Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements.

BACKGROUND: Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE: To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN: Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS: We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH: We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS: Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS: Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.

Percutaneous vertebroplasty and kyphoplasty for pathologic vertebral fractures in the Medicare population: safer and less expensive than open surgery.

PURPOSE: To compare cost and outcomes of surgical and percutaneous treatments of pathologic vertebral fractures. MATERIALS AND METHODS: Standard Medicare 5% anonymized inpatient files (1999-2009) were retrospectively reviewed. Patients with a diagnosis of vertebral fracture without spinal cord injury and primary or metastatic bony malignancy were divided into percutaneous or surgical groups based on whether they received vertebroplasty/kyphoplasty or surgical treatment. Patients who had no intervention or both interventions were excluded. Cost, length of stay, and type of discharge were examined while controlling for demographic and comorbidity variables. RESULTS: A total of 451 patients were included; 52% received percutaneous treatment and 48% received surgery. Patients treated percutaneously were older (P < .001) and more likely to be female (P = .04). Percutaneous therapy predicted $14,862 less Medicare cost and $13,565 less overall cost (P < .001 for both), and 4.1 fewer inpatient days (P < .001). Patients who underwent surgery had higher odds of death (odds ratio = 3.38, P = .016), discharge to a rehabilitation facility (odds ratio = 3.3, P = .003), and transfer to another inpatient facility (odds ratio = 8.53, P < .001), and lower odds of discharge to home (odds ratio = 0.42, P < .001) and hospice (odds ratio = 0.08, P = .002). CONCLUSIONS: In a Medicare population with bony malignancy and vertebral fractures, percutaneous therapy predicted significantly reduced cost and length of stay versus surgery. Patients who underwent percutaneous therapy were significantly less likely to die, be transferred, or be discharged to rehabilitation facilities, and were more likely to be discharged to home or hospice.

Interdisciplinary Priorities for Dissemination, Implementation, and Improvement Science: Frameworks, Mechanics, and Measures.

Much of dissemination, implementation, and improvement (DII) science is conducted by social scientists, healthcare practitioners, and biomedical researchers. While each of these groups has its own venues for sharing methods and findings, forums that bring together the diverse DII science workforce provide important opportunities for cross-disciplinary collaboration and learning. In particular, such forums are uniquely positioned to foster the sharing of three important components of research. First: they allow the sharing of conceptual frameworks for DII science that focus on the use and spread of innovations. Second: they provide an opportunity to share strategies for initiating and governing DII research, including approaches for eliciting and incorporating the research priorities of patients, study participants, and healthcare practitioners, and decision-makers. Third: they allow the sharing of outcome measures well-suited to the goals of DII science, thereby helping to validate these outcomes in diverse contexts, improving the comparability of findings across settings, and elevating the study of the implementation process itself.

Promoting electronic health record adoption among small independent primary care practices.

OBJECTIVES: To describe the benefits and limitations of incentive arrangements used to engage small primary care practices to adopt electronic health records (EHRs). STUDY DESIGN: Retrospective review of program outreach efforts and EHR enrollment rates. METHODS: Comparison of benefits and limitations of various promotional strategies in addition to a city subsidy. Measures of enrollment progress include the mean number of outreach attempts, the mean number of days from first attempt to enrollment, and the enrollment yield. Selected practice demographics were collected for comparison purposes. RESULTS: Of 890 providers representing 217 practices who were eligible for the city subsidy, 37.7% enrolled, with a mean of 96.6 days from first attempt to enrollment and a mean of 10 outreach attempts. The offer for full payment of technical assistance fees and hardware yielded an additional 100 providers representing 43 practices, a 14.1% enrollment rate. This group also had the highest mean number of days from first attempt to enrollment (236.0 days) and the highest mean number of outreach attempts (22 attempts). The offer for a partial rebate had the lowest yield (a 6.2% enrollment rate), a mean of 169.3 days from first attempt to enrollment, and a mean number of 19 outreach attempts. CONCLUSIONS: Because of diverse needs and levels of awareness in the EHR adoption process, a flexible milestone-based process is needed to engage primary care providers. In particular, community influence and additional funding were necessary for increasing enrollment among providers in medically underserved neighborhoods. These providers also required persistent and numerous follow-up attempts. Because billions of dollars in federal aid are being offered, effective local recruitment strategies are needed to facilitate provider engagement to increase EHR adoption rates.