Family caregiver experiences and needs across health conditions, relationships, and the lifespan: a Qualitative analysis.

PURPOSE: The purpose of this study was to understand the lived experiences of family caregivers who provide care to individuals across a broad range of ages, caregiving relationships, and health conditions and/or disabilities. Family caregiver research is typically siloed by health condition or by caregiving relationship, leaving gaps in understanding similarities and differences among caregivers. METHODS: We hosted three virtual focus groups with diverse family caregivers (n = 26) caring for an individual with a long-term disability and/or health condition(s). We conducted a qualitative thematic analysis using an iterative, inductive process. RESULTS: Participants primarily expressed shared experiences, despite having unique caregiving situations. We identified themes among a) caregiver experiences: Trying to Do It All, Balancing Complex Emotions, Managing Expectations, and Adjusting to Changes Over Time and b) caregiver needs: Longing for Breaks and Self-Care; Lacking Help, Support and Resources; and Desiring Understanding and Recognition. CONCLUSIONS: These findings emphasize that many elements of the caregiving experience transcend care recipient age, condition, and relationship and are applicable to clinicians, researchers, and policy makers. The evidence of shared caregiver experiences can guide efficiencies in policy and practice (e.g., pooling of existing resources, expansion of interventions) to meet the needs of a broader population of caregivers.

Looking Behind the Curtain: Identifying Factors Contributing to Changes on Care Outcomes During a Large Commercial EHR Implementation.

OBJECTIVE: To identify factors contributing to changes on quality, productivity, and safety outcomes during a large commercial electronic health record (EHR) implementation and to guide future research. METHODS: We conducted a mixed-methods study assessing the impact of a commercial EHR implementation. The method consisted of a quantitative longitudinal evaluation followed by qualitative semi-structured, in-depth interviews with clinical employees from the same implementation. Fourteen interviews were recorded and transcribed. Three authors independently coded interview narratives and via consensus identified factors contributing to changes on 15 outcomes of quality, productivity, and safety. RESULTS: We identified 14 factors that potentially affected the outcomes previously monitored. Our findings demonstrate that several factors related to the implementation (e.g., incomplete data migration), partially related (e.g., intentional decrease in volume of work), and not related (e.g., health insurance changes) may affect outcomes in different ways. DISCUSSION: This is the first study to investigate factors contributing to changes on a broad set of quality, productivity, and safety outcomes during an EHR implementation guided by the results of a large longitudinal evaluation. The diversity of factors identified indicates that the need for organizational adaptation to take full advantage of new technologies is as important for health care as it is for other services sectors. CONCLUSIONS: We recommend continuous identification and monitoring of these factors in future evaluations to hopefully increase our understanding of the full impact of health information technology interventions.

Comprehensive methodology to monitor longitudinal change patterns during EHR implementations: a case study at a large health care delivery network.

OBJECTIVE: To test a systematic methodology to monitor longitudinal change patterns on quality, productivity, and safety outcomes during a large-scale commercial Electronic Health Record (EHR) implementation. MATERIALS AND METHODS: Our method combines an interrupted time-series design with control sites and 41 consensus outcomes including quality (11 measures), productivity (20 measures), and safety (10 measures). The intervention consisted of a phased commercial EHR implementation at a large health care delivery network. Four medium-size hospitals and 39 clinics from 5 geographic regions implementing the new EHR were compared against a parallel control consisting of one medium-size and one large hospital and 10 clinics that had not implemented the new EHR at the time of this study. We collected monthly data from February 2013 to July 2017. RESULTS: The proposed methodology was successfully implemented and significant changes were observed in most measured variables. A significant change attributable to the intervention was observed in 12 (29%) measures in three or more regions; in 32 (78%) measures in two or more regions; and in 40 (98%) measures in at least one region. A similar pattern (i.e., same impact in three or more regions) was detected for nine (22%) measures, a mixed pattern (i.e., same impact in two regions, and different impact in other regions) was detected for nine (22%) measures, and an inconsistent pattern (i.e., did not detect the same impact across regions) was detected for 23 (56%) measures. DISCUSSION: Using a formal methodology to assess changes in a set of consensus measures, we detected various patterns of impact and mixed time-sensitive effects. With an increasing adoption of EHR systems, it is critical for health care organizations to systematically monitor their EHR implementations. The proposed method provides a robust and consistent approach to monitor EHR implementations longitudinally allowing for continuous monitoring after the system becomes stable in order to avoid unexpected effects. CONCLUSION: Our results and methodology can guide the broader medical and informatics communities by informing what and how to continuously monitor EHR impact on quality, productivity, and safety.

Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Development and classification of a robust inventory of near real-time outcome measurements for assessing information technology interventions in health care.

OBJECTIVE: To develop and classify an inventory of near real-time outcome measures for assessing information technology (IT) interventions in health care and assess their relevance as perceived by experts in the field. MATERIALS AND METHODS: To verify the robustness and coverage of a previously published inventory of measures and taxonomy, we conducted semi-structured interviews with clinical and administrative leaders from a large care delivery system to collect suggestions of outcome measures that can be calculated with data available in electronic format for near real-time monitoring of EHR implementations. We combined these measures with the most commonly reported in the literature. We then conducted two online surveys with subject-matter experts to collect their perceptions of the relevance of the measures, and identify other potentially relevant measures. RESULTS: With input from experienced health care leaders and informaticists, we developed an inventory of 102 outcome measures. These measures were classified into a taxonomy of commonly used measures around the categories of quality, productivity, and safety. Safety measures were rated as most relevant by subject-matter experts, especially those measuring medication processes. Clinician satisfaction and measures assessing mean time to complete tasks and time spent on electronic documentation were also rated as highly relevant. DISCUSSION: By expanding the coverage of our previously published inventory and taxonomy, we expect to help providers, health IT vendors and researchers to more effectively and consistently monitor the impact of EHR implementations in near real-time, and report more standardized outcomes in future studies. We identified several measures not commonly assessed by previous studies of IT implementations, especially those of safety and productivity, which deserve more attention from the broader informatics community. CONCLUSION: Our inventory of measures and taxonomy will help researchers identify gaps in their measurement approaches and report more standardized measurements of IT interventions that could be shared among researchers, hopefully facilitating comparison across future studies and increasing our understanding of the impact of IT interventions in health care.

Health information technology adoption: Understanding research protocols and outcome measurements for IT interventions in health care.

OBJECTIVE: To classify and characterize the variables commonly used to measure the impact of Information Technology (IT) adoption in health care, as well as settings and IT interventions tested, and to guide future research. MATERIALS AND METHODS: We conducted a descriptive study screening a sample of 236 studies from a previous systematic review to identify outcome measures used and the availability of data to calculate these measures. We also developed a taxonomy of commonly used measures and explored setting characteristics and IT interventions. RESULTS: Clinical decision support is the most common intervention tested, primarily in non-hospital-based clinics and large academic hospitals. We identified 15 taxa representing the 79 most commonly used measures. Quality of care was the most common category of these measurements with 62 instances, followed by productivity (11 instances) and patient safety (6 instances). Measures used varied according to type of setting, IT intervention and targeted population. DISCUSSION: This study provides an inventory and a taxonomy of commonly used measures that will help researchers select measures in future studies as well as identify gaps in their measurement approaches. The classification of the other protocol components such as settings and interventions will also help researchers identify underexplored areas of research on the impact of IT interventions in health care. CONCLUSION: A more robust and standardized measurement system and more detailed descriptions of interventions and settings are necessary to enable comparison between studies and a better understanding of the impact of IT adoption in health care settings.

The cost of sustaining a patient-centered medical home: experience from 2 states.

