The Most Important Skills Required by Local Public Health Departments for Responding to Community Needs and Improving Health Outcomes.

In 2017, Public Health 3.0 was introduced, providing recommendations that expand traditional public department functions and programs. Operationalizing the framework requires that local health departments invest in the requisite professional skills to respond to their community's needs. The purpose of this paper is to determine the professional skills that are most important for local health departments to respond to large public health issues and challenges that are having a major impact on their communities. The study used a cross-sectional assessment of the education and training needs of local public health departments in Nebraska following the principles of practice-based systems research. The assessment was designed to assess the training and education needs of local health department staff members. The questions measured the perceived importance of and respondent's capacity across 57 core competencies for public health professionals modified from the Council on Linkages Between Academia and Public Health Practice. A total of 104 staff members from seven local health departments were requested to complete the assessment and 100% of the individuals responded to and completed the assessment. Twenty-eight skills were identified as the most important skills needed for local health departments. The skills were themed and categorized into four domains. (1) Data, Evaluation, and Quality Improvement, (2) Community Engagement and Facilitation, (3) Systems Thinking and Leadership, and (4) Policy and Advocacy. The results from this analysis provide direction to strengthen and transform the public health system into one that is connected, responsive, and nimble. Additionally, it also highlighted a glaring omission that Equity, Diversity, and Inclusion should be included as the fifth domain.

Shifts in Community Benefits Spending Among Nonprofit Hospitals in Nebraska and 10 Proximate States, 2012 and 2015.

CONTEXT: Federal and state policy makers have debated the evolving concept of community benefit and the extent to which nonprofit hospitals are providing benefits to the community in exchange for the tax benefits they receive. OBJECTIVE: This study compares community benefits spending by nonprofit hospitals in Nebraska and other selected states in both 2012 and 2015. Expenditures are also examined by rural, regional, and urban hospitals within Nebraska. METHODS: Community benefit expenditure data were taken from Community Benefit Insight and consolidated into the categories of direct patient care, community health improvement initiatives, and health professions education and research. RESULTS: When community benefit expenditures were compared across 11 states, Nebraska had the highest percentage of expenditures for community health improvement initiatives in both 2012 and 2015. Although community benefit expenditures for the 44 nonprofit hospitals within Nebraska increased from 2012 to 2015, they remained flat as a share of total hospital expenditures. In 2015, 63% of community benefit expenditures were allocated to direct patient care, which represented a 7.3% decrease from 2012. This decline led to greater spending on community health improvement initiatives (3.1%) and health professions education and research (4.2%). Rural, regional, and urban hospitals spent more proportionately on community health improvement initiatives in 2015 than in 2012. CONCLUSIONS: The shift in community benefit expenditures from direct patient care to community health improvement initiatives and health professions education and research suggests that hospitals are investing in programs with broader community-wide benefits. Nebraska allocates a significantly larger share of its community benefits spending to community health improvement activities than other Great Plains and Midwestern states. Nebraska is in the process of implementing Medicaid expansion, which may shift future community benefits spending decisions.

Ethics of HIV cure research: an unfinished agenda.

BACKGROUND: The pursuit of a cure for HIV is a high priority for researchers, funding agencies, governments and people living with HIV (PLWH). To date, over 250 biomedical studies worldwide are or have been related to discovering a safe, effective, and scalable HIV cure, most of which are early translational research and experimental medicine. As HIV cure research increases, it is critical to identify and address the ethical challenges posed by this research. METHODS: We conducted a scoping review of the growing HIV cure research ethics literature, focusing on articles published in English peer-reviewed journals from 2013 to 2021. We extracted and summarized key developments in the ethics of HIV cure research. Twelve community advocates actively engaged in HIV cure research provided input on this summary and suggested areas warranting further ethical inquiry and foresight via email exchange and video conferencing. DISCUSSION: Despite substantial scholarship related to the ethics of HIV cure research, additional attention should focus on emerging issues in six categories of ethical issues: (1) social value (ongoing and emerging biomedical research and scalability considerations); (2) scientific validity (study design issues, such as the use of analytical treatment interruptions and placebos); (3) fair selection of participants (equity and justice considerations); (4) favorable benefit/risk balance (early phase research, benefit-risk balance, risk perception, psychological risks, and pediatric research); (5) informed consent (attention to language, decision-making, informed consent processes and scientific uncertainty); and (6) respect for enrolled participants and community (perspectives of people living with HIV and affected communities and representation). CONCLUSION: HIV cure research ethics has an unfinished agenda. Scientific research and bioethics should work in tandem to advance ethical HIV cure research. Because the science of HIV cure research will continue to rapidly advance, ethical considerations of the major themes we identified will need to be revisited and refined over time.

Understanding breast cancer survivors' financial burden and distress after financial assistance.

PURPOSE: Little is known about how breast cancer may impact survivors' financial well-being. This study aims to investigate the financial status, burden, and opinions of breast cancer survivors who received short-term financial assistance, emotional support, and resource navigation from a community organization during treatment. METHODS: Clients previously served by the community organization were mailed a 16-question survey (n = 751) to elicit their perspective on financial status and burden before, during, and after diagnosis and treatment along with general demographic and opinion items. RESULTS: 136 surveys (18.1%) were returned yielding 118 (15.7%) suitable for analyses. Clients' average age was 54.3 years. Most were female (99.2%), Caucasian (66.1%), and diagnosed with Stage 1 or 2 breast cancer (58.5%). Clients reported significantly worse (p < 0.001) financial status after being diagnosed compared to before diagnosis. Financial distress was highest during cancer treatment (mean = 3.92, SD = 0.85), lowest prior to treatment (mean = 2.48, SD = 1.05), and remained high after treatment (mean = 3.59, SD = 1.05). Those with higher distress after treatment were significantly (p = 0.01) more likely to report lower social support during treatment. CONCLUSIONS: Breast cancer survivors reported worsening financial status and distress after being diagnosed and during treatment despite receiving short-term financial assistance, emotional support, and resource navigation. Survivors' financial distress after treatment remained higher than before treatment. However, most felt receiving financial assistance improved their quality of life and made them feel more in control of financial decision-making. Breast cancer survivors who feel they have low social support during treatment may feel higher financial distress posttreatment.

Strengthening Linkages Between Public Health and Health Care in Nebraska.

INTRODUCTION: Effective collaboration between public health and the health care system is essential for connecting medical and community health-related resources and improving population health. We investigated the linkages between local health departments and primary care clinics in Nebraska. METHODS: We conducted a mixed-method study by using semistructured in-person and telephone interviews and surveys in 2017 and 2018 with directors of 19 Nebraska local health departments. Interviews and surveys assessed activities and programs that health departments implemented or planned with clinics in their jurisdictions. Barriers, benefits, and opportunities for building the linkages were identified. RESULTS: Strong linkages existed between local health departments and primary care clinics. Linkages focused on the control and prevention of chronic diseases and on traditional public health programs, including screening for cancer and other chronic diseases, vaccinations, worksite wellness programs, home visits, clinic and medication assistance referrals, health message development, electronic health records data analyses, staff education, and improvements in policies and procedures. The most frequently reported barrier was funding, and the most frequently reported benefit was patient behavior change. The opportunity most frequently reported was chronic disease health coaching. CONCLUSION: Extensive linkages exist between Nebraska local health departments and the health care systems in their areas. Additional funding, effective workforce management, community needs assessments, and program evaluation can support joint initiatives to address community health priorities.

Improving behavioral health workforce supply and needs estimates using active surveillance data.

INTRODUCTION: Previous studies show that supply of behavioral health professionals in rural areas is inadequate to meet the need. Measuring shortage using licensure data on psychiatrists is a common approach. Although inexpensive, the licensure data have many limitations. An alternative is to implement an active surveillance system, which uses licensure data in addition to active data collection to obtain timely and detailed information. METHODS: Nebraska Health Professions Tracking Service (HPTS) data were used to examine differences in workforce supply estimates between the passive (licensure data only) and active (HPTS data) surveillance systems. The impact of these differences on the designation of psychiatric professional shortage areas has been described. Information regarding the number of psychiatrists, advanced practice registered nurses and physician assistants specializing in psychiatry was not available from the licensure database, unlike HPTS. RESULTS: Using licensure data versus HPTS data to estimate workforce, the counts of professionals actively practicing in psychiatry and behavioral health were overestimated by 24.1-57.1%. Ignoring work status, the workforce was overestimated by 10.0-17.4%. Providers spent 54-78% of time seeing patients. Based on primary practice location, 87% of counties did not have a psychiatrist and 9.6% were at or above the Health Professional Shortage Area designation ratio of psychiatrists to population. CONCLUSION: Enumeration methods such as ongoing surveillance, in addition to licensure data, curtails the issues and improves identification of shortage areas and future behavioral workforce related planning and implementation strategies.

