Electronic Health Record Capabilities Research Articles

Considerations in implementation of social risk factor screening and referral in maternal and infant care in Washington, DC: A qualitative study.

The District of Columbia (DC) has striking disparities in maternal and infant outcomes comparing Black to White women and babies. Social determinants of health (SDoH) are widely recognized as a significant contributor to these disparities in health outcomes. Screening for social risk factors and referral for appropriate services is a critical step in addressing social needs and reducing outcome disparities. We conducted interviews among employees (n = 18) and patients (n = 9) across three diverse, urban clinics within a healthcare system and one community-based organization involved in a five-year initiative to reduce maternal and infant disparities in DC. Interviews were guided by the Consolidated Framework for Implementation Research to understand current processes and organizational factors that contributed to or impeded delivery of social risk factor screening and referral for indicated needs. We found that current processes for social risk factor screening and referral differed between and within clinics depending on the patient population. Key facilitators of successful screening included a supportive organizational culture and adaptability of more patient-centered screening processes. Key barriers to delivery included high patient volume and limited electronic health record capabilities to record results and track the status of internal and community referrals. Areas identified for improvement included additional social risk factor assessment training for new providers, patient-centered approaches to screening, improved tracking processes, and facilitation of connections to social services within clinical settings. Despite proliferation of social risk factor screeners and recognition of their importance within health care settings, few studies detail implementation processes for social risk factor screening and referrals. Future studies should test implementation strategies for screening and referral services to address identified barriers to implementation.

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.

Trends in Electronic Health Record Capabilities for Tracking Documentation Time

To understand hospitals' access to and use of data from electronic health record (EHR) developers that quantify the amount of time clinicians spend documenting clinical care in EHRs. Descriptive analysis of 4 waves of a nationally representative survey of US nonfederal acute care hospitals from 2017 to 2019 and 2021 (N = 10,662 across years). We identified the share of hospitals that had access to EHR documentation time measures between 2017 and 2021 and how access varied by hospital and EHR characteristics. We then described how EHR data were used among hospitals with access and whether use varied by developer. The share of hospitals with access to EHR documentation time measures increased significantly each year between 2017 and 2021, when more than two-thirds of hospitals reported having access to these measures. Despite hospitals' increased access to measures that track EHR time, lower-resourced hospitals, nonteaching hospitals, and hospitals with non-market-leading EHR developers were less likely to report having access than their counterparts. In 2021, the 2 most common uses of EHR data were "identifying providers in need of training and support" and "identifying areas to improve clinical workflow." The share of hospitals indicating use of EHR data increased between 2019 and 2021 for all studied uses. A higher proportion of hospitals with access to EHR documentation time measures used them for more purposes over time, suggesting their increased value. Although hospitals' access to and use of EHR documentation measures increased significantly in the last 5 years, future research efforts should investigate whether the use of these measures translates into reduced burden for providers.

Technology about me without me: An examination of the relationship between patient-facing technology and patient experience

To appreciate the role of electronic health records (EHRs) in achieving the goals of patient-centered care, scholars have focused primarily on the influence of EHR capabilities on clinical providers’ behaviors. The objective of this study is to examine the degree to which patient-facing technology (P-Tech) in U.S. hospital EHRs are associated with patient evaluations of their care experience. A cross-sectional OLS regression is executed to examine the relationship between P-Tech and patient experience on a sample of U.S. hospitals (n=1,168) compiled via data from CMS, the American Hospital Association’s (AHA) Annual Survey (2014), and the AHA Health Information Technology supplement (2014). Findings confirm a positive relationship between P-Tech and overall ratings of patient experience. In addition, the results find that P-Tech capabilities correspond to various communication pathways (Exchanging Information, Self-Management, and Administrative Actions) outlined by Street et al.1 The findings show an association between hospitals offering patient-facing EHR technologies that enable exchange of information and better patient evaluations of their care experience. As care delivery continues to explore the advancement of telehealth and telecare services, highlighting patient perspectives and appreciating that patients perceive face-to-face interactions as a complement to digital interactions will be key to the digital transformation of healthcare.