PURPOSE: As medical practices transform to patient-centered medical homes (PCMHs), it is important to identify the ongoing costs of maintaining these "advanced primary care" functions. A key required input is personnel effort. This study's objective was to assess direct personnel costs to practices associated with the staffing necessary to deliver PCMH functions as outlined in the National Committee for Quality Assurance Standards. METHODS: We developed a PCMH cost dimensions tool to assess costs associated with activities uniquely required to maintain PCMH functions. We interviewed practice managers, nurse supervisors, and medical directors in 20 varied primary care practices in 2 states, guided by the tool. Outcome measures included categories of staff used to perform various PCMH functions, time and personnel costs, and whether practices were delivering PCMH functions. RESULTS: Costs per full-time equivalent primary care clinician associated with PCMH functions varied across practices with an average of $7,691 per month in Utah practices and $9,658 in Colorado practices. PCMH incremental costs per encounter were $32.71 in Utah and $36.68 in Colorado. The average estimated cost per member per month for an assumed panel of 2,000 patients was $3.85 in Utah and $4.83 in Colorado. CONCLUSIONS: Identifying costs of maintaining PCMH functions will contribute to effective payment reform and to sustainability of transformation. Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff, or both. Adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions.

Impact of an integrated transition management program in primary care on hospital readmissions.

Poorly executed transitions in care from hospital to home are associated with increased vulnerability to adverse medication events and hospital readmissions, and also excess healthcare costs. Efforts to improve care coordination on hospital discharge have been shown to reduce hospital readmission rates but often rely on interventions that are not fully integrated within the primary care setting. The Patient Centered Medical Home (PCMH) model, whose core principles include care coordination in the posthospital setting, is an approach that addresses transitions in care in a more integrated fashion. We examined the impact of multicomponent transition management (TM) services on hospital readmission rates and time to hospital readmission among 118 patients enrolled in a TM program that is part of Care By Design, the University of Utah Community Clinics' version of the PCMH. We conducted a retrospective analysis comparing outcomes for patients before receiving TM services with outcomes for the same patients after receiving TM services. The all-cause 30-day hospital readmission rate decreased from 17.9% to 8.0%, and the mean time to hospital readmission within 180 days was delayed from 95 to 115 days. These findings support the effectiveness of TM activities integrated within the primary care setting.

Organizational culture associated with provider satisfaction.

BACKGROUND: Organizational culture is key to the successful implementation of major improvement strategies. Transformation to a patient-centered medical home (PCHM) is such an improvement strategy, requiring a shift from provider-centric care to team-based care. Because this shift may impact provider satisfaction, it is important to understand the relationship between provider satisfaction and organizational culture, specifically in the context of practices that have transformed to a PCMH model. METHODS: This was a cross-sectional study of surveys conducted in 2011 among providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design. Measures included the Organizational Culture Assessment Instrument and the American Medical Group Association provider satisfaction survey. RESULTS: Providers were most satisfied with quality of care (mean, 4.14; scale of 1-5) and interactions with patients (mean, 4.12) and were least satisfied with time spent working (mean, 3.47), paperwork (mean, 3.45), and compensation (mean, 3.35). Culture profiles differed across clinics, with family/clan and hierarchical cultures the most common. Significant correlations (P ≤ .05) between provider satisfaction and clinic culture archetypes included family/clan culture negatively correlated with administrative work; entrepreneurial culture positively correlated with the Time Spent Working dimension; market/rational culture positively correlated with how practices were facing economic and strategic challenges; and hierarchical culture negatively correlated with the Relationships with Staff and Resource dimensions. CONCLUSIONS: Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.

Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation.

OBJECTIVE: To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. DATA SOURCE/STUDY SETTING: An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. STUDY DESIGN: Convergent case study mixed methods design. DATA COLLECTION/EXTRACTION METHODS: Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. PRINCIPAL FINDINGS: Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. CONCLUSIONS: Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.

Incidence of online health information search: a useful proxy for public health risk perception.

BACKGROUND: Internet users use search engines to look for information online, including health information. Researchers in medical informatics have found a high correlation of the occurrence of certain search queries and the incidence of certain diseases. Consumers' search for information about diseases is related to current health status with regard to a disease and to the social environments that shape the public's attitudes and behaviors. OBJECTIVE: This study aimed to investigate the extent to which public health risk perception as demonstrated by online information searches related to a health risk can be explained by the incidence of the health risk and social components of a specific population's environment. Using an ecological perspective, we suggest that a population's general concern for a health risk is formed by the incidence of the risk and social (eg, media attention) factors related with the risk. METHODS: We constructed a dataset that included state-level data from 32 states on the incidence of the flu; a number of social factors, such as media attention to the flu; private resources, such as education and health insurance coverage; public resources, such as hospital beds and primary physicians; and utilization of these resources, including inpatient days and outpatient visits. We then explored whether online information searches about the flu (seasonal and pandemic flu) can be predicted using these variables. We used factor analysis to construct indexes for sets of social factors (private resources, public resources). We then applied panel data multiple regression analysis to exploit both time-series and cross-sectional variation in the data over a 7-year period. RESULTS: Overall, the results provide evidence that the main effects of independent variables-the incidence of the flu (P<.001); social factors, including media attention (P<.001); private resources, including life quality (P<.001) and health lifestyles (P=.009); and public resources, such as hospital care utilization (P=.008) and public health funds (P=.02)-have significant effects on Web searches for queries related to the flu. After controlling for the number of reported disease cases and Internet access rate by state, we estimate the contribution of social factors to the public health risk perception levels by state (R(2)=23.37%). The interaction effects between flu incidence and social factors for our search terms did not add to the explanatory power of our regression models (R(2)<1%). CONCLUSIONS: Our study suggests a practical way to measure the public's health risk perception for certain diseases using online information search volume by state. The social environment influences public risk perception regardless of disease incidence. Thus, monitoring the social variables can be very helpful in being ready to respond to the public's behavior in dealing with public health threats.

Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change.

PURPOSE: We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS: Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS: The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS: These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings.

PURPOSE: We examined quality, satisfaction, financial, and productivity outcomes associated with implementation of Care by Design (CBD), the University of Utah's version of the patient-centered medical home. METHODS: We measured the implementation of individual elements of CBD using a combination of observation, chart audit, and collection of data from operational reports. We assessed correlations between level of implementation of each element and measures of quality, patient and clinician satisfaction, financial performance, and efficiency. RESULTS: Team function elements had positive correlations (P ≤.05) with 6 quality measures, 4 patient satisfaction measure, and 3 clinician satisfaction measures. Continuity elements had positive correlations with 2 satisfaction measures and 1 quality measure. Clinician continuity was the key driver in the composite element of appropriate access. Unexpected findings included the negative correlation of use of templated questionnaires with 3 patient satisfaction measures. Trade-offs were observed for performance of blood draws in the examination room and the efficiency of visits, with some positive and some negative correlations depending on the outcome. CONCLUSIONS: Elements related to care teams and continuity appear to be key elements of CBD as they influence all 3 CBD organizing principles: appropriate access, care teams, and planned care. These relationships, as well as unexpected, unfavorable ones, require further study and refined analyses to identify causal associations.

Correlation of the Care by Design primary care practice redesign model and the principles of the patient-centered medical home.

BACKGROUND: Health care reform requires major changes in the organization and delivery of primary care. In 2003, the University of Utah Community Clinics began developing Care by Design (CBD), a primary care model emphasizing access, care teams, and planned care. In 2007, leading primary care organizations published joint principles of the patient-centered medical home (PCMH), the basis for recognition of practices as PCMHs by the National Committee for Quality Assurance (NCQA). The objective of this study was to compare CBD and PCMH metrics conceptually and statistically. METHODS: This was an observational study in 10 urban and rural primary care clinics including 56 providers. A self-evaluation included the CBD Extent of Use survey and self-estimated PCMH values. The main and secondary outcome measures were CBD scores and PCMH values, respectively. RESULTS: CBD and PCMH principles share common themes such as appropriate access, team-based care, the use of an augmented electronic medical record, planned care, and self-management support. CBD focuses more on the process of practice transformation. The NCQA PCMH standards focus more on structure, including policy, capacity, and populated electronic medical record fields. The Community Clinics' clinic-level PCMH/CBD correlations were low (P > .05.) CONCLUSIONS: Practice redesign requires an ability to assess uptake of the redesign as a transformation progresses. The correlation of CBD and PCMH is substantial conceptually but low statistically. PCMH and CBD focus on complementary aspects of redesign: PCMH on structure and CBD on process. Both domains should be addressed in practice reform. Both metrics are works in progress.