Advanced Electronic Health Record Research Articles

DIGITAL TRANSFORMATION IN HEALTHCARE FOR EFFECTIVE INFORMATION GOVERNANCE

Serving as the first Chief Information Governance Officer (CIGO) at a venerable healthcare facility, this paper provides a thorough and strategic framework for switching from traditional paper-based record-keeping to an advanced Electronic Health Records (EHR) system. The organisation's long history spanning more than 50 years and its enormous, diversified data gathering present serious problems relating to data integrity, privacy, and security to this significant transformation that aims to improve patient care and operational efficiency. An in-depth discussion of information governance in healthcare is provided in this paper, with particular attention paid to data quality management, stringent privacy and security regulations, and the tactical use of data to spur innovation in healthcare. Along with providing a comprehensive overview of the digital transformation in healthcare, it critically examines the effects on patient care of emerging digital technologies such as wearable health devices, big data analytics, and the Internet of Things (IoT). An extensive literature review and an annotated bibliography bolster these analyses. Moreover, the paper offers a thorough plan for digital transformation that will guarantee compliance with legal and moral requirements, improve patient care, and establish the company as a pioneer in patient data management and healthcare innovation. In addition to addressing concerns such as data integrity problems brought on by a lack of solid administrative control and data handling standards, the study examines social media's potential as a marketing tool while considering pertinent legal and policy considerations. Finally, the paper offers particular metrics to evaluate the impact and efficacy of the information governance program, ensuring that it aligns with the organisation's objectives and the changing landscape of digital healthcare to guarantee these initiatives' successful implementation and oversight.

Impact of EHRs on Nursing Burnout in a Hospital Setting in Saudi Arabia: Mixed-Methods Study.

This study explores the association between nursing burnout and Electronic Health Record (EHR) use in a Saudi Arabian hospital adopting an advanced EHR system. Utilising a mixed-methods approach, the research combines quantitative analysis of 282 survey responses and qualitative interviews from 21 registered nurses. Despite high EHR acceptance, negative perceptions and stress related to EHR use were identified. Findings indicate a weak link between EHR use and burnout, with resilience acting as a mitigating factor. Specific stressors, including documentation workload and usability issues, were countered by individual and organisational resilience. The study introduces a novel conceptual model emphasising the pivotal role of resilience at both levels in mitigating EHR-related burnout. Recommendations include fostering resilience-building strategies in EHR implementation processes and usability to prevent burnout, emphasising self-care practices, promoting work-life balance, and improving health information infrastructure.

The Ability of Primary Care Practices to Measure and Report on Care Quality.

Creating useful clinical quality measure (CQM) reports in a busy primary care practice is known to depend on the capability of the electronic health record (EHR). Two other domains may also contribute: supportive leadership to prioritize the work and commit the necessary resources, and individuals with the necessary health information technology (IT) skills to do so. Here we describe the results of an assessment of the above 3 domains and their associations with successful CQM reporting during an initiative to improve smaller primary care practices' cardiovascular disease CQMs. The study took place within an AHRQ EvidenceNOW initiative of external support for smaller practices across Washington, Oregon and Idaho. Practice facilitators who provided this support completed an assessment of the 3 domains previously described for each of their assigned practices. Practices submitted 3 CQMs to the study team: appropriate aspirin prescribing, use of statins when indicated, blood pressure control, and tobacco screening/cessation. Practices with advanced EHR reporting capability were more likely to report 2 or more CQMs. Only one-third of practices were "advanced" in this domain, and this domain had the highest proportion of practices (39.1%) assessed as "basic." The presence of advanced leadership or advanced skills did not appreciably increase the proportion of practices that reported 2 or more CQMs. Our findings support previous reports of limited EHR reporting capabilities within smaller practices but extend these findings by demonstrating that practices with advanced capabilities in this domain are more likely to produce CQM reports.

Providers' Perceptions of the Effectiveness of Electronic Health Records in Identifying Opioid Misuse.

This study aimed to understand prescribing providers' perceptions of electronic health record (EHR) effectiveness in enabling them to identify and prevent opioid misuse and addiction. We used a cross-sectional survey designed and administered by KLAS Research to examine healthcare providers' perceptions of their experiences with EHR systems. Univariate analysis and mixed-effects logistic regression analysis with organization-level random effects were performed. A total of 17,790 prescribing providers responded to the survey question related to this article's primary outcome about opioid misuse prevention. Overall, 34% of respondents believed EHRs helped prevent opioid misuse and addiction. Advanced practice providers were more likely than attending physicians and trainees to believe EHRs were effective in reducing opioid misuse, as were providers with fewer than 5 years of experience. Understanding providers' perceptions of EHR effectiveness is critical as the health outcome of reducing opioid misuse depends upon their willingness to adopt and apply new technology to their standardized routines. Healthcare managers can enhance providers' use of EHRs to facilitate the prevention of opioid misuse with ongoing training related to advanced EHR system features.

Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments.

Understand the perceived role of electronic health records (EHR) and workflow fragmentation on clinician documentation burden in the emergency department (ED). From February to June 2022, we conducted semistructured interviews among a national sample of US prescribing providers and registered nurses who actively practice in the adult ED setting and use Epic Systems' EHR. We recruited participants through professional listservs, social media, and email invitations sent to healthcare professionals. We analyzed interview transcripts using inductive thematic analysis and interviewed participants until we achieved thematic saturation. We finalized themes through a consensus-building process. We conducted interviews with 12 prescribing providers and 12 registered nurses. Six themes were identified related to EHR factors perceived to contribute to documentation burden including lack of advanced EHR capabilities, absence of EHR optimization for clinicians, poor user interface design, hindered communication, increased manual work, and added workflow blockages, and five themes associated with cognitive load. Two themes emerged in the relationship between workflow fragmentation and EHR documentation burden: underlying sources and adverse consequences. Obtaining further stakeholder input and consensus is essential to determine whether these perceived burdensome EHR factors could be extended to broader contexts and addressed through optimizing existing EHR systems alone or through a broad overhaul of the EHR's architecture and primary purpose. While most clinicians perceived that the EHR added value to patient care and care quality, our findings underscore the importance of designing EHRs that are in harmony with ED clinical workflows to alleviate the clinician documentation burden.

Physician awareness of social determinants of health documentation capability in the electronic health record.

Healthcare organizations are increasing social determinants of health (SDH) screening and documentation in the electronic health record (EHR). Physicians may use SDH data for medical decision-making and to provide referrals to social care resources. Physicians must be aware of these data to use them, however, and little is known about physicians' awareness of EHR-based SDH documentation or documentation capabilities. We therefore leveraged national physician survey data to measure level of awareness and variation by physician, practice, and EHR characteristics to inform practice- and policy-based efforts to drive medical-social care integration. We identify higher levels of social needs documentation awareness among physicians practicing in community health centers, those participating in payment models with social care initiatives, and those aware of other advanced EHR functionalities. Findings indicate that there are opportunities to improve physician education and training around new EHR-based SDH functionalities.

Advanced EHR system in homes-in-schools’ automation using internet of things and machine learning

Electronic Health Records (EHRs) are the health data collected and stored electronically for informative purposes in today’s healthcare to handle healthcare in patients’ hands, thereby reducing physical contact between healthcare seekers and providers. This paper reviews a complete health monitoring and health status reporting system using IoT technology to gather vital health statistics and machine learning to design an intelligent system. The proposed system will adopt IoT technology to collect health information from students in their residence and use a machine learning method to predict students’ health status from the institution’s Electronic Health Records before rendering health counselling services to students. It will also allow students to report health conditions to educational authorities on a complex Wireless Body Area Network to deploy Raspberry Pi 4B, sensors, cameras.

Abstract P108: Natural Language Processing Extracted Social And Behavioral Determinants Of Health And Newer Glucose-lowering Drug Initiation Among Real-world Patients With Type 2 Diabetes

Background: Sodium-glucose cotransporter-2 inhibitors ( SGLT2i ) and glucagon-like peptide-1 receptor agonists ( GLP1a ) are two newer glucose-lowering drugs ( GLD ) that can reduce cardiovascular disease ( CVD ) risk in patients with type 2 diabetes ( T2D ). Yet, uptake of these newer drugs remains low, especially among racial minority groups. Prior studies evaluating factors associated with underuse of SGLT2i/GLP1a primarily relied on claims or structured electronic health records ( EHR ) data, which contain little information on patients' social and behavioral determinants of health ( SBDoH ). We hypothesized that SBDoH would affect the use of these cardioprotective drugs among real world patients with T2D. Methods: EHR from University of Florida Health system were used to identify T2D patients who initiated a second line GLD in 2015-2020. We used a deep learning based natural language processing (NLP) pipeline to extract SBDoH from clinical notes: employment, housing, marital status, smoking, alcohol use and drug use. We constructed a multilevel logistic regression to determine the association of race/ethnicity and SBDoH with initiation of SGLT2i/GLP1a versus other second line GLDs, including zip codes as random effect and adjusting for clinical factors. Results: Of 2,964 patients in the cohort, mean age was 59 (14) years and 56% were females. In the adjusted model ( Table ), Black race, male sex, unemployment, housing insecurity, being unmarried, smoking, and drug use were associated with lower likelihood of initiating SGLT2i/GLP1a. In subgroup analyses by race, housing insecurity was only a risk factor for non-initiation of SGLT2i/GLP1a among Black patients, and smoking and drug use were only risk factors for White patients. Conclusion: Social and behavioral risk factors contribute to racial disparities in access to novel GLDs. Advanced NLP methods and EHR data enabled us to investigate the social risk associated with real-world treatment access.

A nurse-led multicomponent intervention supported by advanced electronic health records to improve the acute management of stroke patients: A pre- and post-intervention study.

Management of temperature, glycaemia and dysphagia, reffered to as the Fever, Sugar, Swallowing (FeSS) protocol, improves outcome in patients with acute stroke. Electronic health records can assist in efficient alignment of such clinical treatment protocol with daily patient care. To assess the association between the implementation of the FeSS protocol, facilitated by an advanced electronic health record (EHR), and protocol adherence and outcome 90 days after hospital admission. A single centre pre- and post-intervention study amongst patients presenting in the stroke unit within 48h of onset of symptoms. The stroke unit of the comprehensive stroke centre at the University Hospitals Leuven, where a standardized care programme for stroke patients is in place. 495 patients consecutively admitted in 2018 and 2019 with a diagnosis of ischaemic stroke or intracerebral haemorrhage admitted to the stroke unit, with following criteria: (1) ≥18 years of age on admission, (2) presented within 48h of onset of symptoms to the stroke unit. Advanced EHRs including electronic care planning and documentation offered nurses access to and support from FeSS guidelines at the point of care. We studied: (1) adherence to the protocol by nurses, (2) patient outcome as assessed by the modified Rankin Scale. The rate of 90-day death and dependency (modified Rankin Scale ≥2) was lower in the post-intervention group (51.21%) compared to the pre-intervention group (60.34%) (adjusted OR 0.63, 95%CI 0.41-0.97). FeSS elements were more frequently documented in the post-intervention group, particularly temperature monitoring and glycaemia management. However, adherence remained suboptimal, and care plans within the electronic health record were frequently altered by nurses. A multicomponent implementation strategy comprising of traditional implementation strategies and appended by the use of electronic health records facilitated implementation and detailed evaluation of a complex intervention. This implementation was associated with reduced death and dependency. However, a better understanding of the interaction between nurses and the EHR as a means to facilitate their work is of critical importance.

Hospital organizational strategies associated with advanced EHR adoption.

To identify organizational complementarities of adoption and use of electronic health records (EHRs) and assess what organizational strategies were associated with more advanced EHR use. Primary survey data of US hospitals combined with secondary data from the American Hospital Association Annual Survey and IT Supplement. In this cross-sectional study, we describe hospital organizational practices around EHR adoption and use and identify how these practices coalesce into distinct strategies. We then assess the association between those organizational strategies and adoption of advanced EHR functions. Primary data collection consisted of surveys sent to 797 US acute care hospitals in 2018-2019, with 451 complete respondents. There was significant variation in hospital organizational practices for EHR adoption and use. Factor analysis identified practices in three domains: leadership engagement, human capital, and systems integration. Hospitals in the top quartile of the leadership engagement factor were 14 percentage points more likely to have adopted patient engagement EHR functions (P=0.01) while hospitals in the top quartile of human capital were 14 percentage points less likely to have adopted these functions (P=0.02). Hospitals in the top quartile of systems integration were 12 percentage points more likely to have adopted patient engagement functions (P=0.02) and 14 percentage points more likely to have adopted EHR data analytics functions (P=0.02). Our findings suggest that specific organizational strategies are associated with more advanced EHR adoption. Hospital leaders interested in realizing more value from their EHR investment may find it useful to know that there is an association between adoption of more advanced EHR functions, and engaging senior leadership as well as building connectivity between clinical and administrative systems.

Progress and Challenges with Connecting Hospitals with the Public Health System

Improving the health information technology (HIT) infrastructure of the public health system is critical for public health activities and population health management. To strengthen the public health HIT infrastructure, CMS included specific public health reporting capabilities in the Meaningful Use (MU) criteria that comprised the Electronic Health Record (EHR) incentive program for hospitals, now called the Promoting Interoperability (PI) program.Evidence suggests that these incentives have improved hospitals’ public health reporting capabilities, but recent data show that only 60% of hospitals have achieved MU standards, suggesting that barriers remain for electronic integration of hospitals with public health agencies. While progress is promising and may be indicative of improvements in electronic data exchange capabilities, the specific issues that hospitals continue to face are unclear and there remains limited understanding of approaches that may improve hospital public health reporting capabilities.This study uses cross‐sectional data from the 2017 American Hospital Association (AHA) Annual Survey and Information Technology (AHAIT) supplement, which reports the challenges hospitals face in submitting data to public health agencies. Four nonmutually exclusive options included data standards issues, technical capacity issues, uncertainty of who to send data to, and an open‐ended option. Open‐ended responses were qualitatively coded by type of challenge (ie, technology, organization, or environment); responsible/affected party (ie, hospital, public health agency, vendor, or multiple); and the specific issue described. Multivariate logistic regression was used to identify characteristics of hospitals associated with experiencing any challenge.Acute‐care, nonfederal hospitals responding to both the 2017 AHA and AHAIT supplemental surveys.Among 2,794 hospitals included, 1,713 (61%) reported experiencing at least one challenge in reporting health data to a public health agency. Of hospitals experiencing challenges, the vast majority reported organizational issues (85% or 1,458) at public health agencies (84% or 1,226), specifically the technical capacity of public health agencies. Hospital system members (adjusted odds ratio (AOR) 0.80; 95% Confidence Interval (CI) 0.65‐0.98) were less likely to experience challenges, whereas for‐profit hospitals (AOR 1.47; 95% CI 1.07‐2.03), being in the West (AOR 1.72; 95% CI 1.28‐2.30), possessing basic (AOR 1.56; 95% CI 1.06‐2.31) or comprehensive (AOR 1.57; 95% CI 1.06‐2.31) EHRs, and participating in an HIE (AOR 1.87; 95% CI 1.58‐2.22) were associated with increased likelihood of experiencing challenges.Challenges remain in facilitating data exchange between hospitals and public health agencies. Hospitals with more advanced EHRs and HIE were more likely to experience challenges. These hospitals may have technological capabilities that exceed those of public health agencies. Hospitals and public health agencies may also be in competition for a technically trained workforce, and data suggest that both may be experiencing shortages of staff with essential expertise.Efforts to alleviate barriers to hospital reporting of health data to public health agencies should target technological, organizational, and environmental issues. Responses include improvements in the data standards that facilitate exchange; funding for public health agencies to improve their technological capabilities, workforce training programs, and clarifications for PI policy specifications and reporting.

The Doctor Will See You Elsewhere: Enterprise IS and the Changing Control of Firm Activities

In this work, we examine how the adoption of enterprise information systems affects the ability of high agency organizational actors to control the activities performed by firms, including both what those activities are and where they are done. While extant research highlights the ability of managers to more carefully manipulate the activities performed by the firm when enterprise IT is adopted, work has yet to examine whether high agency subordinates will use such technology to appropriate rents. Empirically, we investigate whether surgeons reallocate patients to ambulatory care settings for treatment after the adoption of electronic health records (EHR). Findings suggest that while the adoption of basic EHR technology has limited effect, the adoption of advanced EHRs dramatically increases the number of patients treated in an ambulatory care setting. Interestingly, these relationships are strongly moderated by both the financial incentives of the physician and the profit motives of the hospital. Practical and theoretical implications are discussed within.

Electronic Health Record Adoption and Nurse Reports of Usability and Quality of Care: The Role of Work Environment.

Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care. The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety. This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals. In fully adjusted models, comprehensive EHR adoption was associated with lower odds of nurses reporting poor usability outcomes, such as dissatisfaction with the system (odds ratio [OR]: 0.75; 95% confidence interval [CI]: 0.61-0.92). The work environment was associated with all usability outcomes with nurses in better environments being less likely to report negatively. Comprehensive EHRs (OR: 0.83; 95% CI: 0.71-0.96) and better work environments (OR: 0.47; 95% CI: 0.42-0.52) were associated with lower odds of nurses reporting fair/poor quality of care, while poor patient safety grade was associated with the work environment (OR: 0.50; 95% CI: 0.46-0.54), but not EHR adoption level. Our findings suggest that adoption of a comprehensive EHR is associated with more positive usability ratings and higher quality of care. We also found that-independent of EHR adoption level-the hospital work environment plays a significant role in how nurses evaluate EHR usability and whether EHRs have their intended effects on improving quality and safety of care.

The Doctor Will See You Elsewhere: Enterprise Information Systems and the Changing Control of Firm Activities

In this work, we examine how the adoption of enterprise information systems affects the ability of high agency organizational actors to control the activities performed by firms, including both what those activities are and where they are done. While extant research highlights the ability of managers to more carefully manipulate the activities performed by the firm when enterprise IT is adopted, work has yet to examine whether high agency subordinates will use such technology to appropriate rents. Empirically, we investigate whether surgeons reallocate patients to ambulatory care settings for treatment after the adoption of electronic health records (EHR). Findings suggest that while the adoption of basic EHR technology has limited effect, the adoption of advanced EHRs dramatically increases the number of patients treated in an ambulatory care setting. Interestingly, these relationships are strongly moderated by both the financial incentives of the physician and the profit motives of the hospital. Practical and theoretical implications are discussed within.

A distributed integration system enabling electronic health records: an Italian experience

Today distributed systems are commonly employed in patient data management to improve the care process. Moreover, distributed systems can be usefully applied to realise lean and flexible architectures that facilitate healthcare structure interoperability. Systems used in healthcare structures are characterised by proprietary data flow formats and encoding systems, which hinder the possibility of sharing data in a standard format, and extracting atomic data for further analysis. This paper describes the architecture of a distributed interoperability system able to structure flow data into standard formats and send them to an advanced electronic health record designed as part of the Smart Health 2.0 project (PON04a2_C). The use of the distributed interoperability system within the experimental phase of the electronic health record highlights the flexibility of the proposed solution in meeting the reality of the healthcare structures involved.

A Distributed Integration System Enabling Electronic Health Records: An Italian Experience

Today distributed systems are commonly employed in patient data management to improve the care process. Moreover, distributed systems can be usefully applied to realise lean and flexible architectures that facilitate healthcare structure interoperability. Systems used in healthcare structures are characterised by proprietary data flow formats and encoding systems, which hinder the possibility of sharing data in a standard format, and extracting atomic data for further analysis. This paper describes the architecture of a distributed interoperability system able to structure flow data into standard formats and send them to an advanced electronic health record designed as part of the Smart Health 2.0 project (PON04a2_C). The use of the distributed interoperability system within the experimental phase of the electronic health record highlights the flexibility of the proposed solution in meeting the reality of the healthcare structures involved.

Real-World Outcomes of Patients with Metastatic Non-Small Cell Lung Cancer Treated with Programmed Cell Death Protein 1 Inhibitors in the Year Following U.S. Regulatory Approval.

Evidence from cancer clinical trials has strong internal validity but can be difficult to generalize to real-world patient populations. Here we analyzed real-world outcomes of patients with metastatic non-small cell lung cancer (mNSCLC) treated with programmed cell death protein 1 (PD-1) inhibitors in the first year following U.S. regulatory approval. This retrospective study leveraged electronic health record (EHR) data collected during routine patient care in community cancer care clinics. The cohort included patients with mNSCLC who had received nivolumab or pembrolizumab for metastatic disease (n = 1,344) with >1 EHR-documented visit from January 1, 2011, to March 31, 2016. Patients with a > 90-day gap between advanced disease diagnosis and first EHR structured data entry were excluded. Estimated median overall survival (OS) was 8.0 months (95% confidence interval 7.4-9.0 months). Estimated median OS was 4.7 months (3.4-6.6) for patients with anaplastic lymphoma kinase rearrangement- and epidermal growth factor receptor mutation-positive tumors, and 8.6 months (7.7-10.6) for patients without such mutations. Age at PD-1 inhibitor initiation or line of therapy did not impact OS. This analysis suggests OS in real-world patients may be shorter than in conventional clinical trial patient cohorts, potentially due to narrow trial eligibility criteria. The lack of difference in OS by line of therapy or age at immunotherapy initiation suggests sustained benefit of PD-1 inhibitors in multitreated patients with mNSCLC and that age is not a predictor of outcome. Further studies are underway in patients with comorbidities, organ dysfunction, and multiple prior therapies. This study evaluated data derived from electronic health records of patients with metastatic non-small cell lung cancer treated with programmed cell death protein 1 (PD-1) inhibitors in the year following regulatory approval. This real-world cohort had shorter overall survival (OS) indexed to PD-1 inhibitor initiation than reported in clinical trials. Late-line treatment did not influence OS, and patients aged >75 at immunotherapy initiation did not have worse outcomes than younger patients. As new therapies enter clinical practice, real-world data can complement clinical trial evidence providing information on generalizability and helping inform clinical treatment decisions.

