James P. Halloran

Human Factors Barriers to the Effective Use of Ten HIV Clinical Reminders

OBJECTIVE Substantial variations in adherence to guidelines for human immunodeficiency virus (HIV) care have been documented. To evaluate their effectiveness in improving quality of care, ten computerized clinical reminders (CRs) were implemented at two pilot and eight study sites. The aim of this study was to identify human factors barriers to the use of these CRs. DESIGN Observational study was conducted of CRs in use at eight outpatient clinics for one day each and semistructured interviews were conducted with physicians, pharmacists, nurses, and case managers. MEASUREMENTS Detailed handwritten field notes of interpretations and actions using the CRs and responses to interview questions were used for measurement. RESULTS Barriers present at more than one site were (1) workload during patient visits (8 of 8 sites), (2) time to document when a CR was not clinically relevant (8 of 8 sites), (3) inapplicability of the CR due to context-specific reasons (9 of 26 patients), (4) limited training on how to use the CR software for rotating staff (5 of 8 sites) and permanent staff (3 of 8 sites), (5) perceived reduction of quality of provider-patient interaction (3 of 23 permanent staff), and (6) the decision to use paper forms to enable review of resident physician orders prior to order entry (2 of 8 sites). CONCLUSION Six human factors barriers to the use of HIV CRs were identified. Reducing these barriers has the potential to increase use of the CRs and thereby improve the quality of HIV care.

Clinical Case Registries: Simultaneous Local and National Disease Registries for Population Quality Management

The Department of Veterans Affairs (VA) has a system-wide, patient-centric electronic medical record system (EMR) within which the authors developed the Clinical Case Registries (CCR) to support population-centric delivery and evaluation of VA medical care. To date, the authors have applied the CCR to populations with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Local components use diagnosis codes and laboratory test results to identify patients who may have HIV or HCV and support queries on local care delivery with customizable reports. For each patient in a local registry, key EMR data are transferred via HL7 messaging to a single national registry. From 128 local registry systems, over 60,000 and 320,000 veterans in VA care have been identified as having HIV and HCV, respectively, and entered in the national database. Local and national reports covering demographics, resource usage, quality of care metrics and medication safety issues have been generated.

National quality forum performance measures for HIV/AIDS care: the Department of Veterans Affairs' experience.

BACKGROUND Information technology promises to improve health care through reporting of standardized quality-of-care measures. In 2008, the National Quality Forum (NQF) first endorsed performance measures for human immunodeficiency virus (HIV)/AIDS care. Little is known about performance on these measures in routine medical practice. We assessed performance using available electronic data for the large, diverse population with HIV in the Department of Veterans Affairs (VA) and evaluated the influence of patient and resource factors. METHODS In a retrospective analysis of observational data for 21 564 patients with HIV receiving VA medical care in 2008, we determined performance rates for 10 NQF measures for HIV/AIDS care for the VA nationwide and for 73 facilities with caseloads of 100 or more patients with HIV. RESULTS National rates for 6 measures were greater than 80%; the remaining measures and their rates were as follows: annual syphilis screening (54%), tuberculosis screening (65%), Pneumocystis pneumonia prophylaxis (72%), and HIV RNA control (73%). For all measures, rates varied across facilities. In multivariate logistic regression models, African Americans and hard drug users were less likely to access care and less likely to receive HIV-specific care but more likely to receive indicated general medical care. Resource factors (number of primary care/infectious disease outpatient visits, duration of care, and larger facility caseload) were associated with increased likelihood of receipt of indicated general and HIV-specific care. CONCLUSIONS National performance rates were generally high, but variation in rates across facilities revealed room for improvement. Both patient and resource factors had an impact on the likelihood of receipt of indicated care.

An HIV Collaborative in the VHA: Do Advanced HIT and One-Day Sessions Change the Collaborative Experience?

