Larry Gamm

Health information exchange: persistent challenges and new strategies

Recent federal policies and actions support the adoption of health information exchange (HIE) in order to improve healthcare by addressing fragmented personal health information. However, concerted efforts at facilitating HIE have existed for over two decades in this country. The lessons of these experiences include a recurrence of barriers and challenges beyond those associated with technology. Without new strategies, the current support and methods of facilitating HIE may not address these barriers.

A critical review of the research literature on Six Sigma, Lean and StuderGroup's Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare.

BackgroundU.S. healthcare organizations are confronted with numerous and varied transformational strategies promising improvements along all dimensions of quality and performance. This article examines the peer-reviewed literature from the U.S. for evidence of effectiveness among three current popular transformational strategies: Six Sigma, Lean/Toyota Production System, and Studers Hardwiring Excellence.MethodsThe English language health, healthcare management, and organizational science literature (up to December 2007) indexed in Medline, Web of Science, ABI/Inform, Cochrane Library, CINAHL, and ERIC was reviewed for studies on the aforementioned transformation strategies in healthcare settings. Articles were included if they: appeared in a peer-reviewed journal; described a specific intervention; were not classified as a pilot study; provided quantitative data; and were not review articles. Nine references on Six Sigma, nine on Lean/Toyota Production System, and one on StuderGroup meet the studys eligibility criteria.ResultsThe reviewed studies universally concluded the implementations of these transformation strategies were successful in improving a variety of healthcare related processes and outcomes. Additionally, the existing literature reflects a wide application of these transformation strategies in terms of both settings and problems. However, despite these positive features, the vast majority had methodological limitations that might undermine the validity of the results. Common features included: weak study designs, inappropriate analyses, and failures to rule out alternative hypotheses. Furthermore, frequently absent was any attention to changes in organizational culture or substantial evidence of lasting effects from these efforts.ConclusionDespite the current popularity of these strategies, few studies meet the inclusion criteria for this review. Furthermore, each could have been improved substantially in order to ensure the validity of the conclusions, demonstrate sustainability, investigate changes in organizational culture, or even how one strategy interfaced with other concurrent and subsequent transformation efforts. While informative results can be gleaned from less rigorous studies, improved design and analysis can more effectively guide healthcare leaders who are motivated to transform their organizations and convince others of the need to employ such strategies. Demanding more exacting evaluation of projects consultants, or partnerships with health management researchers in academic settings, can support such efforts.

Electronic medical records: are physicians ready?

The use of electronic medical records (EMR) in healthcare organizations will require substantial changes in the way physicians and their staff provide patient care. This study is the first part of a larger study assessing factors that influence successful implementation of EMR in ambulatory care settings. The purposes of this study were to identify specific attitudes or factors that should be targeted before implementating an EMR project, and demonstrate empirical support for a model of perceived usefulness of EMR. We found that computer experience, computer anxiety, and perceptions of organizational support predict the degree to which physicians and mid-level practitioners view the EMR effort positively. Strategies for the successful management of EMR implementation include engaging the physicians and practitioners in computer activities prior to implementation and providing strong organizational support before and during the redesign effort. Acceptance of EMR by physicians and their support staff is essential if computerization is to be successful, yet anecdotal reports of resistance and negative attitudes are frequently reported. Empirical studies indicate that physicians have not yet embraced this technology. As part of strategic planning and deployment of a computerized patient record, attitudes of end-users must be assessed. Using an integrative framework from the job design literature and management information sciences, we propose that multiple factors influence attitudes toward EMR, offer a conceptual model of end-user acceptance, and present findings from an empirical test of our model.

Determinants of preventable readmissions in the United States: a systematic review

BackgroundHospital readmissions are a leading topic of healthcare policy and practice reform because they are common, costly, and potentially avoidable events. Hospitals face the prospect of reduced or eliminated reimbursement for an increasing number of preventable readmissions under nationwide cost savings and quality improvement efforts. To meet the current changes and future expectations, organizations are looking for potential strategies to reduce readmissions. We undertook a systematic review of the literature to determine what factors are associated with preventable readmissions.MethodsWe conducted a review of the English language medicine, health, and health services research literature (2000 to 2009) for research studies dealing with unplanned, avoidable, preventable, or early readmissions. Each of these modifying terms was included in keyword searches of readmissions or rehospitalizations in Medline, ISI, CINAHL, The Cochrane Library, ProQuest Health Management, and PAIS International. Results were limited to US adult populations.ResultsThe review included 37 studies with significant variation in index conditions, readmitting conditions, timeframe, and terminology. Studies of cardiovascular-related readmissions were most common, followed by all cause readmissions, other surgical procedures, and other specific-conditions. Patient-level indicators of general ill health or complexity were the commonly identified risk factors. While more than one study demonstrated preventable readmissions vary by hospital, identification of many specific organizational level characteristics was lacking.ConclusionsThe current literature on preventable readmissions in the US contains evidence from a variety of patient populations, geographical locations, healthcare settings, study designs, clinical and theoretical perspectives, and conditions. However, definitional variations, clear gaps, and methodological challenges limit translation of this literature into guidance for the operation and management of healthcare organizations. We recommend that those organizations that propose to reward reductions in preventable readmissions invest in additional research across multiple hospitals in order to fill this serious gap in knowledge of great potential value to payers, providers, and patients.