Fewer immigrants have preventable ED visits in the United States.

OBJECTIVE: The aim of this study is to examine differences in having preventable emergency department (ED) visits between noncitizens, naturalized and US-born citizens in the United States. METHODS: We linked the 2008-2012 Medical Expenditure Panel Survey with National Health Interview Survey data to draw a nationally representative sample of US adults. Univariate analysis described distribution of preventable ED visits identified by the Prevention Quality Indicators across immigration status. We also assessed the association between preventable ED visits and immigration status, controlling for demographics, socioeconomic status, health service utilization, and health status. We finally applied the Oaxaca-Blinder decomposition method to measure the contribution of each covariate to differences in preventable ED services utilization between US natives, naturalized citizens, and noncitizens. RESULTS: Of US natives, 2.1% had any preventable ED visits within the past years as compared to 1.0% of noncitizens and 1.5% of naturalized citizens. Multivariate results also revealed that immigrants groups had significantly lower odds (adjusted OR: naturalized citizen 0.77 [0.61-0.96], noncitizen 0.62 [0.48-0.80]) of having preventable ED visits than natives. Further stratified analysis by insurance status showed these differences were only significant among the uninsured and public insurance groups. Race/ethnicity and health insurance explained about 68% of the difference in preventable ED service utilization between natives and noncitizens. CONCLUSION: Our study documents the existing differences in preventable ED visits across immigration status, and highlights the necessity to explore unmet health needs among immigrants and eliminate disparities.

Measuring the Cost and Value of Quality Improvement Initiatives for Local Health Departments.

OBJECTIVE: To demonstrate an approach to measuring the cost and value of quality improvement (QI) implementation in local health departments (LHDs). DESIGN: We conducted cost estimation for 4 LHD QI projects and return-on-investment (ROI) analysis for 2 selected LHD QI projects. SETTING AND PARTICIPANTS: Four Nebraska LHDs varying in rurality and jurisdiction size. MAIN OUTCOME MEASURES: Total costs, unit costs, incremental cost-effectiveness ratios, and ROI. RESULTS: The 4 QI projects vary significantly in their cost estimates. Estimated ROI ratios for 2 QI projects predicted significant savings in health care utilization for respective program participants. A QI project focused on improving breastfeeding rates in WIC (women, infants, and children) clients had a predicted ROI ratio of 3230% and a QI project for improving participation in a Chronic Disease Self-Management Program would need only 34 new participants to have a positive ROI. CONCLUSIONS: We demonstrated how data can be collected and analyzed for cost estimation and ROI analysis to quantify the economic value of QI for LHDs. Our ROI analysis shows that QI initiatives have great potential to enhance the value of LHDs' public health services. A better understanding of the costs and value of QI will enable LHDs to appropriately allocate and utilize their limited resources for suitable QI initiatives.

Rurality, Quality Improvement Maturity, and Accreditation Readiness: A Comparison Study of Colorado, Kansas, and Nebraska Local Health Departments.

OBJECTIVE: To compare local health department (LHD) accreditation readiness (AR) and quality improvement (QI) maturity in 3 states, between LHDs with varying levels of rurality, and across an LHD staffing-level continuum. DESIGN: This was a cross-sectional comparative study that included an online survey administered to LHD directors in Colorado, Kansas, and Nebraska. The survey included 10 questions assessed on a 5-point Likert scale covering 3 QI domains and 13 questions covering 5 AR domains. The median score for both QI maturity and AR was calculated by each state, by the number of full-time equivalent staff employed at the LHD, and by a measure of rurality and population density. SETTING AND PARTICIPANTS: A total of 156 LHDs from the states of Colorado, Kansas, and Nebraska. MAIN OUTCOME MEASURE(S): QI maturity and AR scores. RESULTS: A majority (59%) of the surveyed LHDs plan to apply or have already applied for Public Health Accreditation Board (PHAB) accreditation. The overall QI maturity and AR scores were highest in Nebraska, as was the intent to seek PHAB accreditation and current use of PHAB standards. Across levels of rurality and staffing, LHD QI maturity scores were similar; however, AR scores improved as LHD staffing levels increased and rurality decreased. CONCLUSIONS: Small LHDs and rural LHDs have QI maturity levels that are comparable to larger, less rural LHDs, but their AR is much lower. As accreditation has been found to have positive benefits, it is important that all LHDs have the capacity and resources to meet the performance standards required of accredited LHDs. Small, rural LHDs may need additional resources and support in order to improve their ability to be accredited and/or certain accreditation requirements may need modification to make accreditation more accessible to small LHDs.

The EDIC Method: An Engaging and Comprehensive Approach for Creating Health Department Workforce Development Plans.

In 2013, the Nebraska Department of Health & Human Services, Division of Public Health (Nebraska's State Health Department); and the University of Nebraska Medical Center, College of Public Health developed a comprehensive approach to assess workforce training needs. This article outlines the method used to assess the education and training needs of Division staff, and develop comprehensive workforce development plans to address those needs. The EDIC method (Engage, Develop, Identify, and Create) includes the following four phases: (1) Engage Stakeholders, (2) Develop Assessment, (3) Identify Training Needs, and (4) Create Development Plans. The EDIC method provided a process grounded in science and practice, allowed input, and produced buy-in from staff at all levels throughout the Division of Public Health. This type of process provides greater assurance that the most important gaps in skills and competencies will be identified. Although it is a comprehensive approach, it can be replicated at the state or local level across the country.

Relationship between quality improvement implementation and accreditation seeking in local health departments.

OBJECTIVES: We examined the relationship between quality improvement (QI) maturity and accreditation attributes of US local health departments (LHDs), specifically those in Nebraska. METHODS: Using 2011 Nebraska LHD QI survey data, we conducted Spearman correlation analyses between QI maturity domains and accreditation attributes. Using the 2010 National Association of County and City Health Officials' National Profile of LHDs, we conducted logistic regression analyses to examine the relationships between specific QI strategies and attitude toward seeking accreditation. RESULTS: Leaders' commitment to and length of time engaged in QI were positively associated with LHDs' general attitude toward seeking accreditation. Use of QI strategies and integration of QI policies and practices were positively associated with LHDs' confidence in their capacity to obtain accreditation. LHDs that had used at least 1 QI framework and at least 1 QI technique in the past year were more likely to agree that they would seek accreditation within 2 years of the national accreditation program. CONCLUSIONS: Experience with and expertise in QI implementation play an important role in LHDs' decision to seek accreditation, and their accreditation-seeking efforts may benefit from prior implementation of systematic QI strategies.

A model for training public health workers in health policy: the Nebraska Health Policy Academy.

There is growing recognition that health goals are more likely to be achieved and sustained if programs are complemented by appropriate changes in the policies, systems, and environments that shape their communities. However, the knowledge, skills, and abilities needed to create and implement policy are among the major needs identified by practitioners at both the state and local levels. This article describes the structure and content of the Nebraska Health Policy Academy (the Academy), a 9-month program developed to meet the demand for this training. The Academy is a competency-based training program that aims to increase the capacity of Nebraska's state and local public health staff and their community partners to use public health policy and law as a public health tool. Our initiative allows for participation across a large, sparsely populated state; is grounded in adult learning theory; introduces the key principles and practices of policy, systems, and environmental change; and is offered free of charge to the state's public health workforce. Challenges and lessons learned when offering workforce development on public health policy efforts are discussed.

Utilizing Advocacy to Promote the Adoption and Implementation of Medicaid Policies That Increase Insurance Coverage Among Adolescents.

PURPOSE: The Promise of Adolescence: Realizing Opportunity for All Youth report recommends several Medicaid policies to increase insurance coverage among adolescents: approve Medicaid expansion; eliminate the 5-year Medicaid waiting period for lawfully present adolescent immigrants; increase Medicaid reimbursement rates for adolescent health services to the level of Medicare; and ensure coverage and sufficient reimbursement of comprehensive health services. We designed this study to identify key advocates and factors relevant to adoption and implementation of the recommended Medicaid policies in Nebraska to highlight opportunities for additional advocacy. METHODS: We conducted semistructured interviews January 2022 with 28 adolescent health and health-care access experts in Nebraska, including representatives from health care, education, government, and nonprofit sectors. We recorded the interviews and transcribed them verbatim, then coded data using NVivo software and identified key themes. RESULTS: Participants were unable to identify any Medicaid advocates or advocacy work focused on adolescents, but they did identify 35 organizations working to improve insurance coverage in Nebraska. Coordinated multisector, statewide coalitions secured the adoption of Medicaid expansion through a citizen-supported ballot initiative. Barriers to successful implementation include limited Medicaid outreach to citizens and lawfully present immigrants. Low state government support for increasing Medicaid reimbursement rates and providing comprehensive health services, coupled with the absence of coordinated advocacy, hinder the adoption of these recommendations. DISCUSSION: Advocacy efforts should be implemented to increase adoption and implementation of Medicaid policies recommended to increase adolescents' insurance coverage. These efforts must be built on a foundation of knowledge of state government practices and must utilize sustained partnership among multisector advocates, including adolescent-serving professionals.

A partner protection package for HIV cure-related trials involving analytical treatment interruptions.

Analytical treatment interruptions (ATIs) have become a key methodological approach to evaluate the effects of experimental HIV cure-related research interventions. During ATIs, sex partners of trial participants might be at risk of acquiring HIV. This risk raises both ethical and feasibility concerns about ATI trials. We propose a partner protection package (P3) approach to address these concerns. A P3 approach would provide guidance to investigators, sponsors, and those who are designing and implementing context-specific partner protections in HIV cure-related trials involving ATIs. The approach would also help assure institutional review boards, trial participants, and communities that ATI trials with a P3 would provide appropriate partner protections. We offer a prototype P3 framework that delineates three basic considerations for protecting participants' sex partners during ATI trials: (1) ensuring the scientific and social value of the ATI and the trial, (2) reducing the likelihood of unintended HIV transmission, and (3) ensuring prompt management of any acquired HIV infection. We outline possible ways of implementing these basic considerations.

Resource allocation and funding challenges for regional local health departments in Nebraska.

OBJECTIVE: This study examined the mechanism of resource allocation among member counties and the funding challenges of regional health departments (RHDs) in Nebraska. DESIGN AND STUDY SETTING: In 2009, we conducted a qualitative case study of 2 Nebraska RHDs to gain insight into their experiences of making resource allocation decisions and confronting funding challenges. The 2 RHD sites were selected for this case study on the basis of their heterogeneity in terms of population distribution in member counties. Sixteen semistructured in-person interviews were conducted with RHD directors, staff, and board of health members. Interview data were coded and analyzed using NVivo qualitative analysis software (QSR International [Americas] Inc., Cambridge, MA). RESULTS: Our findings suggested that the directors of RHDs play an integral role in making resource allocation decisions on the basis of community needs, not on a formula or on individual county population size. Interviewees also reported that the size of the vulnerable population served by the RHD had a significant impact on the level of resources for RHD's programs. The RHD's decisions about resource allocation were also dependent on the amount and type of resources received from the state. Interviewees identified inadequacy and instability of funding as the 2 main funding challenges for their RHD. These challenges negatively impacted workforce capacity and the long-term sustainability of some programs. CONCLUSIONS: Regional health departments may not benefit from better leveraging resources and building a stronger structural capacity unless the issues of funding inadequacy and instability are addressed. Strategies that can be used by RHDs to address these funding challenges include seeking grants to support programs, leveraging existing resources, and building community partnerships to share resources. Future research is needed to identify RHDs' optimal workforce capacity, required funding level, and potential funding mechanisms.

Assessment of workforce capacity for Local Health Departments in Nebraska: a perspective from public health programmatic areas.

OBJECTIVE: This study assessed the workforce capacity of Nebraska Local Health Departments (LHDs) from the perspective of public health programmatic areas. DESIGN AND OUTCOMES MEASURES: We conducted a mail survey of 21 LHD directors in Nebraska and collected the information on LHD workforce capacity, training, and competency by public health programmatic areas (eg, environmental health, mental health). An FTE shortage index score for each public health programmatic area was calculated to estimate an LHD's current shortage in that area. Spearman correlation analysis was conducted to examine the relationships between LHD capacity, manpower shortage, and staff training and competency. RESULTS: Our results indicated that a significant proportion of the 18 responding LHDs in Nebraska did not have staff to cover the areas of mental health (66.7%), sexually transmitted diseases (44.4%), occupational safety and injury (38.9%), oral health (27.8%), and health disparities (22.2%). The results also suggest that Nebraska's LHDs experienced the greatest workforce shortages in environmental health (mean shortage index = 0.45), followed by chronic diseases (0.44), health disparities (0.41), and sexually transmitted diseases (0.41). CONCLUSIONS: The identified shortage areas should be a high priority for federal and state policy makers to address through developing appropriate strategies and providing adequate funding for LHD workforce development in Nebraska. Using the public health programmatic area approach to collect workforce data may help fill some gaps in the current efforts of LHD workforce enumeration. Future research is needed to examine the validity and reliability of the workforce measures based on public health programmatic areas.

Effectiveness and challenges of regional public health partnerships in Nebraska.

OBJECTIVE: The purpose of this study is to examine the effectiveness and challenges of regional public health partnerships by exploring the experiences of 2 multicounty LHDs in Nebraska. SETTINGS: The selection of the 2 local health department (LHD) sites was on the basis of the history of prior collaborative partnership in the LHD jurisdiction. Both regional LHD jurisdictions cover a service area of 9 counties. DESIGN: A mixed method research design was used for this study. We first conducted an online survey to create an inventory of partnerships for each LHD site. Then, we collected quantitative data to measure the effectiveness of partnerships through a survey of community partners in both LHD sites. We also collected qualitative information through telephone interviews with community partners and LHD staff to examine the challenges for building an effective regional partnership. RESULTS: Regional public health partnerships are most effective in efficiency, but less effective in the areas of management and resource sufficiency. More effort is still needed to maximize the collaborative potential for the majority of partnerships in both regions. In particular, geographic distance and work demand were identified as the 2 major challenges by community partners. The community health planning partnership in the LHD site with prior history of collaboration was more effective than its counterpart without such history. CONCLUSIONS: Policy makers should consider developing policies to assist multicounty LHDs with improving their management of regional partnerships and with providing sufficient resources to support their regional partnerships. If possible, the formation of regional community health planning partnership should follow the geographic boundaries where prior collaboration already existed.

The relationship between county variation in macro contextual factors and the performance of public health practice in regional public health systems in Nebraska.

OBJECTIVE: This study examined the relationship between county variation in macro contextual variables and the performance of public health practice in regional local health departments (LHDs) in Nebraska. DESIGN AND MAIN OUTCOMES MEASURES: County-level data from the US Census Bureau, the Nebraska Department of Health and Human Services, and the University of Nebraska Medical Center's Health Professions Tracking Services were used to create macro context variables (eg, demographic, geographic, social, economic, population health status). The public health performance data were collected through a mail survey of the directors of regional LHDs in Nebraska in 2008. Public health performance measures were created to indicate LHD's general performance as well as core function specific performance (ie, assessment, assurance, policy development). The coefficients of variation were estimated and used to categorize each regional LHD into either a larger county variation group or a smaller county variation group for each domain of macro context variables. Statistical comparisons of public health performance measures were then made between these 2 groups for each domain. RESULTS: The results suggest that the county variation in macro contextual variables within a regional public health district, in general, is negatively associated with the performance of public health practice in regional LHDs. The regional LHD's performance in specific public health core function (eg, assurance) is negatively associated with the county variation in specific types of macro context factors (eg, geographic factors such as land size and population density). CONCLUSIONS: Regional LHDs may design and implement their public health programs on the basis of the type and degree of heterogeneity among the member counties within their jurisdiction. The formation of regional LHDs, if possible, should follow geographic boundaries that minimize the heterogeneity of county composition in terms of macro contextual factors.

The Impact of Meaningful Use and Electronic Health Records on Hospital Patient Safety.

The HITECH Act aimed to leverage Electronic Health Records (EHRs) to improve efficiency, quality, and patient safety. Patient safety and EHR use have been understudied, making it difficult to determine if EHRs improve patient safety. The objective of this study was to determine the impact of EHRs and attesting to Meaningful Use (MU) on Patient Safety Indicators (PSIs). A multivariate regression analysis was performed using a generalized linear model method to examine the impact of EHR use on PSIs. Fully implemented EHRs not attesting to MU had a positive impact on three PSIs, and hospitals that attested to MU had a positive impact on two. Attesting to MU or having a fully implemented EHR were not drivers of PSI-90 composite score, suggesting that hospitals may not see significant differences in patient safety with the use of EHR systems as hospitals move towards pay-for-performance models. Policy and practice may want to focus on defining metrics and PSIs that are highly preventable to avoid penalizing hospitals through reimbursement, and work toward adopting advanced analytics to better leverage EHR data. These findings will assist hospital leaders to find strategies to better leverage EHRs, rather than relying on achieving benchmarks of MU objectives.