Experiences of Transgender People Reviewing Their Electronic Health Records, a Qualitative Study

BackgroundThe 21st Century Cures Act and the OpenNotes movement have brought patients immediate access to their electronic health records (EHRs). The experiences of marginalized people, including transgender people, accessing and reviewing their EHRs could inform documentation guidelines to improve patient-clinician rapport and reduce harm.ObjectiveTo investigate the experiences of transgender people reviewing EHRs.DesignQualitative study using community-engaged research and an interpretive description methodology. Participants were recruited via social media, snowball sampling was employed, and purposive sampling was used to ensure diversity in terms of age, race/ethnicity, and other factors. In focus groups, participants were asked to discuss their experiences reviewing their EHRs and, for those participants who were clinicians, their experiences reviewing other clinicians’ documentation.ParticipantsThirty transgender adults aged 20 to 67 years, including 10 clinicians.Approach: Digital audio-recordings of focus groups were transcribed verbatim. Content was analyzed to identify emerging essential elements and analysis was continued until no new themes emerged (i.e., saturation).Key ResultsFour themes were noted. (1) Using the wrong name, pronoun, or gender marker for patients is common in the EHR, erodes trust, and causes trauma. (2) Various aspects of clinicians’ notes contradict, blame, or stigmatize patients, across multiple axes of oppression. (3) Limitations of EHR capabilities create barriers to quality care. (4) Certain medical customs set the stage for marginalizing, objectifying, and pathologizing transgender people.ConclusionsTransgender people experience harm via various aspects of EHR documentation, suggesting that changes must be made to improve patient-clinician relationships and reduce ill-effects for patients.

ESyM: An Electronic Health Record-Integrated Patient-Reported Outcomes-Based Cancer Symptom Management Program Used by Six Diverse Health Systems.

Collecting patient-reported outcomes (PROs) can improve symptom control and quality of life, enhance doctor-patient communication, and reduce acute care needs for patients with cancer. Digital solutions facilitate PRO collection, but without robust electronic health record (EHR) integration, effective deployment can be hampered by low patient and clinician engagement and high development and deployment costs. The important components of digital PRO platforms have been defined, but procedures for implementing integrated solutions are not readily available. As part of the NCI's IMPACT consortium, six health care systems partnered with Epic to develop an EHR-integrated, PRO-based electronic symptom management program (eSyM) to optimize postoperative recovery and well-being during chemotherapy. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Whenever possible, the system used validated content from the public domain and took advantage of existing EHR capabilities to automate processes. eSyM includes symptom surveys on the basis of the PRO-Common Terminology Criteria for Adverse Events (PRO-CTCAE) plus two global wellness questions; reminders and symptom self-management tip sheets for patients; alerts and symptom reports for clinicians; and population management dashboards. EHR dependencies include a secure Health Insurance Portability and Accountability Act-compliant patient portal; diagnosis, procedure and chemotherapy treatment plan data; registries that identify and track target populations; and the ability to create reminders, alerts, reports, dashboards, and charting shortcuts. eSyM incorporates validated content and leverages existing EHR capabilities. Build challenges include the innate technical limitations of the EHR, the constrained availability of site technical resources, and sites' heterogenous EHR configurations and policies. Integration of PRO-based symptom management programs into the EHR could help overcome adoption barriers, consolidate clinical workflows, and foster scalability and sustainability. We intend to make eSyM available to all Epic users.

Development of an innovative partnership between a health-system department of pharmacy and external community pharmacies.

Our organization implemented a health-system pharmacy/community pharmacy transitions of care (TOC) program, developing a scalable model to improve care transitions from the health system to the community setting for shared patients. In this report, we describe our organization's experiences in taking a purposeful approach to building and pilot testing a partnership between our department of pharmacy and 14 community pharmacies within a larger statewide network to improve TOC across care settings. We have been successful in partnering with our electronic health record (EHR) vendor to enhance access capabilities to allow for documentation by community pharmacists (external to the organization) to be included in the patient record as a note. The goal of the partnership with community pharmacies is to elevate TOC for patients, identify and resolve medication therapy problems that may occur post discharge and lead to poor outcomes, and improve continuity of care across practice settings. Our department of pharmacy has led a successful initiative to promote collaboration with local external community pharmacies. This program has led to innovative advancements in EHR capabilities, promoting transparency in the documentation of pharmacy services and making this documentation visible to all care team members.

Enabling Transition Service Delivery in a General Gastroenterology Clinic via the Electronic Health Record and System Supports

Enabling Transition Service Delivery in a General Gastroenterology Clinic via the Electronic Health Record and System Supports

Using pharmacy technicians and electronic health record capabilities to improve outcomes for patients with cardiovascular disease

ObjectiveThis study aimed to compare lipid and blood pressure (BP) control before and after implementing a certified pharmacy technician (CPhT) protocol that optimized electronic health record (EHR) capabilities and shifted work from clinical pharmacy specialists (CPSs) to CPhT. SettingKaiser Permanente Colorado’s pharmacist-managed cardiac risk reduction service (which manages dyslipidemia, hypertension, and diabetes for all patients with atherosclerotic cardiovascular disease). Practice descriptionIn 2019, a protocol that optimized EHR capabilities and allowed work to be offloaded from CPS to CPhT was implemented. Filtered views within the EHR were created that bucketed patients with specific lipid results criteria. The CPhT protocol provided guidance to CPhT on determining whether patients were at low-density lipoprotein cholesterol (LDL-C) and non–high-density lipoprotein (non-HDL) goals, on appropriate statin intensity, adherent to medications, and whether the most recent BP was controlled. The CPhT notified CPS of uncontrolled patients who would assess and manage these patients, as necessary. The CPhT notified controlled patients of their results. Practice innovationData on the outcomes of incorporating pharmacy technicians to support CPS clinical activities in ambulatory clinical pharmacy are limited. Evaluation dethodsThis retrospective study compared a “Pharmacist-Driven” (index date: January 1, 2016) with a “Tech-Enhanced” (index date: January 1, 2019) group. The primary outcome was the proportion of patients at all goals defined as LDL-C < 70 mg/dL, non-HDL < 100 mg/dL, and BP < 140/90 mm Hg at 1 year after the index dates. ResultsThere were 6813 patients included (mean age: 70.2 ± 11.1 years, 71.4% male): 3130 and 3683 in the “Pharmacist-Driven” and “Tech-Enhanced” groups, respectively. The proportion of patients who attained LDL-C, non-HDL, and BP goals was higher in the “Tech-Enhanced” group (51.1% vs. 39.7%, P < 0.001) than the “Pharmacist-Driven” group. ConclusionA protocol integrating EHR decision support and CPhTs enabled work to shift to from CPS to CPhT and improved clinical outcomes.

Utilizing Technology to Automate and Standardize Patient Discharge Education

<h3>Introduction</h3> Discharge education is an important part of post-surgical care. Perianesthesia nurses play a vital role in patient discharge instructions. Inclusion of relevant, up-to-date, and consistent information is needed for patients and families to care for themselves at home. <h3>Identification of the problem</h3> Nurses identified manually entering discharge education in the electronic health record (EHR) was nurse dependent and required additional work. Audits revealed that instructions for specific medications such as Scopolamine, were not always entered on the After Visit Summary (AVS), which is given to the patient at discharge. In working to automate the process, it was discovered that the Scopolamine education content varied throughout a large healthcare system. <h3>QI purpose</h3> The purpose of this project was to implement an automated process for Scopolamine education content on the AVS for same day surgery patients via the EHR. A secondary purpose of the project was to standardize Scopolamine patient education for post-operative N/V across the system. <h3>Methods</h3> A team was formed including anesthesia, pharmacy, patient education, clinical informatics, and application analysts. Standardized discharge education was created, and technology was leveraged to build an automated process in the EHR. <h3>Outcomes</h3> After implementation of the automated process, all patients with a Scopolamine patch documented in the EHR had instructions printed on their AVS. Updated, evidence-based, standard medication instructions for Scopolamine are now used across all sites within one large healthcare system. <h3>Discussion</h3> The development of an automated process with standardized medication education was done by forming a team with both technology and clinical expertise. The original manual process took nurse time and could be unintentionally missed. Two medication discharge instructions have been implemented using this process, with two more planned. <h3>Conclusion</h3> Through interdisciplinary partnership and optimal use of EHR capabilities, improvements can be made to reduce nurse burden of entering instructions, increase standardization, and provide patients with appropriate discharge instructions. <h3>Implications for perianesthesia nurses</h3> Nurses should continue to identify and explore opportunities to improve the discharge education process to ensure patients receive relevant printed discharge instructions. Partnering with technology leaders in your organization to investigate automated processes may help eliminate requiring nurses to manually enter some instructions.

Assessment of Variation in Electronic Health Record Capabilities and Reported Clinical Quality Performance in Ambulatory Care Clinics, 2014-2017

Electronic health records (EHRs) are widely promoted to improve the quality of health care, but information about the association of multifunctional EHRs with broad measures of quality in ambulatory settings is scarce. To assess the association between EHRs with different degrees of capabilities and publicly reported ambulatory quality measures in at least 3 clinical domains of care. This cross-sectional and longitudinal study was conducted using survey responses from 1141 ambulatory clinics in Minnesota, Washington, and Wisconsin affiliated with a health system that responded to the Healthcare Information and Management Systems Society Annual Survey and reported performance measures in 2014 to 2017. Statistical analysis was performed from July 10, 2019, through February 26, 2021. A composite measure of EHR capability that considered 50 EHR capabilities in 7 functional domains, grouped into the following ordered categories: no functional EHR, EHR underuser, EHR, neither underuser or superuser, EHR superuser; as well as a standardized composite of ambulatory clinical performance measures that included 3 to 25 individual measures (median, 13 individual measures). In 2014, 381 of 746 clinics (51%) were EHR superusers; this proportion increased in each subsequent year (457 of 846 clinics [54%] in 2015, 510 of 881 clinics [58%] in 2016, and 566 of 932 clinics [61%] in 2017). In each cross-sectional analysis year, EHR superusers had better clinical quality performance than other clinics (adjusted difference in score: 0.39 [95% CI, 0.12-0.65] in 2014; 0.29 [95% CI, -0.01 to 0.59] in 2015; 0.26 [95% CI, -0.05 to 0.56] in 2016; and 0.20 [95% CI, -0.04 to 0.45] in 2017). This difference in scores translates into an approximately 9% difference in a clinic's rank order in clinical quality. In longitudinal analyses, clinics that progressed to EHR superuser status had only slightly better gains in clinical quality between 2014 and 2017 compared with the gains in clinical quality of clinics that were static in terms of their EHR status (0.10 [95% CI, -0.13 to 0.32]). In an exploratory analysis, different types of EHR capability progressions had different degrees of associated improvements in ambulatory clinical quality (eg, progression from no functional EHR to a status short of superuser, 0.06 [95% CI, -0.40 to 0.52]; progression from EHR underuser to EHR superuser, 0.18 [95% CI, -0.14 to 0.50]). Between 2014 and 2017, ambulatory clinics in Minnesota, Washington, and Wisconsin with EHRs having greater capabilities had better composite measures of clinical quality than other clinics, but clinics that gained EHR capabilities during this time had smaller increases in clinical quality that were not statistically significant.

Workflow analysis for design of an electronic health record-based tobacco cessation intervention in community health centers.

ObjectiveTobacco use is the leading cause of preventable morbidity and mortality in the United States. Quitlines are effective telephone-based tobacco cessation services but are underutilized. The goal of this project was to describe current clinical workflows for Quitline referral and design an optimal electronic health record (EHR)-based workflow for Ask-Advice-Connect (AAC), an evidence-based intervention to increase Quitline referrals.Materials and methodsTen Community Health Center systems (CHC), which use three different EHRs, participated in this study. Methods included: 9 group discussions with CHC leaders; 33 observations/interviews of clinical teams' workflow; surveys with 57 clinical staff; and assessment of the EHR ecosystem in each CHC. Data across these methods were integrated and coded according to the Fit between Individual, Task, Technology and Environment (FITTE) framework. The current and optimal workflow were notated using Business Process Modelling Notation. We compared the requirements of the optimal workflow with EHR capabilities.ResultsCurrent workflows are inefficient in data collection, variable in who, how, and when tobacco cessation advice and referral are enacted, and lack communication between referring clinics and the Quitline. In the optimal workflow, medical assistants deliver a standardized AAC intervention during the visit intake. Referrals are submitted electronically, and there is bidirectional communication between the clinic and Quitline. We implemented AAC within all three EHRs; however, deviations from the optimal workflow were necessary.ConclusionCurrent workflows for Quitline referral are inefficient and ineffective. We propose an optimal workflow and discuss improvements in EHR capabilities that would improve the implementation of AAC.

A Practical Guide for Navigating the Design, Build, and Clinical Integration of Electronic Patient-Reported Outcomes in the Radiation Oncology Department

The development and integration of electronic patient-reported outcomes (ePROs) into the radiation oncology clinic workflow provide novel opportunities, accompanied by unique design considerations and implementation challenges. The processes required for implementation of ePROs are entirely distinct from standard paper-based surveys, with the majority of time devoted to conception and design before initiating questionnaire build, detailed workflow process mapping including development of new workflows, comprehensive communication of the vision between providers and the information technology team, and quality assurance. Based on our experience with implementation of ePROs in our radiation oncology department, we developed a stepwise framework for approaching ePRO conceptual design, build, workflow integration, and the electronic health record interface. Here, we provide a guide for the numerous considerations, decision points, and solutions associated with the implementation of ePROs in the radiation oncology department setting. Although various ePRO tools and electronic health record capabilities impose different requirements, opportunities, and limitations, the conceptual processes and many of the electronic build considerations are broadly applicable.

Hospital adoption of electronic health record functions to support age-friendly care: results from a national survey.

To measure US hospitals' adoption of electronic health record (EHR) functions that support care for older adults, focusing on structured documentation of the 4Ms (What Matters, Medication, Mentation, and Mobility) and electronic health information exchange/communication with patients, caregivers, and long-term care providers. In an online survey of a national, random sample of 797 US acute-care hospitals in 2018-2019, 479 (60.1%) responded. We calculated nationally representative measures of the percentages of hospitals with EHRs that include structured documentation of the 4Ms and exchange/communications functions. Structured EHR documentation of the 4Ms was fully implemented in at least 1 unit in 64.0% of hospitals and across all units in 41.5% of hospitals. Of the 4Ms, structured documentation was the highest for medications (91.3% in at least 1 unit) and the lowest for mentation (70.3% in at least 1 unit). All exchange/communication functions had been implemented in at least 1 unit in 16.2% of facilities and across all units in 7.6% of hospitals. Less than half of the hospitals had an EHR portal for long-term care facilities to access hospital information (45.4% in at least 1 unit), sent information electronically to long-term care facilities (44.6%), and had training for adults/caregivers on the patient portal (32.1%). Despite significant national investment in EHRs, hospital EHRs do not yet include key documentation, exchange, and communication functions needed to support evidence-based care for the older adults who comprise the majority of the inpatient population. Additional policy efforts are likely needed to promote the expansion of EHR capabilities into these high-value domains. US acute-care hospital EHRs are lacking key functions that support care for older adults.

Understanding Factors Influencing Quality Improvement Capacity Among Ambulatory Care Practices Across the MidSouth Region: An Exploratory Qualitative Study.

Success in choosing and implementing quality metrics, necessary in a value-based care model, depends on quality improvement (QI) capacity-the shared knowledge, understanding, and commitment to continuous improvement. We set out to explore factors influencing QI capacity among ambulatory care practices in the MidSouth Practice Transformation Network. As part of network participation, 82 practices submitted a plan for implementing self-selected quality metrics. This plan asked practices to identify factors that would assist or impede successful implementation of interventions to meet metric targets. We used a qualitative thematic analysis approach to explore barriers and facilitators to developing QI capacity among ambulatory care practices. Recurrent facilitators included external change agents, protected time for QI, a framework for improvement, and infrastructure including electronic health record (EHR) capabilities. Frequent barriers included lack of QI knowledge, lack of time, frequent staff turnover, inadequate EHR capabilities, lack of an internal change agent, and a belief that performance was outside of the practice's control. These findings provide insight into factors influencing the adoption and implementation of QI metrics across a diverse group of ambulatory care practices and suggest that targeting the Inner Setting of practices may be an appropriate approach for developing practice-level QI capacity, which is necessary for success in a value-based care model.

Wearable Health Technology and Electronic Health Record Integration: Scoping Review and Future Directions.

BackgroundDue to the adoption of electronic health records (EHRs) and legislation on meaningful use in recent decades, health systems are increasingly interdependent on EHR capabilities, offerings, and innovations to better capture patient data. A novel capability offered by health systems encompasses the integration between EHRs and wearable health technology. Although wearables have the potential to transform patient care, issues such as concerns with patient privacy, system interoperability, and patient data overload pose a challenge to the adoption of wearables by providers.ObjectiveThis study aimed to review the landscape of wearable health technology and data integration to provider EHRs, specifically Epic, because of its prevalence among health systems. The objectives of the study were to (1) identify the current innovations and new directions in the field across start-ups, health systems, and insurance companies and (2) understand the associated challenges to inform future wearable health technology projects at other health organizations.MethodsWe used a scoping process to survey existing efforts through Epic’s Web-based hub and discussion forum, UserWeb, and on the general Web, PubMed, and Google Scholar. We contacted Epic, because of their position as the largest commercial EHR system, for information on published client work in the integration of patient-collected data. Results from our searches had to meet criteria such as publication date and matching relevant search terms.ResultsNumerous health institutions have started to integrate device data into patient portals. We identified the following 10 start-up organizations that have developed, or are in the process of developing, technology to enhance wearable health technology and enable EHR integration for health systems: Overlap, Royal Philips, Vivify Health, Validic, Doximity Dialer, Xealth, Redox, Conversa, Human API, and Glooko. We reported sample start-up partnerships with a total of 16 health systems in addressing challenges of the meaningful use of device data and streamlining provider workflows. We also found 4 insurance companies that encourage the growth and uptake of wearables through health tracking and incentive programs: Oscar Health, United Healthcare, Humana, and John Hancock.ConclusionsThe future design and development of digital technology in this space will rely on continued analysis of best practices, pain points, and potential solutions to mitigate existing challenges. Although this study does not provide a full comprehensive catalog of all wearable health technology initiatives, it is representative of trends and implications for the integration of patient data into the EHR. Our work serves as an initial foundation to provide resources on implementation and workflows around wearable health technology for organizations across the health care industry.

Updates to the HL7 2.5.1 Implementation Guide for Syndromic Surveillance

Updates to the HL7 2.5.1 Implementation Guide for Syndromic Surveillance

Variation in electronic health record adoption in European public hospitals: a configurational analysis of key functionalities

The potential of electronic health record (EHR) to support the delivery of health care and save money and lives is well recognized; and their association with performance relies on the patterns of functionalities that are used by clinicians. However, the majority of research has investigated EHR adoption with a dichotomous dependent variable measuring EHR adoption or not. Other have studied individual EHR component or functionality. While these studies have contributed to understanding of EHR adoption, they provide an incomplete picture of hospital EHR capabilities and the study of EHR functionalities and associated configuration has only begun to be examined in detail, knowledge of which may generate important insights on actual practices of hospitals. It will assist healthcare executives to consider basing their decisions on empirically grounded knowledge rather than on purely normative discourses. Based on configurational approach, we use factor analysis and cluster analysis to uncover clusters of European public hospitals with similar patterns of EHR key functionalities made available to clinicians. As well we investigate the relationship between these patterns and hospital characteristics. Drawing on data from the European Hospital Survey, we empirically derive a 3-cluster solution, composed of three well-separated groups, from a data set of 711 European public hospitals. We find in addition that the three configurations exhibit great heterogeneity with regard to their polarity; that is the number and the nature of dominant categories of EHR key functionalities within each cluster. The three hospital profiles are: unipolar – hospitals with one dominant category of EHR functionalities (28% of the sample), tripolar - hospitals with three dominant categories of EHR functionalities (55%), and apolar - hospitals with no dominant category of EHR functionalities (17%), with tripolar being the largest and the most sophisticated. In particular, all the three clusters are distinct in terms of availability of key EHR functionalities namely, medical documentation, results viewing, and medication and prescription list functionalities available to their clinicians. The study also reveals the conditions under which these configuration occur. Our results provide an empirically and conceptually grounded taxonomy of European public hospitals with regard to EHR key functionalities.

