into clinical workflows and educational experiences. Little is known about how the relationships with hospitals and health systems affect these transformation efforts. Data from the Colorado Residency PCMH Project were analyzed. Results show that teaching hospitals and health systems have significant opportunities to influence residency practices' transformation, particularly in the areas of supporting team-based care, value-based payment reforms, and health information technology.

Doctors' opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system

BACKGROUND

Clinical coordination is considered a health policy priority as its absence can lead to poor quality of care and inefficiency. A key challenge is to identify which strategies should be implemented to improve coordination. The aim is to analyse doctors' opinions on the contribution of mechanisms to improving clinical coordination between primary and outpatient secondary care and the factors influencing their use.

METHODS

A qualitative descriptive study in three healthcare networks of the Catalan national health system. A two-stage theoretical sample was designed: in the first stage, networks with different management models were selected; in the second, primary care (n = 26) and secondary care (n = 24) doctors. Data were collected using semi-structured interviews. Final sample size was reached by saturation. A thematic content analysis was conducted, segmented by network and care level.

RESULTS

With few differences across networks, doctors identified similar mechanisms contributing to clinical coordination: 1) shared EMR facilitating clinical information transfer and uptake; 2) mechanisms enabling problem-solving communication and agreement on clinical approaches, which varied across networks (joint clinical case conferences, which also promote mutual knowledge and training of primary care doctors; virtual consultations through EMR and email); and 3) referral protocols and use of the telephone facilitating access to secondary care after referrals. Doctors identified organizational (insufficient time, incompatible timetables, design of mechanisms) and professional factors (knowing each other, attitude towards collaboration, concerns over misdiagnosis) that influence the use of mechanisms.

DISCUSSION

Mechanisms that most contribute to clinical coordination are feedback mechanisms, that is those based on mutual adjustment, that allow doctors to exchange information and communicate. Their use might be enhanced by focusing on adequate working conditions, mechanism design and creating conditions that promote mutual knowledge and positive attitudes towards collaboration.

Health Reform in Minnesota: An Analysis of Complementary Initiatives Implementing Electronic Health Record Technology and Care Coordination

Background: Minnesota enacted legislation in 2007 that requires all health care providers in the state to implement an interoperable electronic health record (EHR) system by 2015. 100% of hospitals and 98% of clinics had adopted EHR systems by end of 2015. Minnesota’s 2008 health reform included a health care home (HCH) program, Minnesota’s patient centered medical home. By end of 2014, 43% of HCH eligible clinics were certified with 335 certified HCHs and 430 eligible but not certified clinics.

Objectives: To study the association between adoption and use of EHRs in primary care clinics and HCH certification, including use of clinical decision support tools, patient registries, electronic exchange of patient information, and availability of patient portals.

Methods: Study utilized data from the 2015 Minnesota Health Information Technology Clinic Survey conducted annually by the Minnesota Department of Health. The response rate was 80% with 1,181 of 1,473 Minnesota clinics, including 662 HCH eligible primary care clinics. The comparative analysis focused on certified HCHs (311) and eligible but not certified clinics (351).

Results: HCH clinics utilized the various tools of EHR technology at a higher rate than non-HCH clinics. This greater utilization was noted across a range of functionalities: clinical decision support, patient disease registries, EHR to support quality improvement, electronic exchange of summary care records and availability of patient portals. HCH certification was significant for clinical decision support tools, registries and quality improvement.

Conclusions: HCH requirements of care management, care coordination and quality improvement can be better supported with EHR technology, which underscores the higher rate of utilization of EHR tools by HCH clinics. Optimizing electronic exchange of health information remains a challenge for all clinics, including HCH certified clinics. This research presents the synergy between complementary initiatives supporting EHR adoption and HCH certification. Ultimately, improvement in health outcomes depends on effective intersection of people, processes and technology.

The Association of Electronic Health Record Adoption with Staffing Mix in Community Health Centers

OBJECTIVE

To assess how medical staffing mix changed over time in association with the adoption of electronic health records (EHRs) in community health centers (CHCs).

STUDY SETTING

Community health centers within the 50 states and Washington, DC.

STUDY DESIGN

Estimated how the change in the share of total medical staff full-time equivalents (FTE) by provider category between 2007 and 2013 was associated with EHR adoption using fractional multinomial logit.

DATA COLLECTION

2007-2013 Uniform Data System, an administrative data set of Section 330 federal grant recipients; and Readiness for Meaningful Use and HIT and Patient Centered Medical Home Recognition Survey responses collected from Section 330 recipients between December 2010 and February 2011.

PRINCIPAL FINDINGS

Having an EHR system did significantly shift the share of workers over time between physicians and each of the other categories of health care workers. While an EHR system significantly shifted the share of physician and other medical staff, this effect did not significantly vary over time. CHCs with EHRs by the end of the study period had a relatively greater proportion of other medical staff compared to the proportion of physicians.

CONCLUSIONS

Electronic health records appeared to influence staffing allocation in CHCs such that other medical staff may be used to support adoption of EHRs as well as be leveraged as an important care provider.

Obstacles Experienced by Care Managers in Managing Information for the Care of Chronically Ill Patients

Care managers play a key role in coordinating care, especially for patients with chronic conditions. They use multiple health information technology application in order to access, process and communicate patient-related information. Using the work system model and its extension, the SEIPS model (Carayon et al., 2006a; Smith and Carayon-Sainfort, 1989), we describe obstacles experienced by care manager in managing patient-related information. A web-based questionnaire was used to collect data from 80 care managers (61% response rate) located in clinics, hospitals and a call center. Care managers were more likely to consider 'inefficiencies in access to patient-related information' and 'having to use multiple information systems' as major obstacles than 'lack of computer training and support' and 'inefficient use of case management software.' Care managers who reported inefficient use of software as an obstacle were more likely to report high workload. Future research should explore strategies used by care managers' to address obstacles, and efforts should be targeted at improving the health information technologies used by care managers.

An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act

The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability.