Peter Gordon

HIV patients’ willingness to share personal health information electronically

OBJECTIVEnTo assess the attitudes of persons living with HIV/AIDS (PLWH) towards having their personal health information (PHI) stored and shared electronically.nnnMETHODSnPLWH (n = 93) in New York City completed surveys using audio computer-assisted self-interview (ACASI) that assessed willingness to share their PHI with various people and entities via a secure electronic network. The survey also included questions on satisfaction with and trust of health care providers, current health, HIV-associated stigma, and frequency of internet access. Data were analyzed with descriptive and multivariate statistical methods.nnnRESULTSnThe majority (84%) of individuals were willing to share their PHI with clinicians involved in their care. Fewer individuals (39%) were as willing to share with non-clinical staff. Willingness to share PHI was positively associated with trust and respect of clinicians.nnnCONCLUSIONnPLWH accepted clinicians need for access to accurate information. Patients trust in their primary care providers highlights the importance of the clinician-patient relationship which can be used to engage patients support for health information exchange initiatives.nnnPRACTICE IMPLICATIONSnAs electronic storage and sharing of PHI is increasing, clinicians and PLWH should discuss patients attitudes towards sharing PHI electronically.

Processes and Outcomes of Developing a Continuity of Care Document for Use as a Personal Health Record by People Living with HIV/AIDS in New York City

PURPOSEnTo describe the processes and outcomes of developing and implementing a Continuity of Care Document (CCD), My Health Profile, as a personal health record for persons living with HIV (PLWH) in an HIV/AIDS Special Needs Plan in New York City.nnnMETHODSnMultiple qualitative and quantitative data sources were used to describe the processes and outcomes of implementing My Health Profile including focus groups, Audio Computer Assisted Self Interview (ACASI) surveys, administrative databases, chart abstraction, usage logs, and project management records. Qualitative data were thematically analyzed. Quantitative data analytic methods included descriptive and multivariate statistics. Data were triangulated and synthesized using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework.nnnRESULTSnReach - SNP members are predominantly African American or Hispanic/Latino and about one-third are female. A larger proportion of African Americans and smaller proportions of Hispanics/Latinos and Whites were trained to use My Health Profile.Efficacy/Effectiveness - CCDs were produced for 8249 unique members and updated on a monthly basis, 509 members were trained to use My Health Profile. Total number of member logins for 112 active users was 1808 and the longest duration of use was 1008 days. There were no significant differences between users and non-users of My Health Profile in clinical outcomes, perceptions of the quality of medical care, or health service utilization. Adoption -My Health Profile was well-matched to organizational mission, values, and priorities related to coordination of care for a high-risk population of PLWH. Implementation - Pre-implementation focus group participants identified potential barriers to use of My Health Profile including functional and computer literacy, privacy and confidentiality concerns, potential reluctance to use technology, and cognitive challenges. Key strategies for addressing barriers included a dedicated bilingual coach for recruitment, training, and support; basic computer and My Health Profile training; transparent audit trail revealing clinician and case manager access of My Health Profile, time-limited passwords for sharing My Health Profile with others at the point of need, and emergency access mechanism. Maintenance -My Health Profile was integrated into routine operational activities and its sustainability is facilitated by its foundation on standards for Health Information Exchange (HIE).nnnCONCLUSIONSnAlthough potential barriers exist to the use of personal health records (PHRs) such as My Health Profile, PLWH with complex medical needs, low socioeconomic status, and limited computer experience will use such tools when a sufficient level of user support is provided and privacy and confidentiality concerns are addressed.

Perceptions of factors influencing use of an electronic record for case management of persons living with HIV

Abstract Case managers (CMs) facilitate continuity of care for persons living with HIV (PLWH) by coordination of resources and referrals to social services and medical care. The complexity of the management of HIV drives the need for more coordination, which can be achieved through the use of health information technology (HIT). However, HIT has not been well studied in the context of HIV services. The primary aim of this qualitative study was to assess CMs’ perceptions regarding factors that influence acceptance and use of an electronic continuity of care record (CCR) for PLWH. Focus group methodology was used to gather perceptions from 37 CMs. Major themes related to factors for CCR adoption and use included: predisposing (system functionality and confidentiality), enabling (user training and computer access), reinforcing (work efficiency, continuity of care, information quality, and communication). Electronic CCRs have the potential to improve coordination of services and information sharing for PLWH. Careful attention must be paid to factors that predispose, enable, and reinforce use of HIT such as CCRs so that potential benefits in terms of quality and efficiency can be realized.

The HIV Workforce in New York State: Does Patient Volume Correlate with Quality?

BACKGROUNDnKnowledge of care practices among clinicians who annually treat <20 human immunodeficiency virus (HIV)-positive patients with antiretroviral therapy (ART) is insufficient, despite their number, which is likely to increase given shifting healthcare policies. We analyze the practices, distribution and quality of care provided by low-volume prescribers (LVPs) based on available data sources in New York State.nnnMETHODSnWe communicated with 1278 (66%) of the LVPs identified through a statewide claims database to determine the circumstances under which they prescribed ART in federal fiscal year 2009. We reviewed patient records from 84 LVPs who prescribed ART routinely and compared their performance with that of experienced clinicians practicing in established HIV programs.nnnRESULTSnOf the surveyed LVPs, 368 (29%) provided routine ambulatory care for 2323 persons living with HIV/AIDS, and 910 LVPs cited other reasons for prescribing ART. Although the majority of LVPs (73%) practiced in New York City, patients living upstate were more likely to be cared for by a LVP (odds ratio, 1.7; 95% confidence interval, 1.4-1.9). Scores for basic HIV performance measures, including viral suppression, were significantly higher in established HIV programs than for providers who wrote prescriptions for <20 persons living with HIV/AIDS (P < .01). We estimate that 33% of New York State clinicians who provide ambulatory HIV care are LVPs.nnnCONCLUSIONSnOur findings suggest that the quality of care associated with providers who prescribe ART for <20 patients is lower than that provided by more experienced providers. Access to experienced providers as defined by patient volume is an important determinant of delivering high-quality care and should guide HIV workforce policy decisions.

The role of patient-provider interactions: Using an accounts framework to explain hospital discharges against medical advice.

The phenomenon of leaving the hospital against medical advice (AMA) despite being quite common and associated with significant deleterious health outcomes remains inadequately understood and addressed. Researchers have identified certain patient characteristics as predictors of AMA discharges, but the patients reasons for these events have not been comprehensively explored. Moreover, because the medical authority model dominates this research area, providers experiences of AMA discharges remain unstudied. We examined the AMA discharge from a patient-centered perspective by analyzing the content of notes providers generate to record such events. We analyzed providers notes for all inpatients with a primary HIV diagnosis (Nxa0=xa033) that, in 2012, left an urban hospital AMA. Applying the Scott and Lyman accounts framework, we identified that the notes constituted records of providers and patients excuses and justifications for failing to meet the expectations of a provider offering patient-centered care and a compliant patient receiving care. Alongside the patients reasons for leaving AMA, the notes also revealed the providers reasons for honoring or discrediting the patients accounts. The style of the accounts and the professional status of the notes authors enabled us to contextualize the production and sharing of AMA notes in the hospital hierarchy. Conceptualizing AMA notes as dyadic accounts elicited specific factors that challenge the patient-provider relationship, and generated insights on how to strengthen it, and thus decrease the rates of AMA discharges and their associated health effects.

Readmissions in HIV-infected inpatients: A large cohort analysis

Objective:Hospital readmissions impose considerable physical and psychological hardships on patients and represent a high, but possibly preventable, cost for insurers and hospitals alike. The objective of this study was to identify patient characteristics associated with 30-day readmission among persons living with HIV/AIDS (PLWH) using a statewide administrative database and to characterize the movement of patients between facilities. Design:Retrospective cohort analysis of HIV-infected individuals in New York State using a comprehensive, all-payer database. Setting:All hospitals in New York State. Participants:HIV-infected adults admitted to a medical service in 2012. PLWH identified using International Classification of Disease (ICD)-9 diagnosis codes 042 and V08. Results:Of 23,544 index hospitalizations, 21.8% (5121) resulted in readmission. Multivariable predictors of readmission included insurance status, housing instability, psychoses, multiple comorbid chronic conditions, substance use, and past inpatient and emergency department visits. Over 30% of readmissions occurred at a different facility than that of the initial hospitalization. Conclusion:A number of patient characteristics were independently associated with hospital readmission within 30 days. Behavioral health disorders and comorbid conditions may be the strongest predictors of readmission in PLWH. Readmissions, especially those in urban areas, often result in fragmented care which may compromise the quality of care and result in harmful discontinuity of medical treatment.

“Against Medical Advice” Discharges Among HIV-Infected Patients: Health and Health Services Outcomes

&NA; Nurses are often first to identify and manage a patient leaving against medical advice (AMA), and so they are critical contributors to the development of strategies to address this problem. We studied AMA discharge in order to help develop useful interventions. We performed a cross‐sectional analysis of 55,938 discharges from a single urban hospital for the years 2002‐2003 and 2012‐2013. AMA discharge rates were higher for HIV‐infected patients than for patients with alcohol‐related disorders or sickle cell anemia in both time periods, even after adjustment for age, race, sex, insurance status, and household income. For HIV infection, 25% of AMA discharges occurred in patients with multiple AMA discharges and 30‐day readmission rates were higher after an AMA discharge: odds ratio 1.57 (95% confidence interval 1.01 to 2.43, p = .046). Team‐based and nursing interventions that incorporate the treatment‐based values and preferences of HIV‐infected patients with prior AMA discharges may improve linkage to care and reduce readmissions.

Perceptions of Predisposing, Enabling, and Reinforcing Factors Influencing the Use of a Continuity of Care Document in Special Needs PLWH

The provision of personal health information through electronic personal health management tools (EPHMT) has the potential to improve health outcomes. However, little is known about factors that affect EPHMT use in special needs people living with HIV/AIDS (PLWH). The purpose of this study was to describe PLWH perceptions of predisposing, enabling, and reinforcing factors affecting use of one type of EPHMT, a continuity of care document (CCD). Data were collected through focus groups and qualitative interviews with PLWH (n=35), health care providers (N=19) and care site managers (N=5). All participant types identified predisposing barriers to CCD use including literacy, privacy, and technology access and enabling factors to promote CCD use including user support and password simplicity. People living with HIV/AIDS also identified reinforcing factors for recurring CCD use including emergent situations and reducing test redundancy. Results inform methods to promote use of the CCD and other EPHMT by special needs PLWH.

Employing the FITT framework to explore HIV case managers’ perceptions of two electronic clinical data (ECD) summary systems

PURPOSEnCase managers facilitate continuity of care for persons living with HIV (PLWH) by coordination of resources and referrals to social services and medical care. The complexity of HIV care and associated comorbidities drives the need for medical and psychosocial care coordination, which may be achieved through health information exchange (HIE) systems. However, the use of HIE has not been well studied in the context of HIV services. The purpose of this descriptive qualitative study is to explore factors influencing case managers adoption of electronic clinical data (ECD) summaries as an HIE strategy in HIV care through application of the fit between individuals, task and technology (FITT) framework.nnnMETHODSnFocus group methodology was used to gather perceptions from 48 participants who provided direct case management services for PLWH in New York City. Questions addressed current quality and efficiency challenges to HIE utilization in the context of case management of PLWH as well as barriers and enablers to use of an ECD summary. Analysis of the data was guided by the FITT framework.nnnRESULTSnMajor themes by interaction type were: (1) task-technology fit - resources, time and workflow; (2) individual-task fit - training and technical support; and 3) individual-technology fit - ECD summary functionality, technical difficulties and the need of a computer for each end-user.nnnCONCLUSIONSnOur findings provide evidence for the applicability of the FITT framework to explore case managers perceptions of factors influencing the adoption of ECD summary systems for HIV care prior to actual implementation. Assessment of fit among individual, task, and technology and addressing the concerns identified prior to implementation is critical to successful adoption of health information technology as a strategy to improve quality and efficiency in health care.

Using the Federated Council for Internal Medicine curricular guide and administrative codes to assess IM residents' breadth of experience.

Purpose. To estimate internal medicine residents’ breadth of experience using a published curricular guide and an electronic medical record. Method. A cohort of 41 internal medicine residents at Columbia University Medical Center, a large, inner-city, primary and tertiary care center, were followed over their three years of training in the late 1990s. Residents were mapped to the patients they cared for, the diagnoses those patients were assigned, and the Federated Council for Internal Medicine (FCIM) competencies covered. The proportion and distribution of competencies covered (potential to achieve a competency) were measured. Results. Residents covered 76% of priority 1 competencies (those identified by FCIM as optimally learned through direct responsibility for patients) and 67% of all competencies. Although the number of patients cared for was correlated with breadth of experience, the effect was small. Rare diagnoses appear to have been distributed well. Conclusion. Internal medicine residents had the potential to achieve the majority of competencies via direct patient care, but no residents achieved full coverage. The electronic medical record may provide a mechanism to track residents and study training programs.