Forecasting the Maturation of Electronic Health Record Functions Among US Hospitals: Retrospective Analysis and Predictive Model.

BackgroundThe Meaningful Use (MU) program has promoted electronic health record adoption among US hospitals. Studies have shown that electronic health record adoption has been slower than desired in certain types of hospitals; but generally, the overall adoption rate has increased among hospitals. However, these studies have neither evaluated the adoption of advanced functionalities of electronic health records (beyond MU) nor forecasted electronic health record maturation over an extended period in a holistic fashion. Additional research is needed to prospectively assess US hospitals’ electronic health record technology adoption and advancement patterns.ObjectiveThis study forecasts the maturation of electronic health record functionality adoption among US hospitals through 2035.MethodsThe Healthcare Information and Management Systems Society (HIMSS) Analytics’ Electronic Medical Record Adoption Model (EMRAM) dataset was used to track historic uptakes of various electronic health record functionalities considered critical to improving health care quality and efficiency in hospitals. The Bass model was used to predict the technological diffusion rates for repeated electronic health record adoptions where upgrades undergo rapid technological improvements. The forecast used EMRAM data from 2006 to 2014 to estimate adoption levels to the year 2035.ResultsIn 2014, over 5400 hospitals completed HIMSS’ annual EMRAM survey (86%+ of total US hospitals). In 2006, the majority of the US hospitals were in EMRAM Stages 0, 1, and 2. By 2014, most hospitals had achieved Stages 3, 4, and 5. The overall technology diffusion model (ie, the Bass model) reached an adjusted R-squared of .91. The final forecast depicted differing trends for each of the EMRAM stages. In 2006, the first year of observation, peaks of Stages 0 and 1 were shown as electronic health record adoption predates HIMSS’ EMRAM. By 2007, Stage 2 reached its peak. Stage 3 reached its full height by 2011, while Stage 4 peaked by 2014. The first three stages created a graph that exhibits the expected “S-curve” for technology diffusion, with inflection point being the peak diffusion rate. This forecast indicates that Stage 5 should peak by 2019 and Stage 6 by 2026. Although this forecast extends to the year 2035, no peak was readily observed for Stage 7. Overall, most hospitals will achieve Stages 5, 6, or 7 of EMRAM by 2020; however, a considerable number of hospitals will not achieve Stage 7 by 2035.ConclusionsWe forecasted the adoption of electronic health record capabilities from a paper-based environment (Stage 0) to an environment where only electronic information is used to document and direct care delivery (Stage 7). According to our forecasts, the majority of hospitals will not reach Stage 7 until 2035, absent major policy changes or leaps in technological capabilities. These results indicate that US hospitals are decades away from fully implementing sophisticated decision support applications and interoperability functionalities in electronic health records as defined by EMRAM’s Stage 7.

Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study.

Support for ongoing care management and coordination between office visits for patients with multiple chronic conditions has been inadequate. In January 2015, Medicare introduced the Chronic Care Management (CCM) payment policy, which reimburses providers for CCM activities for Medicare beneficiaries occurring outside of office visits. To explore the experiences, facilitators, and challenges of practices providing CCM services, and their implications going forward. Semi-structured telephone interviews from January to April 2016 with 71 respondents. Sixty billing and non-billing providers and practice staff knowledgeable about their practices' CCM services, and 11 professional society representatives. Practice respondents noted that most patients expressed positive views of CCM services. Practice respondents also perceived several patient benefits, including improved adherence to treatment, access to care team members, satisfaction, care continuity, and care coordination. Facilitators of CCM provision included having an in-practice care manager, patient-centered medical home recognition, experience developing care plans, patient trust in their provider, and supplemental insurance to cover CCM copayments. Most billing practices reported few problems obtaining patients' consent for CCM, though providers felt that CMS could better facilitate consent by marketing CCM's goals to beneficiaries. Barriers reported by professional society representatives and by billing and non-billing providers included inadequacy of CCM payments to cover upfront investments for staffing, workflow modification, and time needed to manage complex patients. Other barriers included inadequate infrastructure for health information exchange with other providers and limited electronic health record capabilities for documenting and updating care plans. Practices owned by hospital systems and large medical groups faced greater bureaucracy in implementing CCM than did smaller, independent practices. Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients.