Informed Application of the Standards on Support Surface Performance for Clinically Meaningful Use.

BACKGROUND: The Support Surface Standards Initiative (S3I) has evolved with the goal of standardizing language and performance evaluation of support surfaces. There is a consumer need for education about support surface standards to transfer new information with clinical relevance. OBJECTIVE: To develop a framework for meaningful dialogue through consensus building that drives value-based purchasing, propose a clinically relevant path for understanding how to apply data from the standards into critical interprofessional analysis and support surface selection, and navigate the first tier of a process targeted as an educational initiative within the Standards Committee. METHODS: The authors purposively sampled the S3I Tissue Integrity Group with a semi-structured qualitative survey to identify the essential components of support surfaces standard performance testing. A two-phase interview and review process was implemented within the larger S3I group to achieve consensus on content for knowledge transfer, with a threshold of 80% agreement within the Standards Committee. RESULTS: Meaningful consensus was achieved on content associated with knowledge transfer of standards data. These standards will function as reliable benchmarks, enabling consumers to compare individual characteristics of one support surface to another. Product comparison will be based on the single characteristics of support surfaces and how those characteristics are relevant to the specific needs of the individual patient or patient populations, transferred in language that is meaningful to end users of the standards. CONCLUSIONS: The consensus process facilitated construction of a clinically relevant, interprofessional framework for the product selection process within the Standards Committee. It will enable the next tier of educational dissemination beyond the Standards Committee to a broader base of consumers to engage in value-based purchasing with enhanced understanding of support surface performance characteristics.

Impact of Age on Patients' Communication and Technology Preferences in the Era of Meaningful Use: Mixed Methods Study.

BACKGROUND: Identifying effective means of communication between patients and their health care providers has a positive impact on patients' satisfaction, adherence, and health-related outcomes. OBJECTIVE: This study aimed to identify the impact of patients' age on their communication and technology preferences when managing their health. We hypothesize that a patient's age affects their communication and technology preferences when interacting with clinicians and managing their health. METHODS: A mixed methods study was conducted to identify the preferences of patients with cardiovascular diseases. Results were analyzed based on the patients' age. Grounded theory was used to analyze the qualitative data. Patients were recruited based on age, gender, ethnicity, and zip code. RESULTS: A total of 104 patients were recruited: 34 young adults (19-39 years), 33 middle aged (40-64), and 37 senior citizens (>65). Young adults (mean 8.29, SD 1.66) reported higher computer self-efficacy than middle-aged participants (mean 5.56, SD 3.43; P<.05) and senior citizens (mean 47.55, SD 31.23; P<.05). Qualitative analysis identified the following three themes: (1) patient engagement (young adults favored mobile technologies and text messaging, middle-aged patients preferred phone calls, and senior citizens preferred direct interactions with the health care provider); (2) patient safety (young adults preferred electronic after-visit summaries [AVS] and medication reconciliation over the internet; middle-aged patients preferred paper-based or emailed AVS and medication reconciliation in person; senior citizens preferred paper-based summaries and in-person medication reconciliation); (3) technology (young adults preferred smartphones and middle-aged patients and senior citizens preferred tablets or PCs). Middle-aged patients were more concerned about computer security than any other group. A unique finding among senior citizens was the desire for caregivers to have access to their personal health record (PHR). CONCLUSIONS: Patients of different ages have different communication and technology preferences and different preferences with respect to how they would like information presented to them and how they wish to interact with their provider. The PHR is one approach to improving patient engagement, but nontechnological options need to be sustained to support all patients.

Quantifying the competitiveness of the electronic health record market and its implications for interoperability.

OBJECTIVE: The objective of this study was to quantify both the competitiveness of the EHR vendor market in the United States of America (US) and the degree of fragmentation of individual Medicare beneficiaries' medical records across the differing EHR vendors found in the US healthcare system. METHODS AND MATERIALS: We determined the Part A and Part B Medicare-expenditure weighted market shares of EHR vendors and estimated the rate of attestation of meaningful use (MU) for EHRs among Medicare Part A & B providers from 2011 to 2016. Based on these data we calculated the annual Herfindahl-Hirschman Index to quantify the competitiveness of the EHR market as well as the number of vendors individual Medicare beneficiaries' medical records were stored in for the period 2014-2016. RESULTS: We find that as of 2016 the EHR vendor environment was competitive but trending towards becoming highly concentrated soon. We also found that patient medical records were highly fragmented as only 4.5 % of expenditure-weighted individual Medicare beneficiaries had their MU medical records associated with a single vendor, while 19.8 % of expenditure-weighted beneficiaries had their MU medical records stored in 8 or more vendors. DISCUSSION: These results indicate that there are tradeoffs between EHR market competition, and the challenges associated with achieving interoperability across numerous competing vendors. CONCLUSION: Uncertainty of interoperability among different EHR vendors may make transmission of medical records among different providers challenging, mitigating the benefit of vendor competition. This highlights the critical importance of current interoperability efforts moving forward.

Clinically Meaningful Use of Mental Health Apps and its Effects on Depression: Mixed Methods Study.

BACKGROUND: User engagement is key to the effectiveness of digital mental health interventions. Considerable research has examined the clinical outcomes of overall engagement with mental health apps (eg, frequency and duration of app use). However, few studies have examined how specific app use behaviors can drive change in outcomes. Understanding the clinical outcomes of more nuanced app use could inform the design of mental health apps that are more clinically effective to users. OBJECTIVE: This study aimed to classify user behaviors in a suite of mental health apps and examine how different types of app use are related to depression and anxiety outcomes. We also compare the clinical outcomes of specific types of app use with those of generic app use (ie, intensity and duration of app use) to understand what aspects of app use may drive symptom improvement. METHODS: We conducted a secondary analysis of system use data from an 8-week randomized trial of a suite of 13 mental health apps. We categorized app use behaviors through a mixed methods analysis combining qualitative content analysis and principal component analysis. Regression analyses were used to assess the association between app use and levels of depression and anxiety at the end of treatment. RESULTS: A total of 3 distinct clusters of app use behaviors were identified: learning, goal setting, and self-tracking. Each specific behavior had varied effects on outcomes. Participants who engaged in self-tracking experienced reduced depression symptoms, and those who engaged with learning and goal setting at a moderate level (ie, not too much or not too little) also had an improvement in depression. Notably, the combination of these 3 types of behaviors, what we termed "clinically meaningful use," accounted for roughly the same amount of variance as explained by the overall intensity of app use (ie, total number of app use sessions). This suggests that our categorization of app use behaviors succeeded in capturing app use associated with better outcomes. However, anxiety outcomes were neither associated with specific behaviors nor generic app use. CONCLUSIONS: This study presents the first granular examination of user interactions with mental health apps and their effects on mental health outcomes. It has important implications for the design of mobile health interventions that aim to achieve greater user engagement and improved clinical efficacy.

Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era.

The US health system has recently achieved widespread adoption of electronic health record (EHR) systems, primarily driven by financial incentives provided by the Meaningful Use (MU) program. Although successful in promoting EHR adoption and use, the program, and other contributing factors, also produced important unintended consequences (UCs) with far-reaching implications for the US health system. Based on our own experiences from large health information technology (HIT) adoption projects and a collection of key studies in HIT evaluation, we discuss the most prominent UCs of MU: failed expectations, EHR market saturation, innovation vacuum, physician burnout, and data obfuscation. We identify challenges resulting from these UCs and provide recommendations for future research to empower the broader medical and informatics communities to realize the full potential of a now digitized health system. We believe that fixing these unanticipated effects will demand efforts from diverse players such as health care providers, administrators, HIT vendors, policy makers, informatics researchers, funding agencies, and outside developers; promotion of new business models; collaboration between academic medical centers and informatics research departments; and improved methods for evaluations of HIT.

Meaningful Use: Does Physician Participation Move the Needle on Quality Metrics?

INTRODUCTION: To determine the association between pattern of participation in the Meaningful Use (MU) initiative and self-reported clinical quality metrics. METHODS: We used state-level Medicaid electronic health record (EHR) incentive program data to categorize physicians based on receipt of MU payments (single year vs. multiple years) and self-reported quality metrics from 2011 to 2016. RESULTS: Among 4,198 participating physicians, only 36% received more than one EHR incentive payment. Physicians participating for a single year had better cancer-screening metrics. By comparison, physicians who participated for multiple years reported better medication-related metrics and chronic disease management metrics. CONCLUSIONS: Nature of participation may have varying degrees of influence on types of clinical quality metrics. Sustained participation may support management of chronic conditions. Administrative claims data will help to elucidate our findings.

Use of Both Qualitative and Quantitative Methods to Estimate Meaningful Change Thresholds for Key Endpoints in Pediatric Asthma Trials.

INTRODUCTION: Diary-derived symptom score and rescue medication use endpoints, such as symptom-free days (SFDs) and rescue medication-free days (RFD), are frequently used as clinical trial endpoints. Estimates of meaningful change for SFDs and RFDs have not been generated in pediatric populations. This research aimed to generate evidence supporting estimates of the individual within-patient changes that constitute an important or meaningful change in SFDs, RFDs, and updated estimates on the Childhood Asthma Control Test (C-ACT) in pediatric asthma populations aged 5-11 years. METHODS: Semistructured, qualitative interviews were conducted with children (ages 8-11 years) who had asthma and parents/caregivers of children (4-11 years) with asthma. Before the interview (4-9 days) participants were asked to complete a morning and evening diary. RESULTS: On average, parent/caregiver estimates of the difference in SFDs between a "very bad" and a "little bad" week for their children's asthma were largely concordant with the values reported by their children (differences of 1.8 and 1.4 SFDs, respectively). Both parents/caregivers and children were able to articulate what a meaningful level of change would be on the C-ACT at the item level. This qualitative study generated C-ACT item-level meaningful change estimates in the region of 1-3 category change, which potentially suggests that, if scaled up to represent C-ACT total score, this would lead to change estimates of 7-15 points. CONCLUSIONS: Our findings suggest that both children with asthma and parents/caregivers can quantitatively estimate and to some extent qualitatively articulate meaningful change in SFDs and RFDs.

Sensitivity of Claims-Based Algorithms to Ascertain Smoking Status More Than Doubled with Meaningful Use.

BACKGROUND: The "meaningful use of certified electronic health record" policy requires eligible professionals to record smoking status for more than 50% of all individuals aged 13 years or older in 2011 to 2012. OBJECTIVES: To explore whether the coding to document smoking behavior has increased over time and to assess the accuracy of smoking-related diagnosis and procedure codes in identifying previous and current smokers. METHODS: We conducted an observational study with 5,423,880 enrollees from the year 2009 to 2014 in the Truven Health Analytics database. Temporal trends of smoking coding, sensitivity, specificity, positive predictive value, and negative predictive value were measured. RESULTS: The rate of coding of smoking behavior improved significantly by the end of the study period. The proportion of patients in the claims data recorded as current smokers increased 2.3-fold and the proportion of patients recorded as previous smokers increased 4-fold during the 6-year period. The sensitivity of each International Classification of Diseases, Ninth Revision, Clinical Modification code was generally less than 10%. The diagnosis code of tobacco use disorder (305.1X) was the most sensitive code (9.3%) for identifying smokers. The specificities of these codes and the Current Procedural Terminology codes were all more than 98%. CONCLUSIONS: A large improvement in the coding of current and previous smoking behavior has occurred since the inception of the meaningful use policy. Nevertheless, the use of diagnosis and procedure codes to identify smoking behavior in administrative data is still unreliable. This suggests that quality improvements toward medical coding on smoking behavior are needed to enhance the capability of claims data for smoking-related outcomes research.

[Meaning and humanity in care]. / Sens et humanité dans le soin.

Nursing practice is founded on numerous theories. While life sciences use evidence to design the most effective practices from a biomedical point of view, human sciences sometimes struggle to corroborate the perception of patients as caregivers in their humanised practice. This article presents a perspective of care in a resolutely human dimension, where the main objective is to be of use to the person.

Addressing meaningful use and maintaining an accurate medication list in primary care.

OBJECTIVES: The primary objective of this project was to determine the difference in medication list accuracy between an initial and follow-up medication reconciliation visit in a primary care office. Secondary objectives were to identify the difference in medication-related problems most commonly encountered during the visits, factors that may influence patient understanding of their medication regimen, and physician perceptions of the medication review visit. SETTING: Quasi-experimental study part of a larger pilot project to address the ability of how health information technology can be used to maintain an active medication list. PRACTICE DESCRIPTION: Three family medicine residency clinics in the Midwest. Adult patients with diabetes or chronic obstructive pulmonary disease who had 6 or more long-term medications listed in the electronic health record (EHR) were recruited to participate. PRACTICE INNOVATION: An initial comprehensive medication reconciliation visit was conducted by a resident physician and a pharmacist with the goal of ensuring an accurate, easy-to-follow, electronically developed medication list. A follow-up visit with the pharmacist occurred 3-6 months after the initial visit. EVALUATION: Medication list accuracy and medication-related problems were assessed at the initial and follow-up visits. Patient-related factors that could affect medication understanding were collected at the initial visit with status of enrollment in the EHR patient portal. RESULTS: Fifty-seven of 65 patients completed the study. The number of patients with an accurate medication list increased from 40% to 49% (P = 0.38). The number of medication-related problems decreased from 146 to 91 (P < 0.001). The use of special tools (e.g., pillboxes) was associated with fewer medication regimen errors (P = 0.036). Patients enrolled in the EHR patient portal were more likely to know the purpose of their medications as compared with those not enrolled (P = 0.019). CONCLUSION: An intentionally scheduled medication review with a primary care provider and pharmacist did not significantly improve the accuracy of the medication list, but it was associated with fewer drug-related problems.

Documenting Stage 1 and 2 Meaningful Use criteria: A comparison of clinical pharmacists with other healthcare providers.

PURPOSE: Documentation of Stage 1 and Stage 2 Meaningful Use (MU) criteria for patients with type 2 diabetes mellitus between clinical pharmacists and other healthcare providers was compared. METHODS: Patients seen at 8 clinics in a federally qualified health center who had type 2 diabetes mellitus and were seen by clinical pharmacists or other healthcare providers were randomly selected for inclusion in this retrospective study. Approximately half of the encounters were evaluated for Stage 1 MU compliance (encounters from October through December 2014), and half were evaluated for Stage 2 MU compliance (encounters from January through March 2015). Categorical and descriptive variables were analyzed by calculating frequencies and percentages. Chi-square tests were used to compare groups with an a priori level of significance set at 0.05. RESULTS: A total of 790 patients were seen by 46 providers, 8 (18%) of whom were clinical pharmacists. The study also included 24 medical doctors, 8 family nurse practitioners, 1 physician assistant, and 5 doctors of osteopathic medicine. Other healthcare providers more consistently documented 5 Stage 1 MU criteria than did clinical pharmacists. Clinical pharmacists more consistently documented 2 core objectives than did other healthcare providers. Otherwise, no significant differences in documentation were detected. CONCLUSION: Other healthcare providers more consistently documented 5 Stage 1 MU criteria than did clinical pharmacists. Clinical pharmacists more consistently documented 2 core objectives than did other healthcare providers.

Assessing the value of the Meaningful Use Clinical Summary for patients and families with pediatric asthma.

Electronic clinical summaries are innovations supported by the Electronic Health Record Incentive Program, known as "Meaningful Use" (MU). The MU clinical summary documents the shared understanding of the plan of care for patients and assists families in managing asthma-related health care. The purpose of this analysis was to identify the communicative value of the summaries to patients and families. Readability measurements, content analysis, and descriptive statistics were employed in a review of twenty clinical summaries and compared with provider encounter notes. The average age of the patients from whom we collected clinical summaries was six years old. The average reading level of the summaries was ninth grade. Neither summaries nor health education contained visual images. There was a total of nine different asthma diagnoses. A full list of diagnoses was present in 45% of summaries. The average medications per patient was 5.75, and there were multiple medication changes noted (dosage adjustment, add, discontinued). Allergies, vital signs, and smoking status were reliably reported (99-100%). Provider orders present included medication, follow up, and return to the clinic instructions. The plan of care was replicated on 45% of summaries. There was variable reporting of various asthma guidelines. Opportunities to improve the clinical summary include using plain language to promote readability, action, understanding, and health literacy, training providers to standardize their documentation and include asthma action plans, and configuring EHR settings to ensure diagnoses and plan of care is carried over from provider notes to the summary.

Complexity of Chronic Conditions' Impact on End-of-Life Expense Trajectories of Medicare Decedents.

OBJECTIVE: The aim of this study is to determine if the pattern of monthly medical expense can be used to identify individuals at risk of dying, thus supporting providers in proactively engaging in advanced care planning discussions. BACKGROUND: Identifying the right time to discuss end of life can be difficult. Improved predictive capacity has made it possible for nurse leaders to use large data sets to guide clinical decision making. METHODS: We examined the patterns of monthly medical expense of Medicare beneficiaries with life-limiting illness during the last 24 months of life using analysis of variance, t tests, and stepwise hierarchical linear modeling. RESULTS: In the final year of life, monthly medical expense increases rapidly for all disease groupings and forms distinct patterns of change. CONCLUSION: Type of condition can be used to classify decedents into distinctly different cost trajectories. Conditions including chronic disease, system failure, or cancer may be used to identify patients who may benefit from supportive care.

Tool-supported Interactive Correction and Semantic Annotation of Narrative Clinical Reports.

OBJECTIVES: Our main objective is to design a method of, and supporting software for, interactive correction and semantic annotation of narrative clinical reports, which would allow for their easier and less erroneous processing outside their original context: first, by physicians unfamiliar with the original language (and possibly also the source specialty), and second, by tools requiring structured information, such as decision-support systems. Our additional goal is to gain insights into the process of narrative report creation, including the errors and ambiguities arising therein, and also into the process of report annotation by clinical terms. Finally, we also aim to provide a dataset of ground-truth transformations (specific for Czech as the source language), set up by expert physicians, which can be reused in the future for subsequent analytical studies and for training automated transformation procedures. METHODS: A three-phase preprocessing method has been developed to support secondary use of narrative clinical reports in electronic health record. Narrative clinical reports are narrative texts of healthcare documentation often stored in electronic health records. In the first phase a narrative clinical report is tokenized. In the second phase the tokenized clinical report is normalized. The normalized clinical report is easily readable for health professionals with the knowledge of the language used in the narrative clinical report. In the third phase the normalized clinical report is enriched with extracted structured information. The final result of the third phase is a semi-structured normalized clinical report where the extracted clinical terms are matched to codebook terms. Software tools for interactive correction, expansion and semantic annotation of narrative clinical reports has been developed and the three-phase preprocessing method validated in the cardiology area. RESULTS: The three-phase preprocessing method was validated on 49 anonymous Czech narrative clinical reports in the field of cardiology. Descriptive statistics from the database of accomplished transformations has been calculated. Two cardiologists participated in the annotation phase. The first cardiologist annotated 1500 clinical terms found in 49 narrative clinical reports to codebook terms using the classification systems ICD 10, SNOMED CT, LOINC and LEKY. The second cardiologist validated annotations of the first cardiologist. The correct clinical terms and the codebook terms have been stored in a database. CONCLUSIONS: We extracted structured information from Czech narrative clinical reports by the proposed three-phase preprocessing method and linked it to electronic health records. The software tool, although generic, is tailored for Czech as the specific language of electronic health record pool under study. This will provide a potential etalon for porting this approach to dozens of other less-spoken languages. Structured information can support medical decision making, quality assurance tasks and further medical research.

Relating Complexity and Error Rates of Ontology Concepts. More Complex NCIt Concepts Have More Errors.

OBJECTIVES: Ontologies are knowledge structures that lend support to many health-information systems. A study is carried out to assess the quality of ontological concepts based on a measure of their complexity. The results show a relation between complexity of concepts and error rates of concepts. METHODS: A measure of lateral complexity defined as the number of exhibited role types is used to distinguish between more complex and simpler concepts. Using a framework called an area taxonomy, a kind of abstraction network that summarizes the structural organization of an ontology, concepts are divided into two groups along these lines. Various concepts from each group are then subjected to a two-phase QA analysis to uncover and verify errors and inconsistencies in their modeling. A hierarchy of the National Cancer Institute thesaurus (NCIt) is used as our test-bed. A hypothesis pertaining to the expected error rates of the complex and simple concepts is tested. RESULTS: Our study was done on the NCIt's Biological Process hierarchy. Various errors, including missing roles, incorrect role targets, and incorrectly assigned roles, were discovered and verified in the two phases of our QA analysis. The overall findings confirmed our hypothesis by showing a statistically significant difference between the amounts of errors exhibited by more laterally complex concepts vis-à-vis simpler concepts. CONCLUSIONS: QA is an essential part of any ontology's maintenance regimen. In this paper, we reported on the results of a QA study targeting two groups of ontology concepts distinguished by their level of complexity, defined in terms of the number of exhibited role types. The study was carried out on a major component of an important ontology, the NCIt. The findings suggest that more complex concepts tend to have a higher error rate than simpler concepts. These findings can be utilized to guide ongoing efforts in ontology QA.

How do Kenyan orphan girls experience less meaningful lives and how much does it matter for 'health'?

BACKGROUND: Currently, 2.5 million orphaned children are living in Kenya and 56 million orphaned children are living across sub-Saharan Africa. No empirical research has investigated meaningfulness of life among this population, and few studies provide perspectives on the life-course consequences of losing a parent during childhood. METHODS: In this study, we assess life meaningfulness in cross section of Kenyan women (n = 1974) in a semi-rural area of the country (Meru County) collected during June 2015. We used two sets of mediation analyses to assess (1) whether meaningfulness of life was lower among women who reported a parental death during their childhood, and how this association was mediated by social support, family functioning, school completion and HIV+ status of household, and (2) the extent to which lower subjective overall health among women who experienced orphanhood during childhood was mediated by less meaningfulness of life. RESULTS: Women who experienced a parental death during childhood reported significantly less meaningful lives as adults. Lower social support and family functioning explained approximately 40% of the disparity. Women who experienced a parental death during childhood also had significantly worse subjective overall health, 18% of which was explained by lower meaningfulness of life. CONCLUSIONS: Further study on life meaningfulness and family capital in the context of the orphan crisis in sub-Saharan Africa is warranted, and required to promote equity across the lifespan. Policy efforts to support orphans and vulnerable children should target strengthening support networks and family functioning to optimize self-reported health outcomes.

Hospital Characteristics are Associated With Readiness to Attain Stage 2 Meaningful Use of Electronic Health Records.

PURPOSE: To examine the difference between rural and urban hospitals as to their overall level of readiness for stage 2 meaningful use of electronic health records (EHRs) and to identify other key factors that affect their readiness for stage 2 meaningful use. METHODS: A conceptual framework based on the theory of organizational readiness for change was used in a cross-sectional multivariate analysis using 2,083 samples drawn from the HIMSS Analytics survey conducted with US hospitals in 2013. FINDINGS: Rural hospitals were less likely to be ready for stage 2 meaningful use compared to urban hospitals in the United States (OR = 0.49) in our final model. Hospitals' past experience with an information exchange initiative, staff size in the information system department, and the Chief Information Officer (CIO)'s responsibility for health information management were identified as the most critical organizational contextual factors that were associated with hospitals' readiness for stage 2. Rural hospitals lag behind urban hospitals in EHR adoption, which will hinder the interoperability of EHRs among providers across the nation. The identification of critical factors that relate to the adoption of EHR systems provides insights into possible organizational change efforts that can help hospitals to succeed in attaining meaningful use requirements. CONCLUSION: Rural hospitals have increasingly limited resources, which have resulted in a struggle for these facilities to attain meaningful use. Given increasing closures among rural hospitals, it is all the more important that EHR development focus on advancing rural hospital quality of care and linkages with patients and other organizations supporting the care of their patients.

Nurses' Attitudes Toward Meaningful Use Technologies: An Integrative Review.

Nurses comprise the largest segment of the healthcare workforce. As such, their perceptions of any new technology are important to understand, as it may ultimately mean the difference between acceptance and rejection of a product. The three-stage meaningful use program is intended to help improve and standardize data capture and advance clinical processes to improve patient and population outcomes in the US. With more than 471 000 healthcare providers having already received meaningful use incentive payments totaling more than $20 billion as of June 2015, it is critical to understand how these technologies are being viewed and utilized in practice. Understanding nurses' attitudes toward healthcare technology may help drive acceptance, as well as maximize the inherent potential of the new technologies toward improving patient care. Thus, the purpose of this integrative review is to highlight what is known about nurses' attitudes toward meaningful use technologies.