Stephen E. Ross

Systematic Review of Health Information Exchange in Primary Care Practices

Background: Unprecedented federal interest and funding are focused on secure, standardized, electronic transfer of health information among health care organizations, termed health information exchange (HIE). The stated goals are improvements in health care quality, efficiency, and cost. Ambulatory primary care practices are essential to this process; however, the factors that motivate them to participate in HIE are not well studied, particularly among small practices. Methods: We conducted a systematic review of the literature about HIE participation from January 1990 through mid-September 2008 to identify peer-reviewed and non–peer-reviewed publications in bibliographic databases and websites. Reviewers abstracted each publication for predetermined key issues, including stakeholder participation in HIE, and the benefits, barriers, and overall value to primary care practices. We identified themes within each key issue, then grouped themes and identified supporting examples for analysis. Results: One hundred and sixteen peer-reviewed, non–peer-reviewed, and web publications were retrieved, and 61 met inclusion criteria. Of 39 peer-reviewed publications, one-half reported original research. Among themes of cost savings, workflow efficiency, and quality, the only benefits to be reliably documented were those regarding efficiency, including improved access to test results and other data from outside the practice and decreased staff time for handling referrals and claims processing. Barriers included cost, privacy and liability concerns, organizational characteristics, and technical barriers. A positive return on investment has not been documented. Conclusions: The potential for HIE to reduce costs and improve the quality of health care in ambulatory primary care practices is well recognized but needs further empiric substantiation.

Improving personal health records for patient-centered care

OBJECTIVE To assess the patient-centeredness of personal health records (PHR) and offer recommendations for best practice guidelines. DESIGN Semi-structured interviews were conducted in seven large early PHR adopter organizations in 2007. Organizations were purposively selected to represent a variety of US settings, including medium and large hospitals, ambulatory care facilities, insurers and health plans, government departments, and commercial sectors. MEASUREMENTS Patient-centeredness was assessed against a framework of care that includes: (1) respect for patient values, preferences, and expressed needs; (2) information and education; (3) access to care; (4) emotional support to relieve fear and anxiety; (5) involvement of family and friends; (6) continuity and secure transition between healthcare providers; (7) physical comfort; (8) coordination of care. Within this framework we used evidence for patient preferences (where it exists) to compare existing PHR policies, and propose a best practice model. RESULTS Most organizations enable many patient-centered functions such as data access for proxies and minors. No organization allows patient views of clinical progress notes, and turnaround times for PHR reporting of normal laboratory results can be up to 7 days. CONCLUSION Findings suggest patient-centeredness for personal health records can be improved, and recommendations are made for best practice guidelines.

Health information exchange in small-to-medium sized family medicine practices: Motivators, barriers, and potential facilitators of adoption

PURPOSE For small-to-medium sized primary care practices (those with 20 or fewer clinicians), determine desired functions of health information exchange (HIE) and potential motivators, barriers, and facilitators of adoption. METHODS Case study approach with mixed quantitative and qualitative methods. Nine practices in Colorado were purposively selected. Five used paper records and four were already participating in health information exchange. RESULTS Practices particularly desired HIE functions to allow anywhere/anytime lookup of test results and to consolidate delivery of test results. HIE-generated quality reporting was the least desired function. Practices were motivated to adopt HIE to improve the quality and efficiency of care, although they did not anticipate financial gains from adoption. The greatest facilitator of HIE adoption would be technical assistance and support during and after implementation. Financial incentives were also valued. Trust in HIE partners was a major issue, and practices with rich professional and social networks appeared to be especially favorable settings for HIE adoption. CONCLUSIONS These findings may assist policymakers in promoting adoption of HIE among small-to-medium sized primary care practices, a major component of the US healthcare system.

Designing a personal health application for older adults to manage medications

Older adults with multiple chronic conditions are prone to care transitions, such as seeing a new doctor or being discharged after a prolonged hospital stay. These transitions are often uncoordinated and can imperil patients by omitted, duplicative, or contradictory treatment plans. We developed an open source, web-based Personal Health Application (PHA) using an iterative participatory design process that provides older adults and their caregivers the ability to manage their personal health information during care transitions. We report our findings from six user studies that establish the imperative need for interdisciplinary research and collaboration among all stakeholders - patients, caregivers, health professionals, designers, and health informaticians - to create effective PHAs. We conclude with design guidelines that encourage researchers to gradually increase functionality as users become more proficient interacting with the PHA.

Colorado Care Tablet: The design of an interoperable Personal Health Application to help older adults with multimorbidity manage their medications

Medication errors are common and cause serious health issues during care transitions, particularly for older adults with multiple chronic conditions. In this paper, we discuss the design and evaluation of the Colorado Care Tablet, a Personal Health Application (PHA) that helps older adults and their lay caregivers manage their medication regimes during care transitions. We created a PHA that older adults with limited computing experience could easily use by designing an application based on their real world artifacts and workflows.

Effects of Clinical Pathways for Common Outpatient Infections on Antibiotic Prescribing

BACKGROUND Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. METHODS Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period. RESULTS In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P<.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P<.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P<.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group. CONCLUSIONS This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

A Usability Inspection of Medication Management in Three Personal Health Applications

We present the findings of a cognitive walkthrough inspection on three Personal Health Applications (PHAs). Two of the PHAs, Google Health and Microsoft HealthVault, are general purpose PHAs that are freely available to the general public. The last PHA, Colorado Care Tablet, is a prototype PHA that was designed specifically for older adults to manage their medication information. Older adults need a way to manage medications and share this information with their caregivers and healthcare providers to avoid complications during transitions of care. PHAs provide people with the ability to collect and share health information. However, given the problems older adults have with navigating applications and web pages, we needed to inspect currently available PHAs and identify problems older adults may have when using them for medication management before conducting user studies. Based on our findings, we encourage the design community to place more of an emphasis on interface consistency and tightly coupling information with links.