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.

Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review.

OBJECTIVE: Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system. DESIGN: Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded. RESULTS: 47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data. CONCLUSIONS: We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.

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.

Smoking-Cessation Assistance: Before and After Stage 1 Meaningful Use Implementation.

INTRODUCTION: Brief smoking-cessation interventions in primary care settings are effective, but delivery of these services remains low. The Centers for Medicare and Medicaid Services' Meaningful Use (MU) of Electronic Health Record (EHR) Incentive Program could increase rates of smoking assessment and cessation assistance among vulnerable populations. This study examined whether smoking status assessment, cessation assistance, and odds of being a current smoker changed after Stage 1 MU implementation. METHODS: EHR data were extracted from 26 community health centers with an EHR in place by June 15, 2009. AORs were computed for each binary outcome (smoking status assessment, counseling given, smoking-cessation medications ordered/discussed, current smoking status), comparing 2010 (pre-MU), 2012 (MU preparation), and 2014 (MU fully implemented) for pregnant and non-pregnant patients. RESULTS: Non-pregnant patients had decreased odds of current smoking over time; odds for all other outcomes increased except for medication orders from 2010 to 2012. Among pregnant patients, odds of assessment and counseling increased across all years. Odds of discussing or ordering of cessation medications increased from 2010 compared with the other 2 study years; however, medication orders alone did not change over time, and current smoking only decreased from 2010 to 2012. Compared with non-pregnant patients, a lower percentage of pregnant patients were provided counseling. CONCLUSIONS: Findings suggest that incentives for MU of EHRs increase the odds of smoking assessment and cessation assistance, which could lead to decreased smoking rates among vulnerable populations. Continued efforts for provision of cessation assistance among pregnant patients is warranted.

Meaningful Use of an Electronic Personal Health Record (ePHR) among Pediatric Cancer Survivors.

Background and Objectivs: Survivors of pediatric and adolescent cancer are at an increased risk of chronic and debilitating health conditions and require life-long specialized care. Stand-alone electronic personal health records (ePHRs) may aid their self-management. This analysis characterizes young adult survivors and parents who meaningfully use an ePHR, Cancer SurvivorLinkTM, designed for survivors of pediatric and adolescent cancer. METHODS: This was a retrospective observational study of patients seen at a pediatric survivor clinic for annual survivor care. Young adult survivors and/or parent proxies for survivors <18 years old who completed ePHR registration prior to their appointment or within 90 days were classified as registrants. Registrants who uploaded or downloaded a document and/or shared their record were classified as meaningful users. RESULTS: Overall, 23.7% (148/624) of survivors/parents registered and 38% of registrants used SurvivorLink meaningfully. Young adult registrants who transferred to adult care during the study period were more likely to be meaningful users (aOR: 2.6 (95% CI: 1.1, 6.1)) and used the ePHR twice as frequently as those who continued to receive care in our institution's pediatric survivor clinic. Among survivors who continued to receive care at our institution, being a registrant was associated with having an annual follow-up visit (aOR: 2.6 (95% CI: 1.2, 5.8)). CONCLUSIONS: While ePHRs may not be utilized by all survivors, SurvivorLink is a resource for a subset and may serve as an important bridge for patients who transfer their care. Using SurvivorLink was also associated with receiving recommended annual survivor care.

JOURNAL CLUB: Predictors of Provider Response to Clinical Decision Support: Lessons Learned From the Medicare Imaging Demonstration.

OBJECTIVE: The efficacy of imaging clinical decision support (CDS) varies. Our objective was to identify CDS factors contributing to imaging order cancellation or modification. SUBJECTS AND METHODS: This pre-post study was performed across four institutions participating in the Medicare Imaging Demonstration. The intervention was CDS at order entry for selected outpatient imaging procedures. On the basis of the information entered, computerized alerts indicated to providers whether orders were not covered by guidelines, appropriate, of uncertain appropriateness, or inappropriate according to professional society guidelines. Ordering providers could override or accept CDS. We considered actionable alerts to be those that could generate an immediate order behavior change in the ordering physician (i.e., cancellation of inappropriate orders or modification of orders of uncertain appropriateness that had a recommended alternative). Chi-square and logistic regression identified predictors of order cancellation or modification after an alert. RESULTS: A total of 98,894 radiology orders were entered (83,114 after the intervention). Providers ignored 98.9%, modified 1.1%, and cancelled 0.03% of orders in response to alerts. Actionable alerts had a 10 fold higher rate of modification (8.1% vs 0.7%; p < 0.0001) or cancellation (0.2% vs 0.02%; p < 0.0001) orders compared with nonactionable alerts. Orders from institutions with preexisting imaging CDS had a sevenfold lower rate of cancellation or modification than was seen at sites with newly implemented CDS (1.4% vs 0.2%; p < 0.0001). In multivariate analysis, actionable alerts were 12 times more likely to result in order cancellation or modification. Orders at sites with preexisting CDS were 7.7 times less likely to be cancelled or modified (p < 0.0001). CONCLUSION: Using results from the Medicare Imaging Demonstration project, we identified potential factors that were associated with CDS effect on provider imaging ordering; these findings may have implications for future design of such computerized systems.

Effectiveness and Safety of a Clinical Decision Rule to Reduce Repeat Ionized Calcium Testing: A Pre/Post Test Intervention.

The American Recovery and Reinvestment Act authorizes the Centers for Medicare and Medicaid Services to reimburse hospitals that demonstrate meaningful use of certified electronic health record technology. We sought to demonstrate meaningful use by developing and implementing one clinical decision support rule in the computerized physician order entry system that targets clinician-ordered repeat ionized calcium measurement at the University of Connecticut Health Center. The rule consists of a pop-up computer reminder that is triggered by ordering a second ionized calcium test within 72 hours after an initial normal test, with no clear indication for repeat testing. We implemented the rule on December 14, 2010, and have reviewed all data collected through December 2014. We found that the number of repeat tests decreased from 46% to 14% with no significant increase in the number of serious adverse events. We conclude that computerized reminders can decrease unnecessary repeat testing in the inpatient setting.

A content analysis of the Meaningful Use clinical summary: do clinical summaries promote patient engagement?

AIM: This study analyzed Meaningful Use (MU) clinical summaries (CS) given to 100 older adults (⩾ 65) from 10 family physicians in an urban primary care practice. BACKGROUND: In the United States, MU was designed to promote and enhance patient engagement in hospitals and clinics across the country, providing financial incentives to physicians attesting to the Meaningful Use of a certified Electronic Health Record by meeting a series of measures and objectives. The CS is intended to support patient and family engagement by communicating elements discussed during the clinical encounter including an updated medication list, problem list, and plan of care (POC). Despite the $27.7 billion spent distributing MU payments to more than 418,000 Eligible Professionals in ambulatory care to date, there is little discussion in the scholarly literature supporting the use of the CS to facilitate patient engagement. METHODS: Ten CS were accessed from each of 10 family physicians during a regular practice week. Directed content analysis and descriptive statistics were used to evaluate the summaries. Key variables of analysis included diagnoses, medications, plan of care content, availability, completeness, health literacy, format, and readability. FINDINGS: CS contained an average of 5.2 diagnoses and 10 medications. Summaries contained vital signs (98%), lab results (9%), smoking status (88%), professional care team members (4%), follow-up appointments (46%), and POC (67%); 37% of CS were judged to be incomplete. Readability scores indicated that a university education was required to understand the CS. CS support patient engagement by supplying information that supports behavior change and self-management, however barriers to patient engagement exist, including (a) access, (b) poor document readability, and

Identification of Patient Safety Risks Associated with Electronic Health Records: A Software Quality Perspective.

Although Electronic Health Records (EHR) can offer benefits to the health care process, there is a growing body of evidence that these systems can also incur risks to patient safety when developed or used improperly. This work is a literature review to identify these risks from a software quality perspective. Therefore, the risks were classified based on the ISO/IEC 25010 software quality model. The risks identified were related mainly to the characteristics of "functional suitability" (i.e., software bugs) and "usability" (i.e., interface prone to user error). This work elucidates the fact that EHR quality problems can adversely affect patient safety, resulting in errors such as incorrect patient identification, incorrect calculation of medication dosages, and lack of access to patient data. Therefore, the risks presented here provide the basis for developers and EHR regulating bodies to pay attention to the quality aspects of these systems that can result in patient harm.

Optimizing Safety, Fidelity and Usability of an Intelligent Clinical Support Tool (ICST) For Acute Hospital Care: an Australian Case Study Using a Multi-Method Delphi Process.

This research focuses on a major health priority for Australia by addressing existing gaps in the implementation of nursing informatics solutions in healthcare. It serves to inform the successful deployment of IT solutions designed to support patient-centered, frontline acute healthcare delivery by multidisciplinary care teams. The outcomes can guide future evaluations of the contribution of IT solutions to the efficiency, safety and quality of care delivery in acute hospital settings.

Reducing duplicate testing: a comparison of two clinical decision support tools.

OBJECTIVES: Unnecessary duplicate laboratory testing is common and costly. Systems-based means to avert unnecessary testing should be investigated and employed. METHODS: We compared the effectiveness and cost savings associated with two clinical decision support tools to stop duplicate testing. The Hard Stop required telephone contact with the laboratory and justification to have the duplicate test performed, whereas the Smart Alert allowed the provider to bypass the alert at the point of order entry without justification. RESULTS: The Hard Stop alert was significantly more effective than the Smart Alert (92.3% vs 42.6%, respectively; P < .0001). The cost savings realized per alert activation was $16.08/alert for the Hard Stop alert vs $3.52/alert for the Smart Alert. CONCLUSIONS: Structural and process changes that require laboratory contact and justification for duplicate testing are more effective than interventions that allow providers to bypass alerts without justification at point of computerized physician order entry.

Patient-centered handovers between hospital and primary health care: an assessment of medical records.

BACKGROUND: Handovers between hospital and primary healthcare possess a risk for patient care. It has been suggested that the exchange of a comprehensive medical record containing both medical and patient-centered aspects of information can support high quality handovers. OBJECTIVE: The objective of this study was to explore patient handovers between primary and secondary care by assessing the levels of patient-centeredness of medical records used for communication between care settings and by assessing continuity of patient care. METHODS: Quantitative content analysis was used to analyze the 76 medical records of 22 Swedish patients with chronic diseases and/or polypharmacy. RESULTS: The levels of patient-centeredness documented in handover records were assessed as poor, especially in regards to informing patients and achieving a shared understanding/agreement about their treatment plans. The follow up of patients' medical and care needs were remotely related to the discharge information sent from the hospital to the primary care providers, or to the hospital provider's request for patient follow-up in primary healthcare. CONCLUSION: The lack of patient-centered documentation either indicates poor patient-centeredness in the encounters or low priority given by the providers on documenting such information. Based on this small study, discharge information sent to primary healthcare cannot be considered as a means of securing continuity of patient care. Healthcare providers need to be aware that neither their discharge notes nor their referrals will guarantee continuity of patient care.

[Deterministic record linkage with indirect identifiers: data of the Berlin Myocardial Infarction Registry and the AOK Nordost for patients with myocardial infarction]. / Deterministisches Record Linkage mit indirekten Identifikatoren: Daten des Berliner Herzinfarktregisters und der AOK Nordost zum Herzinfarkt.

AIM OF THE STUDY: How can 2 pseudonymised data sets be linked? Using the example of data from the Berlin Myocardial Infarction Registry and from a German sickness fund (AOK Nordost) we will demonstrate how record linkage can be achieved without personal identifiers. METHODS: In different steps the method of deterministic record linkage with indirect identifiers: age, sex, hospital admission date and time, will be explained. RESULTS: We were able to show that 80.6% of the expected maximum number of patients were matched with our approach. As a result we had no duplicate matches in the linkage process, where one AOK patient was linked to 2 or more BMIR patients or vice versa. The matching variables produced enough uniqueness to be used as indirect patient identifiers. CONCLUSION: Deterministic record linkage with the following indirect indicators: age, sex, hospital admission date and time was possible in our study of patients with myocardial infarction in a circumscribed geographical region, which limited the number of cases and avoided mismatches.

[Integration of primary and secondary data in the Study of Health in Pomerania and description of clinical outcomes using stroke as an example]. / Die Integration von Primär- und Sekundärdaten in der Study of Health in Pomerania und die Beschreibung von klinischen Endpunkten am Beispiel Schlaganfall.

OBJECTIVE: This study describes (i) the procedure of obtaining patients' consent for secondary data usage, (ii) the complexity of integrating data from multiple sources, and (iii) the correspondence among patients' self-reports, physician reports, routine data, hospital discharge diagnosis, and cause-of-death coding regarding stroke. METHODS: Data from the first follow-up (N=3 186) of the population-based Study of Health in Pomerania (SHIP) were used. These data were combined with secondary data from the Greifswald University Hospital, the association of statutory health insurance physicians Mecklenburg-Western Pomerania, physician reports, and death certificates. RESULTS: Consent for using health-related information from all data sources in question was obtained from more than 90% of the SHIP participants. Follow-up data from at least one source were available for 2 747 (86%) participants. For 92 participants information about the occurrence of stroke was found in at least one data source. In 59 cases the event appeared in only one data source, in 24 cases the event was found in 2 sources, and for 9 participants 3 data sources reported on the event. CONCLUSION: Participants of a population-based cohort are highly willing to give consent for using their health-related information from secondary data sources. Yet, data integration is challenging due to considerable differences in data type, structure and coverage.