BACKGROUND Many organizations participate in quality collaboratives, yet the return on investment of the associated time and costs is unclear. METHOD Semistructured interviews, surveys, and direct observation were used to assess experiences, improvement activities, and costs associated with participation in a year-long modified Institute for Healthcare Improvement-style collaborative designed to improve HIV care within the Veterans Health Administration. All nine sites had access to automated patient registries and semi-automated clinical measure reports; five sites also received computerized clinical reminders. Three one-day learning sessions were conducted. RESULTS Participants reported that burden was small and value high, although many suggested that more time for peer-to peer learning would have been helpful. Teams averaged five quality improvement activities per site and most reported improvements in HIV care processes. The average annual cost per site was dollars 28,000 but costs varied considerably by site. DISCUSSION Shortened learning sessions and the incorporation of health information technology can reduce some of the costs and burdens associated with collaboratives, yet peer-to-peer interaction and local organizational factors remain important to ensuring perceived effectiveness of collaboratives.

‘A routine thing’: clinician strategies for implementing HIV testing for at-risk patients in a busy healthcare organisation (and implications for implementation of other new practice recommendations)

Increasing HIV testing is a necessary step toward control of the disease. Many experts suggest routinely offering HIV testing to specific population segments. We explore provider discourse regarding an HIV test implementation project with the aim of illuminating a structurally emergent clinician strategy for promoting testing and the socio-cultural factors underlying it. Twenty US Veterans Affairs Healthcare System clinical care providers were interviewed. Using standard anthropological text analysis techniques, themes, their relationships, and the significance of these for increasing appropriately targeted HIV test offers were established. Presenting the HIV test offer to their patients as if routine (‘routinisation’) supported providers’ desire to do no harm by lessening the tests potential stigma. Offering the test helped providers maintain professional integrity: it empowered veterans to realise access to care and fit with providers’ sense of honour and duty. Routinising HIV testing also helped providers to manage scarce time effectively. Findings can be leveraged to support routine screenings successful roll-out. The carefully managed introduction of routine HIV test offering policies will formalise and legitimise productive strategies of destigmatisation already being enacted by some front-line providers. The fact that routinisation strategies are in use although HIV testing is not actually routine attests to the potential power routinisation has to reduce HIVs stigma, increase HIV test uptake, and thereby improve access to care. What I’ve learned about tough questions is: The more routine you make them, the easier it is to get the questions answered, the less destructive it is to the relationship and thats the sort of paradigm I’ve come to believe in and will use now into the future. (Marvin K, MD)

Assessment of the Quality of Diabetes Care for HIV-Infected Patients in a National Health Care System

Combination antiretroviral treatment has markedly reduced morbidity and mortality from HIV-related complications. Consequently, age-related medical conditions such as diabetes, hypertension and ischemic heart disease are rapidly becoming the leading causes of death among HIV-infected patients making the quality of their health care for these conditions increasingly important. The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of U.S. managed health care plans as well as the U.S. Department of Veterans Affairs (VA), to measure quality of medical care including diabetes care. The VA is the largest single provider of HIV care in the United States. In 2009, over 100 VA facilities across the country provided care to over 24,000 HIV-infected veterans, of whom approximately 20% had diabetes. Mindful of the prevalence of diabetes in the VA HIV population, the increasing importance of diabetes as a cause of death among HIV-infected patients, and the widespread use of the HEDIS measures, we performed a retrospective cohort study to document VA performance in 2009 on seven HEDIS Comprehensive Diabetes Care (CDC) measures for the large VA population with both HIV and diabetes. We qualitatively compared the performance rates on these measures to reported rates for all diabetics in VA, and for diabetics seen in commercial, Medicare and Medicaid health maintenance organizations (HMOs). We also examined performance rates across VA facilities and the extent to which high performance on one measure was related to high performance on multiple measures. The data for this analysis were drawn from the VA’s national Clinical Case Registry (CCR) which includes information on diagnosis codes (International Classification of Diseases, Ninth Revision [ICD-9]), laboratory results, medications, outpatient visits and procedures (Current Procedure Terminology [CPT]). To be included in the study cohort, a veteran had to be in VA care in 2009, have laboratory confirmation of HIV infection, be between the ages of 18 and 75 and alive as of December 31, 2009, and meet the HEDIS definition for a diagnosis of type 1 or type 2 diabetes (as indicated by specified ICD-9 codes or an outpatient prescription fill for insulin or a qualifying oral hypoglycemic/antihyperglycemic). For each patient we then determined whether the performance criteria had been met for each of the seven HEDIS CDC measures: