J. Mac McCullough

Electronic health information exchange in underserved settings: examining initiatives in small physician practices & community health centers

BackgroundHealth information exchange (HIE) is an important tool for improving efficiency and quality and is required for providers to meet Meaningful Use certification from the United States Centers for Medicare and Medicaid Services. However widespread adoption and use of HIE has been difficult to achieve, especially in settings such as smaller-sized physician practices and federally qualified health centers (FQHCs). We assess electronic data exchange activities and identify barriers and benefits to HIE participation in two underserved settings.MethodsWe conducted key-informant interviews with stakeholders at physician practices and health centers. Interviews were recorded, transcribed, and then coded in two waves: first using an open-coding approach and second using selective coding to identify themes that emerged across interviews, including barriers and facilitators to HIE adoption and use.ResultsWe interviewed 24 providers, administrators and office staff from 16 locations in two states. They identified barriers to HIE use at three levels—regional (e.g., lack of area-level exchanges; partner organizations), inter-organizational (e.g., strong relationships with exchange partners; achieving a critical mass of users), and intra-organizational (e.g., type of electronic medical record used; integration into organization’s workflow). A major perceived benefit of HIE use was the improved care-coordination clinicians could provide to patients as a direct result of the HIE information. Utilization and perceived benefit of the exchange systems differed based on several practice- and clinic-level factors.ConclusionsThe adoption and use of HIE in underserved settings appears to be impeded by regional, inter-organizational, and intra-organizational factors and facilitated by perceived benefits largely at the intra-organizational level. Stakeholders should consider factors both internal and external to their organization, focusing efforts in changing modifiable factors and tailoring HIE efforts based on all three categories of factors. Collective action between organizations may be needed to address inter-organizational and regional barriers. In the interest of facilitating HIE adoption and use, the impact of interventions at various levels on improving the use of electronic health data exchange should be tested.

Patterns and Correlates of Public Health Informatics Capacity Among Local Health Departments

Objective: Little is known about the nationwide patterns in the use of public health informatics systems by local health departments (LHDs) and whether LHDs tend to possess informatics capacity across a broad range of information functionalities or for a narrower range. This study examined patterns and correlates of the presence of public health informatics functionalities within LHDs through the creation of a typology of LHD informatics capacities. Methods: Data were available for 459 LHDs from the 2013 National Association of County and City Health Officials Profile survey. An empirical typology was created through cluster analysis of six public health informatics functionalities: immunization registry, electronic disease registry, electronic lab reporting, electronic health records, health information exchange, and electronic syndromic surveillance system. Three-categories of usage emerged (Low, Mid, High). LHD financial, workforce, organization, governance, and leadership characteristics, and types of services provided were explored across categories. Results: Low-informatics capacity LHDs had lower levels of use of each informatics functionality than high-informatics capacity LHDs. Mid-informatics capacity LHDs had usage levels equivalent to high-capacity LHDs for the three most common functionalities and equivalent to low-capacity LHDs for the three least common functionalities. Informatics capacity was positively associated with service provision, especially for population-focused services. Conclusion: Informatics capacity is clustered within LHDs. Increasing LHD informatics capacity may require LHDs with low levels of informatics capacity to expand capacity across a range of functionalities, taking into account their narrower service portfolio. LHDs with mid-level informatics capacity may need specialized support in enhancing capacity for less common technologies.

Impact of clinical decision support on receipt of antibiotic prescriptions for acute bronchitis and upper respiratory tract infection.

OBJECTIVE Antibiotics are commonly recognized as non-indicated for acute bronchitis and upper respiratory tract infection (URI), yet their widespread use persists. Clinical decision support in the form of electronic warnings is hypothesized to prevent non-indicated prescriptions. The purpose of this study was to identify the effect of clinical decision support on a common type of non-indicated prescription. MATERIALS AND METHODS Using National Ambulatory Medical Care Survey data from 2006 to 2010, ambulatory visits with a primary diagnosis of acute bronchitis or URI and orders for antibiotic prescriptions were identified. Visits were classified on the basis of clinician report of decision-support use. Generalized estimating equations were used to assess the effect of decision support on likelihood of antibiotic prescription receipt, controlling for patient, provider, and practice characteristics. RESULTS Clinician use of decision support increased sharply between 2006 (16% of visits) and 2010 (55%). Antibiotic prescribing for acute bronchitis and URI increased from ∼35% of visits in 2006 to ∼45% by 2010. Use of decision support was associated with a 19% lower likelihood of receiving an antibiotic prescription, controlling for patient, provider, and practice characteristics. DISCUSSION In spite of the increased use of decision-support systems and the relatively fewer non-indicated antibiotic prescriptions resulting from the use of decision support, a secular upward trend in non-indicated antibiotic prescribing offset these improvements. CONCLUSIONS The overall effect of decision support suggests an important role for technology in reducing non-indicated prescriptions. Decision support alone may not be sufficient to eliminate non-indicated prescriptions given secular trends.

Evolution of the nation's blood supply system

A fter the human immunodeficiency virus epidemic, changes began in the US blood supply system. Quality and regulatory activities became more stringent, blood supply organizations became more business-like, and operations and finances became more tightly managed. Longstanding unspoken understandings regarding donor groups and hospital service areas were no longer recognized and competition for hospital blood contracts and for donor groups emerged. At the same time, efforts to contain health care costs caused hospitals to press for lower costs for their blood supply. Recently new medical data regarding indications for transfusion, the management of anemic or bleeding patients, and the complications of transfusion have appeared. It is clear that patients can be maintained at lower hemoglobin levels than have been the longstanding custom. Robotic, minimally invasive, and other surgical techniques have led to decreases in surgically related blood transfusion. Pharmacologic agents such as erythropoietin or tranexamic acid have eliminated transfusion in some situations. Implementing these practice changes using blood management programs is a positive for patients, but has resulted in declining blood use, which has led to decreasing revenue for blood supply organizations. These organizations are now experiencing major financial pressure in attempts to reset production capacity while implementing technology, regulatory, and quality developments. While revenues decline, there have been increased costs. Screening tests such as West Nile virus and Trypanosoma cruzi and bacterial culture of platelets (PLTs) have been added. Some test methods involve DNA amplification and thus must be done in complex laboratories. These factors and changes have transformed the organizations that provide the nation’s blood supply into barebones operations, with little product development and tense competition for hospital contracts and blood donors. There has been wonderful innovation in transfusion medicine supported by blood centers, federal funding, industry, and universities. Federal funding continues at a substantially reduced level, but there is almost no support for innovation from the other three sources. Industry is no longer willing to develop new products as there is little likelihood that the innovations will be implemented. There has even been a call for federal mandate as a way to introduce innovation. As a result, blood supply organizations are exploring new organizational structures and strategic alliances including: 1) affiliations, 2) purchasing groups, 3) partnerships, and 4) networks. However, these strategies do not constitute sufficient integration and alignment to respond effectively to the turbulent market conditions. With a few exceptions, true integration is not yet occurring and the benefits of consolidation will not be achieved. For example, there is continuation of multiple Food and Drug Administration (FDA) licenses, overlapping sets of standard operating procedures, inconsistent policies regarding donor selection and deferral, quality systems, conflicting approaches to regulatory affairs, and multiple accounting and software systems are coexisting. Providing blood and blood products is costly. Some activities can be carried out more efficiently by larger organizations through economy of scale. However, while the United States has seen consolidation across many of its health care sectors, that impact on quality (i.e., patient outcomes) is less clear. “The harsh reality is that it is difficult to find well-documented examples of health care mergers that have generated measurably better outcomes or lower overall costs.” As hospitals, health insurers, and physician groups have experienced, cost pressures usually lead to a smaller number of larger organizations thus altering the current structure; yet the same tools, tests, and workflow are still likely to be in place. There is very little evidence that mergers improve quality and costs will not necessarily decrease. Thus, policy makers should anticipate that a new blood supply system will develop.

Local health and social services expenditures: An empirical typology of local government spending

The conceptual importance of social services to health outcomes is well known and recent empirical evidence has linked social services spending to better population health outcomes. Yet little research has been devoted to what social services spending actually entails as it relates to population health and whether broadly similar spending patterns may exist across communities. The purpose of this study was to identify empirical patterns in spending, and explore health status and outcome correlates with social services spending. Spending data come from the 2012 U.S. Census Bureaus Census of Governments, which includes spending data for 14 social services within 3129 U.S. counties. Additional 2012 demographic, socioeconomic, and population health data were obtained and analyzed at the county-level in 2017. Hierarchical cluster analysis revealed 5 clusters of counties according to local government spending. One group had significantly lower income, social services spending, health indicators, and health outcomes than other counties. Two other groups had relatively high income, high social services spending, and strong health outcomes and indicators. Yet these latter two groups invested differently, with one spreading spending across a larger number of social services and the other concentrating spending in a smaller number of services such as education. Determining the extent to which spending approaches contribute to population health may offer communities guidance for maximizing population health. While it cannot establish causality, this study adds to the literature regarding the ways in which communities invest in both health care and social services to prevent disease and promote population health.

Timing of Clinical Billing Reimbursement for a Local Health Department

Objectives. A major responsibility of a local health department (LHD) is to assure public health service availability throughout its jurisdiction. Many LHDs face expanded service needs and declining budgets, making billing for services an increasingly important strategy for sustaining public health service provision. Yet, little practice-based data exist to guide practitioners on what to expect financially, especially regarding timing of reimbursement receipt. This study provides results from one LHD on the lag from service delivery to reimbursement receipt. Methods. Reimbursement records for all transactions at Maricopa County Department of Public Health immunization clinics from January 2013 through June 2014 were compiled and analyzed to determine the duration between service and reimbursement. Outcomes included daily and cumulative revenues received. Time to reimbursement for Medicaid and private payers was also compared. Results. Reimbursement for immunization services was received a median of 68 days after service. Payments were sometimes taken back by payers through credit transactions that occurred a median of 333 days from service. No differences in time to reimbursement between Medicaid and private payers were found. Conclusions. Billing represents an important financial opportunity for LHDs to continue to sustainably assure population health. Yet, the lag from service provision to reimbursement may complicate budgeting, especially in initial years of new billing activities. Special consideration may be necessary to establish flexibility in the budget-setting processes for services with clinical billing revenues, because funds for services delivered in one budget period may not be received in the same period. LHDs may also benefit from exploring strategies used by other delivery organizations to streamline billing processes.

Local Health Departments' Partners and Challenges in Electronic Exchange of Health Information

The health care sector is undergoing a health information technology and informatics revolution with an unprecedented volume of health information being created, presenting opportunities for local health departments to access these data. This study utilizes novel, nationwide data to explore the current capacity for electronically exchanging information at local health departments, and the barriers to such an exchange.

Clinical Data Systems to Support Public Health Practice: A National Survey of Software and Storage Systems Among Local Health Departments.

Although numerous software and data storage systems are used by local health departments to manage clinical and nonclinical data needs, information is lacking regarding current usage patterns. This study examines and analyzes current usage of clinical data storage and software types by local health departments and identifies characteristics of local health departments associated with these usage patterns.