Cynthia J. Sieck

Worksite cardiovascular wellness programs as a route to substance abuse prevention.

This study addresses the question of worksites as an effective route to alcohol abuse prevention. Hypotheses tested include: (1) Cardiovascular disease risk reduction programs provide effective access for alcohol behavior change. (2) Proactive outreach and follow-up have more impact on health behavior change than health education classes. (3) Ongoing follow-up counseling produces the most behavior change. (4) Screening alone produces little change. The study population included 2000 employees, recruited through cardiovascular disease health screening, who were randomly assigned to individual outreach or classes interventions. Changes in the organization of work required more visible outreach, which produced demands for counseling services from many employees who were not in the original group targeted for outreach. After 3 years of intervention, rescreening results strongly supported hypotheses 1 and 2. Spill-over effects from counseling produced plant-wide improvements, so that hypotheses 3 and 4 were not confirmed. This demonstrates that highly visible outreach provides a cost-effective strategy for cardiovascular disease and alcohol prevention.

Evidence-based management of ambulatory electronic health record system implementation: An assessment of conceptual support and qualitative evidence

OBJECTIVES While electronic health record (EHR) systems have potential to drive improvements in healthcare, a majority of EHR implementations fall short of expectations. Shortcomings in implementations are often due to organizational issues around the implementation process rather than technological problems. Evidence from both the information technology and healthcare management literature can be applied to improve the likelihood of implementation success, but the translation of this evidence into practice has not been widespread. Our objective was to comprehensively study and synthesize best practices for managing ambulatory EHR system implementation in healthcare organizations, highlighting applicable management theories and successful strategies. METHODS We held 45 interviews with key informants in six U.S. healthcare organizations purposively selected based on reported success with ambulatory EHR implementation. We also conducted six focus groups comprised of 37 physicians. Interview and focus group transcripts were analyzed using both deductive and inductive methods to answer research questions and explore emergent themes. RESULTS We suggest that successful management of ambulatory EHR implementation can be guided by the Plan-Do-Study-Act (PDSA) quality improvement (QI) model. While participants did not acknowledge nor emphasize use of this model, we found evidence that successful implementation practices could be framed using the PDSA model. Additionally, successful sites had three strategies in common: 1) use of evidence from published health information technology (HIT) literature emphasizing implementation facilitators; 2) focusing on workflow; and 3) incorporating critical management factors that facilitate implementation. CONCLUSIONS Organizations seeking to improve ambulatory EHR implementation processes can use frameworks such as the PDSA QI model to guide efforts and provide a means to formally accommodate new evidence over time. Implementing formal management strategies and incorporating new evidence through the PDSA model is a key element of evidence-based management and a crucial way for organizations to position themselves to proactively address implementation and use challenges before they are exacerbated.

Information technology to support patient engagement: where do we stand and where can we go?

Objective Given the strong push to empower patients and make them partners in their health care, we evaluated the current capability of hospitals to offer health information technology that facilitates patient engagement (PE). Materials and Methods Using an ontology mapping approach, items from the American Hospital Association Information Technology Supplement were mapped to defined levels and categories within the PE Framework. Points were assigned for each health information technology function based upon the level of engagement it encompassed to create a PE-information technology (PE-IT) score. Scores were divided into tertiles, and hospital characteristics were compared across tertiles. An ordered logit model was used to estimate the effect of characteristics on the adjusted odds of being in the highest tertile of PE-IT scores. Results Thirty-six functions were mapped to specific levels and categories of the PE Framework, and adoption of each item ranged from 23.5 to 96.7%. Hospital characteristics associated with being in the highest tertile of PE-IT scores included medium and large bed size (relative to small), nonprofit (relative to government nonfederal), teaching hospital, system member, Midwest and South regions, and urban location. Discussion Hospital adoption of PE-oriented technology remains varied, suggesting that hospitals are considering how technology can create partnerships with patients. However, PE functionalities that facilitate higher levels of engagement are lacking, suggesting room for improvement. Conclusion While hospitals have reached modest levels of adoption of PE technologies, consistent monitoring of this capacity can identify opportunities to use technology to facilitate engagement.

Connecting Emergency Department Patients to Primary Care

Background: Inappropriate emergency department (ED) use among Medicaid enrollees is considered a problem because of cost. We developed and evaluated a system change innovation designed to remove system barriers to primary care access for Medicaid patients. Methods: Patients who presented to the ED without an identified primary care provider were randomized to the intervention (n = 72) or comparison group (n = 68) for a 12-month study designed to connect these patients to primary care offices. Evaluation was mixed quantitative/qualitative. Results: Significantly more intervention participants attended at least 1 primary care visit 3 months after the intervention (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.06–6.02), though this difference was not significant by 12 months (OR, 1.74; 95% CI, 0.79–3.84). The intervention participants also did not have lower odds of returning to the ED for nonurgent reasons by the 12-month follow-up (OR, 1.27; 95% CI, 0.65–2.48). Patient-reported barriers to attending a primary care appointment were primarily social and health system–related factors. Conclusion: The intervention did not decrease ED visits nor increase primary care use over the 12 months of the study period. The qualitative results provide insight into nonurgent ED utilization by patients with Medicaid, suggesting potential future interventions.

Meaningful Engagement of ACOs With Communities: The New Population Health Management.

Objectives:Population health management (PHM) activities within health care organizations have traditionally focused on coordinating services for populations who present for care in physicians’ offices. With the recent proliferation of Accountable Care Organizations (ACOs), however, the reach of PHM has expanded. We aimed to study ACOs’ evolving definitions of their patient populations, and how these definitions might be linked to different types of PHM activities pursued by ACOs. Methods:Over a 2-year period, we conducted in-depth case studies of 4 ACOs operating in the private sector, including 149 interviews with 89 informants. Although the main study focused on the ACO implementation process, our use of both inductive and deductive qualitative methods enabled us to study emergent topics such as we report here about PHM. Results:Interviewees across sites described their ACO populations using terms indicating both panel management and community/neighborhood involvement in the context of PHM. Further, all 4 sites reported conducting PHM activities that extended beyond traditional provider-based PHM; these ranged from wellness registries to school-based clinics. Executives at all 4 ACOs also discussed providing, or planning to provide, health care services to all community members in local settings. Conclusions:Administrators and physicians in private sector ACOs were proponents of ACO-led programs delivered in community settings that provided health care to all members of the community, and reported their ACOs engaged in multisector collaborations designed to improve neighborhood health. These community engagement activities point to a distinction from 90s era managed and integrated care organizations and may contribute to the sustainability of the ACO model.

Fundamental issues in implementing an ambulatory care electronic health record.

Background: The use of a fully functional electronic health record (EHR) system is linked to improved quality measures. However, almost half of ambulatory providers with an EHR do not use the full functionality. Attempts to encourage optimal use of EHRs must address barriers associated with the need to change medical practice. Methods: Our primary research question was, what are the fundamental issues associated with the need to change medical practice that created barriers to electronic health record (EHR) implementation and use? In this qualitative study we analyzed the data from 47 interviews with administrative and physician informants and 6 focus groups including 35 practicing physicians across 6 health care organizations that were deemed to be successful with ambulatory EHR implementation. Results: Comments from informants revealed 6 fundamental issues: (1) need to change practice style; (2) threat to professionalism; (3) shift of expertise; (4) required changes to interactions with patients; (5) concern about the impact on medical education and training; and (6) concern about effects on clinical care. Conclusion: The physician experience must be at the forefront of efforts to increase the rate of ambulatory physician use of the full functionalities of an EHR. The issues highlighted here illuminate potential points of intervention when engaging physicians to ensure optimal use of EHRs.

A healthcare utilization cost comparison between employees receiving a worksite mindfulness or a diet/exercise lifestyle intervention to matched controls 5 years post intervention

OBJECTIVE To compare healthcare costs and utilization among participants in a study of two active lifestyle interventions implemented in the workplace and designed to foster awareness of and attention to health with a propensity score matched control group. DESIGN AND SETTING We retrospectively compared changes in healthcare (HC) utilization among participants in the mindfulness intervention (n=84) and the diet/exercise intervention (n=86) to a retrospectively matched control group (n=258) drawn for this study. The control group was matched from the non-participant population on age, gender, relative risk score, and HC expenditures in the 9 month preceding the study. MAIN OUTCOME MEASURES Measures included number of primary care visits, number and cost of pharmacy prescriptions, number of hospital admissions, and overall healthcare costs tracked for 5 years after the intervention. RESULTS Significantly fewer primary care visits (p<.001) for both intervention groups as compared to controls, with a non-significant trend towards lower overall HC utilization (4,300.00 actual dollar differences) and hospital admissions for the intervention groups after five years. Pharmacy costs and number of prescriptions were significantly higher for the two intervention groups compared to controls over the five years (p<0.05), yet still resulted in less HC utilization costs, potentially indicating greater self-management of care. CONCLUSION This study provides valuable information as to the cost savings and value of providing workplace lifestyle interventions that focus on awareness of ones body and health. Health economic studies validate the scale of personal and organization health cost savings that such programs can generate.

The Challenge of Improving Breast Cancer Care Coordination in Safety-net Hospitals: Barriers, Facilitators, and Opportunities.

Background:Minority breast cancer patients tend to have higher rates of adjuvant treatment underuse. We implemented a web-based intervention that closes referral loops between surgeons and oncologists at inner-city safety-net hospitals serving high volumes of minority breast cancer patients to assist these hospitals and improve care coordination. Research Design:Following intervention implementation, we conducted interviews with key personnel to improve our understanding of the implementation process and to identify barriers, facilitators, and opportunities for improvement. We used the constant comparative method of analysis to code interview transcripts and identify common themes regarding intervention implementation. Subjects:We interviewed 64 administrative and clinical key informants from 10 inner-city safety-net hospitals with high volumes of minority breast cancer patients. Results:We found substantial barriers to implementing an intervention designed to support care coordination efforts, despite initial feedback that the intervention itself was both easy to use and in line with organizational goals. We also characterized facilitators and challenges of breast cancer care coordination in the safety-net environment, as well as opportunities to improve intervention design to support increased quality of breast cancer care. Conclusions:Coordination of care for women with breast cancer is extremely important, but safety-net hospitals face considerable resource constraints from lack of time, support, and information systems. As safety-net hospital networks grow across numerous care sites, the challenge of care coordination will likely increase, highlighting the importance of interventions that can be successfully implemented and used to promote better care.

A 3-Year Assessment of the Effects of a Self-Administered Health Risk Assessment on Health Care Utilization, Costs, and Health Risks

Objective: This study examines the effect of taking a health risk assessment (HRA) on health care costs, utilization, and member health risks over a 3-year period. Methods: This retrospective cohort study examined changes utilization, costs, and health risks among a random sample of 500 employees completing an HRA compared with a matched group of 500 employees who did not complete an HRA. Results: The HRA group accessed services more frequently and at a lower overall cost, was more likely to utilize primary care and preventive services after the HRA, and improved on seven out of eight health risk measures. Conclusions: This study demonstrates that significant and sustained improvement in health risks and lower health care costs may be achievable with efforts such as an HRA that seeks to engage employees in health improvement efforts.

A Pragmatic Introduction of Mindfulness in a Continuing Education Setting: Exploring Personal Experience, Bridging to Professional Practice

Context: Continuing Medical Education and Continuing Professional Education (CME/CPE) provide a context through which to introduce practicing Healthcare Professionals (HCPs) to emerging mind/body approaches. Objective: To introduce mindfulness to practicing HCPs for application in their practice through an experiential CME/CPE session. Design: This descriptive study included surveys administered in the context of a CME/CPE session at professional meetings, as well as a three‐month follow‐up survey. Setting: The mindfulness session was administered at 5 state‐wide professional CME/CPE meetings throughout Ohio. Participants: Participants practicing dieticians, nurses, psychologists, and smoking cessation educators, among others. Intervention: A brief experiential introduction to mindfulness and the potential application within healthcare. Measures: These included participants prior awareness and use of Complementary and Alternative Medicine (CAM) techniques, and subsequent likelihood of investigating these modalities further for personal and professional use. Results: 64.4% of HCPs had used CAM for personal use and 49.3% had used CAM in their clinical practice, while 74.8% of HCPs had been asked by patients about CAM and 84.3% of the HCPs perceived a need for more education on CAM.94.79% of respondents reported likeliness to investigate mindfulness for personal use and 92.58% for professional use. Conclusion: A brief mindfulness intervention for HCPs utilizing a CME/CPE mechanism is a feasible and effective way to introduce HCPs to a mind/body therapy such as mindfulness. CME/CPE instruction ensures that the information provided is in line with evidenced based practice and an experiential component of the instruction demonstrates for the HCP an appropriate use of CAM with patients.