Factors motivating and affecting health information exchange usage.

OBJECTIVE Health information exchange (HIE) is the process of electronically sharing patient-level information between providers. However, where implemented, reports indicate HIE system usage is low. The aim of this study was to determine the factors associated with different types of HIE usage. DESIGN Cross-sectional analysis of clinical data from emergency room encounters included in an operational HIE effort linked to system user logs using crossed random-intercept logistic regression. MEASUREMENTS Independent variables included factors indicative of information needs. System usage was measured as none, basic usage, or a novel pattern of usage. RESULTS The system was accessed for 2.3% of all encounters (6142 out of 271,305). Novel usage patterns were more likely for more complex patients. The odds of HIE usage were lower in the face of time constraints. In contrast to expectations, system usage was lower when the patient was unfamiliar to the facility. LIMITATIONS Because of differences between HIE efforts and the fact that not all types of HIE usage (ie, public health) could be included in the analysis, results are limited in terms of generalizablity. CONCLUSIONS This study of actual HIE system usage identifies patients and circumstances in which HIE is more likely to be used and factors that are likely to discourage usage. The paper explores the implications of the findings for system redesign, information integration across exchange partners, and for meaningful usage criteria emerging from provisions of the Health Information Technology for Economic & Clinical Health Act.

Medical homes: "where you stand on definitions depends on where you sit".

The medical home is a potentially transformative strategy to address issues of access, quality, and efficiency in the delivery of health care in the United States. While numerous organizations support a physician-driven definition, it is by no means the universally accepted definition. Several professional groups, payers, and researchers have offered differing, or nuanced, definitions of medical homes. This lack of consensus has contributed to uncertainty among providers about the medical home. We conducted a systematic review of the literature on the medical home and identified 29 professional, government, and academic sources offering definitions. While consensus appears to exist around a core of selected features, the medical home means different things to different people. The variation in definitions can be partly explained by the obligation of organizations to their members and whether the focus is on the patient or provider. Differences in definitions have implications at both the policy and practice levels.

Advancing community health through community health partnerships.

EXECUTIVE SUMMARY Improving a communitys health is a key goal of health services organizations. Effectively pursuing that goal requires health services organizations to create partnerships with other organizations to help identify community health needs and to create and carry out programs that bring together community members and needed health services. Drawing on community systems concepts and a recent study of community health partnership efforts in three cities, this article provides a framework for such partnerships. Types of partnerships described include: Community action partnerships, in which the partnership forms to address a specific problem or pursue a specific opportunity; Community organization partnerships, in which a set of organizations in a similar service sector agree to collaborate for mutually agreed upon goals; and Community development partnerships, in which a partnership attempts to increase participation by people and organizations in collaborative activities that advance the community on multiple fronts or that contribute to community assets and services in multiple areas. The article also describes how the pressures to create large integrated delivery systems can affect creation of partnerships to improve community health. Increasingly, healthcare leaders are being held accountable for the health of communities they serve. When creating partnerships for community health and carrying out health‐improvement activities, leaders should be aware of and respond to four key dimensions of accountability: political accountability, commercial accountability, clinical/patient accountability, and community accountability.

Dimensions of Accountability for Not-for-Profit Hospitals and Health Systems

This article examines four dimensions of accountability as they apply to not-for-profit hospitals and health systems: political accountability, particularly relating to the retention of tax-exempt status; commercial accountability associated with the nonprofit hospitals role of selling low cost and high value health services to a variety of commercial payers; community accountability in terms of addressing community health and other social needs, and clinical/patient accountability in terms of access and quality outcomes.

Bedside Shift Reports: What Does the Evidence Say?

Bedside shift reports are viewed as an opportunity to reduce errors and important to ensure communication between nurses and communication. Models of bedside report incorporating the patient into the triad have been shown to increase patient engagement and enhance caregiver support and education. Nurse shift reports and nurse handovers are 2 of the most critical processes in patient care that can support patient safety and reduce medical errors in the United States. Nurses continue to not recognize the evidence supporting this practice and adopt bedside report into practice.

Rural Healthy People 2010, 2020, and beyond: the need goes on.

Rural Healthy People 2010 represented the first effort to specifically include small and rural communities in the Healthy People movement to improve the health of Americans. Rural Healthy People 2010 set rural-specific health priority areas, documented what is known about health in rural areas, identified rural best practice programs/interventions, and promoted rural health services research and researchers. Over the last decade Rural Healthy People 2010 has provided policy makers, rural providers, and rural communities with a valuable resource for planning and policy making. Sustaining the Rural Healthy People project in collaboration with the broader Healthy People 2020 effort will provide an important infrastructure for improving rural health.