Novel electronic health record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout.

A novel approach to advanced electronic health record (EHR) skills training was developed in a large healthcare organization to improve high-quality EHR documentation, while reducing stressors linked to physician burnout.The 3-day intensive EHR education intervention covered best practices in EHR documentation and physician well-being. The specialty physician faculty used interactive teaching including demonstration, facilitation, and individual coaching. Laptops were provided for hands-on practice. Mixed-method evaluation included real-time feedback, daily surveys, and post-activity surveys to measure participant learning and satisfaction, and also collection of performance data from the EHR to measure use of order sets designed to improve quality of care.Since 2014, 46 trainings were held with 3500 physicians. Most physicians (85%–98% across all programs) reported improved quality, readability, and clinical accuracy of documentation; fewer medical errors; and increased efficiency in chart review and data retrieval due to the training. Seventy-eight per cent estimated a time savings of 4 to 5 minutes or more per hour. Physician performance data from the EHR showed significant improvement in use of order sets for several critical health conditions such as sepsis, stroke, and chest pain of possible cardiac cause.This advanced EHR training for physicians was well-received and improved physicians’ use of several order sets designed to improve quality of care. EHR training programs such as this may have impact on the safety, quality, accuracy, and timeliness of care and may also help reduce physician burnout by improving critical skills and reducing time interfacing with all aspects of a patient's health record.

Resource-based view on safety culture's influence on hospital performance: The moderating role of electronic health record implementation.

Patient safety and safety culture have received increasing attention from agencies such as the Agency of Healthcare Research and Quality and the Institute of Medicine. Safety culture refers to the fundamental values, attitudes, and perceptions that provide a unique source of competitive advantage to improve performance. This study contributes to the literature and expands understanding of safety culture and hospital performance outcomes when considering electronic health record (EHR) usage. Based on the resource-based view of the firm, this study examined the association between safety culture and hospital quality and financial performance in the presence of EHR. Data consist of the 2016 Hospital Survey on Patient Safety, Hospital Compare, American Hospital Association's annual survey, and the American Hospital Association's Information Technology supplement. Our final analytic sample consisted of 154 hospitals. We used a two-part nested regression model approach. Safety culture has a direct positive relationship with financial performance (operating margin). Furthermore, having basic EHR as compared to not having EHR further enhances this positive relationship. On the other hand, safety culture does not have a direct association with quality performance (readmissions) in most cases. However, safety culture coupled with basic EHR functionalities, compared to not having EHR, is associated with lower readmissions. Hospitals should strive to improve patient safety culture as part of their strategic plan for quality improvement. In addition, hospital managers should consider implementing EHR as a resource that can support safety culture's effect on outcomes such as financial and quality performance indicators. Future studies can examine the differences between basic and advanced EHR presence in relation to safety culture.

Design and implementation of population-based specialty care programs.

The development, implementation, and scaling of 3 population-based specialty care programs in a large integrated healthcare system are reviewed, and the role of clinical pharmacy services in ensuring safe, effective, and affordable care is highlighted. The Kaiser Permanente (KP) integrated healthcare delivery model allows for rapid development and expansion of innovative population management programs involving pharmacy services. Clinical pharmacists have assumed integral roles in improving the safety and effectiveness of high-complexity, high-cost care for specialty populations. These roles require an appropriate practice scope and are supported by an advanced electronic health record with disease registries and electronic surveillance tools for care-gap identification. The 3 specialty population programs described were implemented to address variation or unrecognized gaps in care for at-risk specialty populations. The Home Phototherapy Program has leveraged internal partnerships with clinical pharmacists to improve access to cost-effective nonpharmacologic interventions for psoriasis and other skin disorders. The Multiple Sclerosis Care Program has incorporated clinical pharmacists into neurology care in order to apply clinical guidelines in a systematic manner. The KP SureNet program has used clinical pharmacists and data analytics to identify opportunities to prevent drug-related adverse outcomes and ensure timely follow-up. Specialty care programs improve quality, cost outcomes, and the patient experience by appropriating resources to provide systematic and targeted care to high-risk patients. KP leverages an integration of people, processes, and technology to develop and scale population-based specialty care.