Patterns of Telemedicine Use in Primary Care for People with Dementia in the Post-pandemic Period.

BACKGROUND: The pandemic rapidly expanded telemedicine, which has persisted as a widely available primary care modality. The uptake of telemedicine among people with dementia specifically in the primary care setting, who have more complex care needs but also benefit from more accessible primary care, is unknown. OBJECTIVE: Among people with dementia, assess uptake of telemedicine-based primary care in the post-pandemic period and determine associations with key socio-demographic characteristics. DESIGN: Retrospective observational study. SUBJECTS: People with dementia at UCSF and Kaiser Permanente Northern CA (KPNC) with at least one primary care encounter in pre- (3/1/2019-2/29/2020) or post-COVID (3/1/2021-2/28/2022) periods, post-COVID sample: N= 419 individuals (UCSF), N=18,037 (KPNC). MAIN MEASURES: Encounter modality: in-person, video telemedicine, or telephone telemedicine. Focal socio-demographic characteristics: age, limited English proficiency, socioeconomic status, driving distance to clinic, and caregiver at encounter. KEY RESULTS: There was a large increase in telemedicine among people with dementia in the post-pandemic period at both sites. At KPNC, those with only in-person primary care visits shrunk from 60.47% (pre) to 26.95% (post). At UCSF, the change was even greater: 98.99% to 35.08%. Across both sites, the only measure significantly associated with use of telemedicine was greater driving distance from home to clinic. At KPNC, those over age 90 were most likely to use telemedicine while patients with limited English proficiency and those with a caregiver at the encounter used telemedicine at lower levels. The relationships were similar at UCSF but not statistically significant. CONCLUSIONS: Telemedicine use is high for people with dementia in the primary care setting in the post-pandemic period. Those with longer drives to clinic and the oldest patients were most likely to use telemedicine, likely due to challenges traveling to appointments. Still, not all people with dementia used telemedicine equally-particularly those with limited English proficiency.

Perceptions of information continuity key to understanding quality of post-acute care transitions.

BACKGROUND: Skilled nursing facilities' (SNFs) ability to provide optimal post-acute care depends on effective receipt of information from hospitals ("information continuity"). Little is known about how SNFs perceive information continuity and how it may relate to upstream information sharing processes, organizational context, and downstream outcomes. PURPOSE: First, this study aims to identify how SNF perceptions of information continuity may be shaped by hospital information sharing practices, including measures of completeness, timeliness, and usability, as well as characteristics of the transitional care environment (i.e., integrated care relationships and/or consistency of information sharing practices across different hospital partners). Second, we analyze which of these characteristics are associated with quality of transitional care (measured by 30-day readmissions). APPROACH: A cross-sectional analysis of nationally representative SNF survey ( N = 212) linked to Medicare claims was performed. RESULTS: SNF perceptions of information continuity are strongly and positively associated with hospital information sharing practices. Adjusting for actual information sharing practices, SNFs that experienced discordance across hospitals reported lower perceptions of continuity (ß = -0.73, p = .022); evidence of stronger relationships with a given hospital partner appears to help facilitate resources and communication that helps to close this gap. Perceptions of information continuity, more so than the upstream information sharing processes reported, exhibited a more reliable and significant association with rates of readmissions as an indicator of transitional care quality. CONCLUSION: SNF perceptions of information continuity are strongly associated with patient outcomes and are reflective of both hospital information sharing practices as well as characteristics of the transitional care environment that can mitigate or amplify the cognitive and administration challenge of their work. PRACTICE IMPLICATIONS: Improving transitional care quality requires that hospitals improve information sharing behaviors but also invest in capacity for learning and process improvement in the SNF environment.

Electronic Connectivity Among US Hospitals Treating Shared Patients.

BACKGROUND: Increasing electronic health information exchange (HIE) between provider organizations is a top policy priority that has been pursued by establishing varied types of networks. OBJECTIVES: To measure electronic connectivity enabled by these networks, including community, electronic health record vendor, and national HIE networks, across US hospitals weighted by the volume of shared patients and identify characteristics that predict connectivity. RESEARCH DESIGN: Cross-sectional analysis of 1721 hospitals comprising 16,344 hospital pairs and 6,492,232 shared patients from 2018 CareSet Labs HOP data and national hospital surveys. SUBJECTS: Pairs of US acute care hospitals that delivered care to 11 or more of the same fee-for-service Medicare beneficiaries in 2018. MEASURES: Whether a patient was treated by a pair of hospitals connected through participation in the same HIE network ("connected hospitals") or not connected because the hospitals participated in different networks, only 1 participated, or both did not participate. RESULTS: Sixty-four percent of shared patients were treated by connected hospitals. Of the remaining shared patients, 14% were treated by hospital pairs that participated in different HIE networks, 21% by pairs in which only 1 hospital participated in an HIE network, and 2% by pairs in which neither participated. Patients treated by pairs with at least 1 for-profit hospital, and by pairs located in competitive markets, were less likely to be treated by connected hospitals. CONCLUSIONS: While the majority of shared patients received care from connected hospitals, remaining gaps could be filled by connecting HIE networks to each other and by incentivizing certain types of hospitals that may not participate because of competitive concerns.

The Abrupt Expansion of Ambulatory Telemedicine: Implications for Patient Safety.

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.

Dispersion in the hospital network of shared patients is associated with less efficient care.

BACKGROUND: There is growing recognition that health care providers are embedded in networks formed by the movement of patients between providers. However, the structure of such networks and its impact on health care are poorly understood. PURPOSE: We examined the level of dispersion of patient-sharing networks across U.S. hospitals and its association with three measures of care delivered by hospitals that were likely to relate to coordination. METHODOLOGY/APPROACH: We used data derived from 2016 Medicare Fee-for-Service claims to measure the volume of patients that hospitals treated in common. We then calculated a measure of dispersion for each hospital based on how those patients were concentrated in outside hospitals. Using this measure, we created multivariate regression models to estimate the relationship between network dispersion, Medicare spending per beneficiary, readmission rates, and emergency department (ED) throughput rates. RESULTS: In multivariate analysis, we found that hospitals with more dispersed networks (those with many low-volume patient-sharing relationships) had higher spending but not greater readmission rates or slower ED throughput. Among hospitals with fewer resources, greater dispersion related to greater readmission rates and slower ED throughput. Holding an individual hospital's dispersion constant, the level of dispersion of other hospitals in the hospital's network was also related to these outcomes. CONCLUSION: Dispersed interhospital networks pose a challenge to coordination for patients who are treated at multiple hospitals. These findings indicate that the patient-sharing network structure may be an overlooked factor that shapes how health care organizations deliver care. PRACTICE IMPLICATIONS: Hospital leaders and hospital-based clinicians should consider how the structure of relationships with other hospitals influences the coordination of patient care. Effective management of this broad network may lead to important strategic partnerships.

Studying Workflow and Workarounds in Electronic Health Record-Supported Work to Improve Health System Performance.

Clinical workflow is the enactment of a series of steps to perform a clinical activity. The transition from paper to electronic health records (EHRs) over the past decade has been characterized by profound challenges supporting clinical workflow, impeding frontline clinicians' ability to deliver safe, efficient, and effective care. In response, there has been substantial effort to study clinical workflow as well as workarounds-exceptions to routine workflow-in order to identify opportunities for improvement. This article describes predominant methods of studying workflow and workarounds and provides examples of the applications of these methods along with the resulting insights. Challenges to studying workflow and workarounds are described, and recommendations for how to approach such studies are given. Although there is not yet a set of standard approaches, this article helps advance workflow research that ultimately serves to inform how to coevolve the design of EHR systems and organizational decisions about processes, roles, and responsibilities in order to support clinical workflow that more consistently delivers on the potential benefits of a digitized health care system.

Alignment of Key Stakeholders' Priorities for Patient-Facing Tools in Digital Health: Mixed Methods Study.

BACKGROUND: There is widespread agreement on the promise of patient-facing digital health tools to transform health care. Yet, few tools are in widespread use or have documented clinical effectiveness. OBJECTIVE: The aim of this study was to gain insight into the gap between the potential of patient-facing digital health tools and real-world uptake. METHODS: We interviewed and surveyed experts (in total, n=24) across key digital health stakeholder groups-venture capitalists, digital health companies, payers, and health care system providers or leaders-guided by the Consolidated Framework for Implementation Research. RESULTS: Our findings revealed that external policy, regulatory demands, internal organizational workflow, and integration needs often take priority over patient needs and patient preferences for digital health tools, which lowers patient acceptance rates. We discovered alignment, across all 4 stakeholder groups, in the desire to engage both patients and frontline health care providers in broader dissemination and evaluation of digital health tools. However, major areas of misalignment between stakeholder groups have stymied the progress of digital health tool uptake-venture capitalists and companies focused on external policy and regulatory demands, while payers and providers focused on internal organizational workflow and integration needs. CONCLUSIONS: Misalignment of the priorities of digital health companies and their funders with those of providers and payers requires direct attention to improve uptake of patient-facing digital health tools and platforms.

Letting a Good Crisis Go to Waste.

The widespread implementation of electronic health records (EHRs) was predicated on hopes that they would rapidly improve care, but initial experiences have been disappointing and thought to be a key part of physician dissatisfaction and burnout. The crisis created by EHR implementation is only in part due to EHRs themselves, and might also be viewed as a crisis that has served to surface longstanding problems in healthcare-ones that if grappled with, will lead to more rapidly effective digital transformation.

EHR audit logs: A new goldmine for health services research?

A byproduct of the transition to electronic health records (EHRs) is the associated observational data that capture EHR users' granular interactions with the medical record. Often referred to as audit log data or event log data, these datasets capture and timestamp user activity while they are logged in to the EHR. These data - alone and in combination with other datasets - offer a new source of insights, which cannot be gleaned from claims data or clinical data, to support health services research and those studying healthcare processes and outcomes. In this commentary, we seek to promote broader awareness of EHR audit log data and to stimulate their use in many contexts. We do so by describing EHR audit log data and offering a framework for their potential uses in quality domains (as defined by the National Academy of Medicine). The framework is illustrated with select examples in the safety and efficiency domains, along with their accompanying methodologies, which serve as a proof of concept. This article also discusses insights and challenges from working with EHR audit log data. Ensuring that researchers are aware of such data, and the new opportunities they offer, is one way to assure that our healthcare system benefits from the digital revolution.

Deploying Patient-Facing Application Programming Interfaces: Thematic Analysis of Health System Experiences.

BACKGROUND: Health systems have recently started to activate patient-facing application programming interfaces (APIs) to facilitate patient access to health data and other interactions. OBJECTIVE: This study sought to ascertain health systems' understanding, strategies, governance, and organizational infrastructure around patient-facing APIs, as well as their business drivers and barriers, to facilitate national learning, policy, and progress toward adoption. METHODS: We performed a content analysis of semistructured interviews with a convenience sample of 10 health systems known to be leading adopters of health technology, having either implemented or planning to implement patient-facing APIs. RESULTS: Of the 10 health systems, eight had operational patient-facing APIs, with organizational strategy driven most by federal policy, the emergence of Health Records on iPhone, and feelings of ethical obligation. The two priority use cases identified were enablement of a patient's longitudinal health record and digital interactions with the health system. The themes most frequently cited as barriers to the increased use of patient-facing APIs were security concerns, an immature app ecosystem that does not currently offer superior functionality compared with widely adopted electronic health record (EHR)-tethered portals, a lack of business drivers, EHR vendor hesitation toward data sharing, and immature technology and standards. CONCLUSIONS: Our findings reveal heterogeneity in health system understanding and approaches to the implementation and use of patient-facing APIs. Ongoing study, targeted policy interventions, and sharing of best practices appear necessary to achieve successful national implementation.

Variation in Physicians' Electronic Health Record Documentation and Potential Patient Harm from That Variation.

BACKGROUND: Physician-to-physician variation in electronic health record (EHR) documentation not driven by patients' clinical status could be harmful. OBJECTIVE: Measure variation in completion of common clinical documentation domains. Identify perceived causes and effects of variation and strategies to mitigate negative effects. DESIGN: Sequential, explanatory, mixed methods using log data from a commercial EHR vendor and semi-structured interviews with outpatient primary care practices. PARTICIPANTS: Quantitative: 170,332 encounters led by 809 physicians in 237 practices. Qualitative: 40 interviewees in 10 practices. MAIN MEASURES: Interquartile range (IQR) of the proportion of encounters in which a physician completed documentation, for each documentation category. Multilevel linear regression measured the proportion of variation at the physician level. KEY RESULTS: Five clinical documentation categories had substantial and statistically significant (p < 0.001) variation at the physician level after accounting for state, organization, and practice levels: (1) discussing results (IQR = 50.8%, proportion of variation explained by physician level = 78.1%); (2) assessment and diagnosis (IQR = 60.4%, physician-level variation = 76.0%); (3) problem list (IQR = 73.1%, physician-level variation = 70.1%); (4) review of systems (IQR = 62.3%, physician-level variation = 67.7%); and (5) social history (IQR = 53.3%, physician-level variation = 62.2%). Drivers of variation from interviews included user preferences and EHR designs with multiple places to record similar information. Variation was perceived to create documentation inefficiencies and risk patient harm due to missed or misinterpreted information. Mitigation strategies included targeted user training during EHR implementation and practice meetings focused on documentation standardization. CONCLUSIONS: Physician-to-physician variation in EHR documentation impedes effective and safe use of EHRs, but there are potential strategies to mitigate negative consequences.

The Limits of Clinician Vigilance as an AI Safety Bulwark.

This Viewpoint examines the potential problems of clinician reliance on the use of artificial intelligence (AI) in health care and offers suggestions on how AI could be designed to promote clinician vigilance.

National Trends in Billing Secure Messages as E-Visits.

This study assesses US trends in e-visit billing using national all-payer claims.

Legal Barriers to the Growth of Health Information Exchange-Boulders or Pebbles?

Policy Points: Historically, in addition to economic and technical hurdles, state and federal health information privacy laws have been cited as a significant obstacle to expanding electronic health information exchange (HIE) in the United States. Our review finds that over the past decade, several helpful developments have ameliorated the legal barriers to HIE, although variation in states' patient consent requirements remains a challenge. Today, health care providers' complaints about legal obstacles to HIE may be better understood as reflecting concerns about the economic and competitive risks of information sharing. CONTEXT: Although the clinical benefits of exchanging patients' health information electronically across providers have long been recognized, participation in health information exchange (HIE) has lagged behind adoption of electronic health records. Barriers erected by federal and state health information privacy law have been cited as a leading reason for the slow progress. A comprehensive assessment of these issues has not been undertaken for nearly a decade, despite a number of salient legal developments. METHODS: Analysis of federal and state health information privacy statutes and regulations and secondary materials. FINDINGS: Although some legal barriers to HIE persist, many have been ameliorated-in some cases, simply through improved understanding of what the law actually requires. It is now clear that the Health Insurance Portability and Accountability Act presents no obstacles to electronically sharing protected health information for treatment purposes and does not hold providers who properly disclose information liable for privacy breaches by recipients. The failure of federal efforts to establish a unique patient identifier number does slow HIE by inhibiting optimal matching of patient records, but other action to facilitate matching will be taken under the 21st Century Cures Act. The Cures Act also creates the legal architecture to begin to combat "information blocking." Varying patient consent requirements under federal and state law are the most important remaining legal barrier to HIE progress. However, federal rules relating to disclosure of substance-abuse treatment information were recently liberalized, and development of a technical standard, Data Segmentation for Privacy, or DS4P, now permits sensitive data requiring special handling to be segmented within a patient's record. Even with these developments, state-law requirements for patient consent remain daunting to navigate. CONCLUSIONS: Although patient consent requirements make HIE challenging, providers' expressed worries about legal barriers to participating in HIE likely primarily reflect concerns that are economically motivated. Lowering the cost of HIE or increasing financial incentives may boost provider participation more than further reducing legal barriers.

The relationship between hospital and ehr vendor market dynamics on health information organization presence and participation.

BACKGROUND: Health Information Organizations (HIOs) are third party organizations that facilitate electronic health information exchange (HIE) between providers in a geographic area. Despite benefits from HIE, HIOs have struggled to form and subsequently gain broad provider participation. We sought to assess whether market-level hospital and EHR vendor dynamics are associated with presence and level of hospital participation in HIOs. METHODS: 2014 data on 4523 hospitals and their EHR vendors were aggregated to the market level. We used multivariate OLS regression to analyze the relationship between hospital and vendor dynamics and (1) probability of HIO presence and (2) percent of hospitals participating in an HIO. RESULTS: 298 of 469 markets (64%) had HIO presence, and in those markets, 47% of hospitals participated in an HIO on average. In multivariate analysis, four characteristics were associated with HIO presence. Markets with more hospitals, markets with more EHR vendors, and markets with an EHR vendor-led HIE approach were more likely to have an HIO. Compared to markets with low hospital competition, markets with high hospital competition had a 25 percentage point lower probability of HIO presence. Two characteristics were associated with level of hospital HIO participation. Markets with more hospitals as well as markets with high vendor competition (compared to low competition) had lower participation. CONCLUSION: Both hospital and EHR vendor dynamics are associated with whether a market has an HIO as well as the level of hospital participation in HIOs.

Association Between Billing Patient Portal Messages as e-Visits and Patient Messaging Volume.

This study evaluates the adoption of clinician billing for patient portal messages as e-visits, prompted by significant increases in patient messaging after the onset of the COVID-19 pandemic.

Interoperability in a Post-Roe Era: Sustaining Progress While Protecting Reproductive Health Information.

This Viewpoint proposes a solution to better safeguard reproductive health information in patient records that are now more complete owing to the interoperability of health information exchange networks.