[Linking claims data and beneficiary survey information to report on the quality of health care: potential, pitfalls, and perspectives]. / Routinedaten der gesetzlichen Krankenversicherung und Versichertenbefragungen in der Qualitätsberichterstattung - Potenzial, Probleme und Perspektiven.

Reports on the quality of care aim at health and patient-reported outcomes in routine clinical care. To achieve meaningful information the study designs must be robust against bias through highly selected patient populations or health care providers but also allow for adequate control of confounding. The article describes the potential and pitfalls of administrative claims data and surveys of beneficiaries. The large potential of using both sources is illustrated in the primary inpatient treatment for prostate cancer. However, linking claims data and patient survey data still leaves some problems to be addressed in the final section. Linking claims data and beneficiary survey information on patient reported outcomes overcomes sectoral barriers and allows for an integrated evaluation of pathways of care in the short-, mid- and long-term. It is economical and well suited for a variety, but not all health care problems. Future efforts might be directed towards more collaboration among sickness funds.

[Linkage of statutory health insurance data with those of a hospital information system: feasible, but also "useful"?]. / Verknüpfung von Routinedaten der Gesetzlichen Krankenversicherung mit Daten eines Krankenhausinformationssystems: Machbar, aber auch "nützlich"?

AIM: Administrative data are increasingly being linked with other data sources for research purposes in the field of epidemiology and health services research abroad. In Germany, the direct linkage of routine data of statutory health insurance (SHI) providers with other data sources is complicated due to strict data protection requirements. The aim of this analysis was to evaluate an indirect linkage of SHI routine data with data of a hospital information system (HIS). METHODS: The dataset comprised data from 2004 to 2010 from 2 sickness funds and one HIS. In both data sources, hospitalisations were restricted to admissions into one hospital with at least one diagnosis of heart failure. The 2 data sources were linked, in cases of the agreement of the admission and discharge dates, as well as the agreement of at least a certain percentage of diagnoses in HIS data when compared to SHI data (full coding depth). Based on the direct linkage using the pseudonymised insurance number as gold standard, the proposed linkage approach was evaluated by means of test statistics. Furthermore, the completeness of relevant information of the HIS was described. RESULTS: The dataset contained 3 731 hospitalisations from the HIS and 8 172 hospitalisations from the SHI routine data. The sensitivity of the linkage approach was 86.7% in the case of an agreement of at least 30% of the diagnoses and decreased to 41.7% in the case of 100% agreement in the diagnoses. The specificity was almost 100% at all studied cut-offs of agreement. Anthropometric measures and diagnostic information were available only for a small fraction of cases in the data of the HIS, whereas information on the health status and on laboratory information was comparatively complete. CONCLUSION: For the linkage of SHI routine data with complementary data sources, indirect linkage methods can be a valuable alternative in comparison to direct linkage, which is time-consuming with regard to planning and application. Since the proposed approach was used in a relatively small sample and a restricted patient population, a replication using nation-wide data without respective restrictions would require an extension of the algorithm. Furthermore, the large administrative effort seems questionable considering the comparatively high amount of missing values in interesting information in the HIS.

Network-based modeling and intelligent data mining of social media for improving care.

Intelligently extracting knowledge from social media has recently attracted great interest from the Biomedical and Health Informatics community to simultaneously improve healthcare outcomes and reduce costs using consumer-generated opinion. We propose a two-step analysis framework that focuses on positive and negative sentiment, as well as the side effects of treatment, in users' forum posts, and identifies user communities (modules) and influential users for the purpose of ascertaining user opinion of cancer treatment. We used a self-organizing map to analyze word frequency data derived from users' forum posts. We then introduced a novel network-based approach for modeling users' forum interactions and employed a network partitioning method based on optimizing a stability quality measure. This allowed us to determine consumer opinion and identify influential users within the retrieved modules using information derived from both word-frequency data and network-based properties. Our approach can expand research into intelligently mining social media data for consumer opinion of various treatments to provide rapid, up-to-date information for the pharmaceutical industry, hospitals, and medical staff, on the effectiveness (or ineffectiveness) of future treatments.

[Documentation quality of histopathology reports of prostate needle biopsies: a snapshot]. / Dokumentationsqualität histopathologischer Befundberichte von Prostatastanzbiopsien : Eine Momentaufnahme.

BACKGROUND: A standardized assessment of findings from prostate needle biopsies in pathology is of great importance for the individual recommendations for therapy of patients with prostate cancer. To this end criteria were developed which are formulated as recommendations in the S3 guidelines for prostate cancer and in joint instructions of the Bundesverband Deutscher Pathologen (BDP, "National Association of German Pathologists") and the Deutsche Gesellschaft für Pathologie (DGP, "German Society of Pathology"). In this article the findings from tumor positive prostate needle biopsies taken from various institutes in Germany, were investigated exclusively to determine to what extent the recommended parameters were followed. MATERIAL AND METHODS: The study encompassed the findings from 91 patients with a mean age of 65.3 years from whom an average of 9.3 biopsy samples from different regions of the prostate were submitted. All diagnosed tumors corresponded to a standard type adenocarcinoma according to the classification of the World Health Organization (WHO) which was detected in an average of 2.5 biopsy regions per patient. The assessment was made from H & E stained serial sections which was supplemented in 11 (12.1%) cases by special staining methods and in 40 (44%) cases by immunohistochemical staining techniques. The length of the needle biopsy was documented in 88 (96.7%) cases and the tumor spread also in 88 cases. The tumor stage was reported in 16 cases (17.6%). RESULTS: The Gleason grading score (GS) was reported in all 91 cases whereby the old GS was explicitly used in 1 case and the modified GS in all other cases. The allocated GS ranged from 4 to 10 whereby 8 cases were graded as ≤5, 46 as GS grade 6, 27 as GS grade 7 and 10 as GS >7. Out of 45 cases with several positive biopsy samples, 38 were uniformly graded (84.4%), 6 out of the 7 samples which were not uniformly graded were allocated a GS of 6 or 7 and 1 sample was graded as GS 6-9. In 64 cases (70.3%) the conventional 3-stage WHO grading (n=42) and the Helpap grading (n=22) were additionally used. The WHO and Helpap grading scores were found to be highly correlated with the GS grading scores and the Union for International Cancer Control (UICC) grading scores derived from it (χ²-test, p<0.001), although surprising allocations were selected in isolated cases. CONCLUSION: In total, the only serious deficits were that in three cases (3.3%) no information was supplied on the estimated spread of the tumor in the tumor positive biopsies because this information can be decisive for therapy decisions, particularly for the selection of an active surveillance strategy. Also a relatively large number of cases were assigned a GS score ≤ 5 which is not recommended in the modified Gleason grading. Furthermore, translation of the GS into the other grading forms used revealed that the biological assessment of the GS showed clear differences between the various participating institutes. In conclusion, the findings of the pathologists as a rule incorporated all the parameters necessary for a therapy decision in accordance with the guidelines so that they can be considered comprehensive and completely valid apart from a few exceptions.

Journal club: Requiring clinical justification to override repeat imaging decision support: impact on CT use.

OBJECTIVE: The purpose of this study was to determine the impact of requiring clinical justification to override decision support alerts on repeat use of CT. SUBJECTS AND METHODS: This before and after intervention study was conducted at a 793-bed tertiary hospital with computerized physician order entry and clinical decision support systems. When a CT order is placed, decision support alerts the orderer if the patient's same body part has undergone CT within the past 90 days. The study cohort included all 28,420 CT orders triggering a repeat alert in 2010. The intervention required clinical justification, selected from a predetermined menu, to override repeat CT decision support alerts to place a CT order; otherwise the order could not be placed and was dropped. The primary outcome, dropped repeat CT orders, was analyzed using three methods: chi-square tests to compare proportions dropped before and after intervention; multiple logistic regression tests to control for orderer, care setting, and patient factors; and statistical process control for temporal trends. RESULTS: The repeat CT order drop rate had an absolute increase of 1.4%; 6.1% (682/11,230) before to 7.5% (1290/17,190) after intervention, which was a 23% relative change (7.5 - 6.1)/6.1 × 100 = 23%; p < 0.0001). Orders were dropped more often after intervention (odds ratio, 1.3; 95% CI, 1.1-1.4; p < 0.0001). Statistical control analysis supported the association between the increase in the drop rate with intervention rather than underlying trends. CONCLUSION: Adding a requirement for clinical justification to override alerts modestly but significantly improves the impact of repeat CT decision support (23% relative change), with the overall effect of preventing one in 13 repeat CT orders.