Perspectives on Challenges and Opportunities for Interoperability: Findings From Key Informant Interviews With Stakeholders in Ohio.

BACKGROUND: Interoperability-the exchange and integration of data across the health care system-remains a challenge despite ongoing policy efforts aimed at promoting interoperability. OBJECTIVE: This study aimed to identify current challenges and opportunities to advancing interoperability across stakeholders. METHODS: Primary data were collected through qualitative, semistructured interviews with stakeholders (n=24) in Ohio from July to October 2021. Interviewees were sampled using a stratified purposive sample of key informants from 4 representative groups as follows: acute care and children's hospital leaders, primary care providers, behavioral health providers, and regional health information exchange networks. Interviews focused on key informant perspectives on electronic health record implementation, the alignment of public policy with organizational strategy, interoperability implementation challenges, and opportunities for health information technology. The interviews were transcribed verbatim followed by rigorous qualitative analysis using directed content analysis. RESULTS: The findings illuminate themes related to challenges and opportunities for interoperability that align with technological (ie, implementation challenges, mismatches in interoperability capabilities across stakeholders, and opportunities to leverage new technology and integrate social determinants of health data), organizational (ie, facilitators of interoperability and strategic alignment of participation in value-based payment programs with interoperability), and environmental (ie, policy) domains. CONCLUSIONS: Interoperability, although technically feasible for most providers, remains challenging for technological, organizational, and environmental reasons. Our findings suggest that the incorporation of end user considerations into health information technology development, implementation, policy, and standard deployment may support interoperability advancement.

Satisfaction with modes of telemedicine delivery during COVID-19: A randomized, single-blind, parallel group, noninferiority trial.

BACKGROUND: Little is known about satisfaction with different modes of telemedicine delivery. The objective of this study was to determine whether patient satisfaction with phone-only was noninferior to video visits. METHODS: We conducted a parallel group, randomized (1:1), single-blind, noninferiority trial in multispecialty clinics at a tertiary academic medical center. Adults age ≥ 60 years or with Medicare/Medicaid insurance were eligible. Primary outcome was visit satisfaction rate (9 or 10 on a 0-10 satisfaction scale). Noninferiority was determined if satisfaction with phone-only (intervention) versus video visits (comparator) was no worse by a -15% prespecified noninferiority margin. We performed modified intent-to-treat (mITT) and per protocol analyses, after adjusting for age and insurance. RESULTS: 200 participants, 43% Black, 68% women completed surveys. Visit satisfaction rates were high. In the mITT analysis, phone-only visits were noninferior by an adjusted difference of 3.2% (95% CI, -7.6% to 14%). In the per protocol analysis, phone-only were noninferior by an adjusted difference of -4.1% (95% CI, -14.8% to 6.6%). The proportion of participants who indicated they preferred the same type of telemedicine visit as their next clinic visit were similar (30.2% vs 27.9% video vs phone-only, p = 0.78) and a majority said their medical concerns were addressed and would recommend a telemedicine visit. CONCLUSIONS: Among a group of diverse, established older or underserved patients, the satisfaction rate for phone-only was noninferior to video visits. These findings could impact practice and policies governing telemedicine.

Quantifying treatment preferences and their association with financial toxicity in women with breast cancer.

BACKGROUND: The objective of the current study was to understand treatment preferences and their association with financial toxicity in Patient Advocate Foundation clients with breast cancer. METHODS: This choice-based conjoint analysis used data from a nationwide sample of women with breast cancer who received assistance from the Patient Advocate Foundation. Choice sets created from 13 attributes of 3 levels each elicited patient preferences and trade-offs. Latent class analysis segmented respondents into distinct preference archetypes. The Comprehensive Score for Financial Toxicity (COST) tool captured financial toxicity. Adjusted generalized linear models estimated COST score differences by preference archetype. RESULTS: Of 220 respondents (for a response rate of 10%), the median age was 58 years (interquartile range, 49-66 years); 28% of respondents were Black, indigenous, or people of color; and approximately 60% had household incomes <$40,000. The majority of respondents were diagnosed with early-stage cancer (91%), 38% had recurrent disease, and 61% were receiving treatment. Treatment choice was most affected by preferences related to affordability and impact on activities of daily living. Two distinct treatment preference archetypes emerged. The "cost-prioritizing group" (75% of respondents) was most concerned about affordability, impact on activities of daily living, and burdening care partners. The "functional independence-prioritizing group" (25% of respondents) was most concerned about their ability to work, physical side effects, and interference with life events. COST scores were found to be similar between the archetypes in adjusted models (cost-prioritizing group COST score, 12 [95% confidence interval, 9-14]; and functional independence-prioritizing COST score, 11 [95% confidence interval, 9-13]). CONCLUSIONS: Patients with breast cancer prioritized affordability or maintaining functional independence when making treatment decisions. Because of this variability, preference evaluation during treatment decision making could optimize patients' treatment experiences.

The patient-centered oncology care on health care utilization and cost: A systematic review and meta-analysis.

BACKGROUND: Optimal cancer care entails coordination among multiple providers and continued follow-up and surveillance over time. The patient-centered care brings opportunities to improve the delivery of cancer care. The adoption of patient-centered oncology care (PCOC) is in its infancy. Evidence synthesis on the model's effectiveness is scant. PURPOSES: This is the first systemic review and meta-analysis on associations of PCOC with cancer patients' adverse health care utilization, cost, patient satisfaction, and quality of care. METHODS: Our study was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework. Quality appraisal was performed using Downs and Black's quality checklist. Study-level effect sizes of adverse health care utilization were computed using Cohen's d and summarized using forest plots. Funnel plots were constructed to examine publication bias. RESULTS: Of 334 studies that were reviewed, 10 met eligibility criteria and were included into the final analysis. Many included studies implemented almost all six of patient-centered care core attributes, plus three additional attributes that specifically addressed cancer patients' needs, including triage pathways, standardized and evidence-based symptom management, as well as support patient navigation. PCOC patients had lower utilization of inpatient care (standardized means difference [SMD] = -0.027, p = .049). Overall positive effect of PCOC on emergency department use was small and not significant (SMD = -0.023, p = .103). With regard to cost and quality of care, our narrative summaries showed an overall positive direction, though we found limitations in individual study quality that precluded a meta-analysis. PUBLIC IMPLICATION: The results showed that it is possible to utilize patient-centered model to support best practice of cancer care. Early evidence shows that the PCOC model has potential to improve health care utilization, cost, and quality of care, but limited numbers of included articles and heterogeneity of those studies implied that more rigorous research is expected to further investigate the model's effects.

Trends and Gaps in Awareness of Direct-to-Consumer Genetic Tests From 2007 to 2014.

INTRODUCTION: Direct-to-consumer genetic tests for inherited disease risks have gained recent approvals from the Food and Drug Administration, and interest in these tests has continued to grow. Broad use of these tests coupled with planning and discussion with health providers regarding genetic risks and potential protective behavior changes have been proposed as preventive tools to reduce health disparities and improve equity in health outcomes. However, awareness of direct-to-consumer genetic testing has historically demonstrated differences by education, income, and race; these disparities could jeopardize potential benefits by limiting access and use. METHODS: The national survey data from the Health Information National Trends Survey was analyzed to understand how overall awareness of direct-to-consumer genetic testing and disparities in awareness across sociodemographic groups have changed since 2007. RESULTS: The findings showed persistent disparities, as well as a widening gap in awareness between Hispanics and non-Hispanic whites (OR2007 =1.52, OR2014 =0.58, pchange =0.0056), despite overall increases in awareness over time. CONCLUSIONS: Given these findings, policies regulating direct-to-consumer genetic tests should prioritize equitable distribution of benefits by including provisions that counteract prevailing disparities in awareness.

Growth Dynamics of Patient-Provider Internet Communication: Trend Analysis Using the Health Information National Trends Survey (2003 to 2013).

BACKGROUND: Communication is key in chronic disease management, and the internet has altered the manner in which patients and providers can exchange information. Adoption of secure messaging differs among patients due to the digital divide that keeps some populations from having effective access to online resources. OBJECTIVE: This study aimed to examine the current state of online patient-provider communication, exploring trends over time in the use of online patient-provider communication tools. METHODS: A 3-part analytic process was used to study the following: (1) reanalysis, (2) close replication across years, and (3) trend analysis extension. During the reanalysis stage, the publicly available Health Information National Trends Survey (HINTS) 1 and 2 data were used with the goal of identifying the precise analytic methodology used in a prior study, published in 2007. The original analysis was extended to add 3 additional data years (ie, 2008, 2011, and 2013) using the original analytical approach with the purpose of identifying trends over time. Multivariate logistic regression was used to analyze pooled data across all years, with year as an added predictor, in addition to a model for each individual data year. RESULTS: The odds of internet users to communicate online with health care providers was significantly and increasingly higher year-over-year, starting in 2003 (2005: odds ratio [OR] 1.31, 95% CI 1.03-1.68; 2008: OR 2.14, 95% CI 1.76-2.59; 2011: OR 2.92, 95% CI 2.33-3.66; and 2013: OR 5.77; 95% CI 4.62-7.20). Statistically significant socio-economic factors found to be associated with internet users communicating online with providers included age, having health insurance, having a history of cancer, and living in an urban area of residence. CONCLUSIONS: The proportion of internet users communicating online with their health care providers has significantly increased since 2003. Although these trends are encouraging, access challenges still exist for some groups, potentially giving rise to a new set of health disparities related to communication.

Insider versus outsider executive succession: The relationship to hospital efficiency.

BACKGROUND: The relationship between Chief Executive Officer (CEO) succession and hospitals' competitive performance is an area of interest for health services researchers. Of particular interest is the impact on overall strategic direction and health system performance that results from selecting a CEO from inside the firm as opposed to seeking outside leadership. Empirical work-to-date has yielded mixed results. Much of this variability has been attributed to design flaws; however, in the absence of a clear message from the evidence, the preference for hiring "outsiders" continues to grow. PURPOSE: This paper investigates on the extent to which insider CEO succession versus outsider succession impacts hospitals' competitive advantage vis-à-vis a sample of organizations that compete in the same sector. METHODS: A hospital matching protocol based on propensity scores is used to control for endogeneity and makes comparisons of productivity across organizations through the use of stochastic frontier estimation. FINDINGS: Succession negatively impacts hospitals' productivity, and firms with outsider CEO succession events closed the gap toward the competitive advantage frontier faster than comparable firms with insider successions. PRACTICE IMPLICATIONS: More research needs to be done on succession planning and its impact on CEO turnover.

Electronic reminder's role in promoting human papillomavirus vaccine use.

OBJECTIVES: To study the association of using an electronic health record (EHR)'s clinical reminder functionality with increased human papillomavirus (HPV) vaccine administration among US office-based physicians. STUDY DESIGN: National Ambulatory Medical Care Survey data from 2007-2012 were pooled together to determine if EHR systems that employ clinical reminders are associated with increased immunization rates in different populations. METHODS: The administration of HPV vaccine served as the dependent variable, with the EHR reminder being the primary independent variable of interest. Logit regression was used to assess the relationship between using EHR reminders and HPV vaccine administration. RESULTS: Analyses indicated that compared with physicians without clinical reminder functions, physicians with clinical reminder functions were more likely to order HPV vaccines. Clinical reminder functions were particularly effective at increasing HPV vaccine use among adolescent males. CONCLUSIONS: Overall, physicians who report using clinical reminders were more likely to order HPV immunizations. However, the association of clinical reminders with HPV immunizations was not significant in the younger adolescent subpopulation. Further, given that HPV incidence decreases significantly even with small gains in vaccination rates, the increase in HPV immunizations found in the male population aged 11 to 21 years is promising. Therefore, targeting males to receive HPV vaccination immunizations through clinical reminders provides a positively disproportionate return on vaccination rates and disease burden.

Measuring Patient Satisfaction's Relationship to Hospital Cost Efficiency: Can Administrators Make a Difference?

OBJECTIVE: The aim of this study was to assess the ability and means by which hospital administrators can influence patient satisfaction and its impact on costs. DATA SOURCES: Data are drawn from the American Hospital Association's Annual Survey of Hospitals, federally collected Hospital Cost Reports, and Medicare's Hospital Compare. STUDY DESIGN: Stochastic frontier analyses (SFA) are used to test the hypothesis that the patient satisfaction-hospital cost relationship is primarily a latent "management effect." The null hypothesis is that patient satisfaction measures are main effects under the control of care providers rather than administrators. PRINCIPLE FINDINGS: Both SFA models were superior to the standard regression analysis when measuring patient satisfaction's relationship to hospitals' cost efficiency. The SFA model with patient satisfaction measures treated as main effects, rather than "latent, management effects," was significantly better comparing the log-likelihood statistics. Higher patient satisfaction scores on the environmental quality and provider communication dimensions were related to lower facility costs. Higher facility costs were positively associated with patients' overall impressions (willingness to recommend and overall satisfaction), assessments of medication and discharge instructions, and ratings of caregiver responsiveness (pain control and help when called). CONCLUSIONS: In the short term, managers have a limited ability to influence patient satisfaction scores, and it appears that working through frontline providers (doctors and nurses) is critical to success. In addition, results indicate that not all patient satisfaction gains are cost neutral and there may be added costs to some forms of quality. Therefore, quality is not costless as is often argued.

Hospital characteristics associated with achievement of meaningful use.

The objective of this study was to identify factors associated with hospitals that achieved the Medicare meaningful use incentive thresholds for payment under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. We employed a cross-sectional design using data from the 2011 American Hospital Association Annual Survey, including the Information Technology Supplement; the Centers for Medicare & Medicaid Services report of hospitals receiving meaningful use payments; and the Health Resources and Services Administration's Area Resource File. We used a lagged value from 2010 to determine electronic health record (EHR) adoption. Our methods were a descriptive analysis and logistic regression to examine how various hospital characteristics are associated with the achievement of Medicare meaningful use incentives. Overall, 1,769 (38%) of 4,683 potentially eligible hospitals achieved meaningful use incentive thresholds by the end of 2012. Characteristics associated with organizations that received incentive payments were having an EHR in place in 2010, having a larger bed size, having a single health information technology vendor, obtaining Joint Commission accreditation, operating under for-profit status, having Medicare share of inpatient days in the middle two quartiles, being eligible for Medicaid incentives, and being located in the Middle Atlantic or South Atlantic census region. Characteristics associated with not receiving incentive payments were being a member of a hospital system and being located in the Mountain or Pacific census region. Thus far, little evidence suggests that the HITECH incentive program has enticed hospitals without an EHR system to adopt meaningful use criteria. Policy makers should consider modifying the incentive program to accelerate the adoption of and meaningful use in hospitals without EHRs.

Hospital website rankings in the United States: expanding benchmarks and standards for effective consumer engagement.

BACKGROUND: Passage of the Patient Protection and Affordable Care Act (ACA) increased the roles hospitals and health systems play in care delivery and led to a wave of consolidation of medical groups and hospitals. As such, the traditional patient interaction with an independent medical provider is becoming far less common, replaced by frequent interactions with integrated medical groups and health systems. It is thus increasingly important for these organizations to have an effective social media presence. Moreover, in the age of the informed consumer, patients desire a readily accessible, electronic interface to initiate contact, making a well-designed website and social media strategy critical features of the modern health care organization. OBJECTIVE: The purpose of this study was to assess the Web presence of hospitals and their health systems on five dimensions: accessibility, content, marketing, technology, and usability. In addition, an overall ranking was calculated to identify the top 100 hospital and health system websites. METHODS: A total of 2407 unique Web domains covering 2785 hospital facilities or their parent organizations were identified and matched against the 2009 American Hospital Association (AHA) Annual Survey. This is a four-fold improvement in prior research and represents what the authors believe to be a census assessment of the online presence of US hospitals and their health systems. Each of the five dimensions was investigated with an automated content analysis using a suite of tools. Scores on the dimensions are reported on a range from 0 to 10, with a higher score on any given dimension representing better comparative performance. Rankings on each dimension and an average ranking are provided for the top 100 hospitals. RESULTS: The mean score on the usability dimension, meant to rate overall website quality, was 5.16 (SD 1.43), with the highest score of 8 shared by only 5 hospitals. Mean scores on other dimensions were between 4.43 (SD 2.19) and 6.49 (SD 0.96). Based on these scores, rank order calculations for the top 100 websites are presented. Additionally, a link to raw data, including AHA ID, is provided to enable researchers and practitioners the ability to further explore relationships to other dynamics in health care. CONCLUSIONS: This census assessment of US hospitals and their health systems provides a clear indication of the state of the sector. While stakeholder engagement is core to most discussions of the role that hospitals must play in relation to communities, management of an online presence has not been recognized as a core competency fundamental to care delivery. Yet, social media management and network engagement are skills that exist at the confluence of marketing and technical prowess. This paper presents performance guidelines evaluated against best-demonstrated practice or independent standards to facilitate improvement of the sector's use of websites and social media.

Overcoming challenges to achieving meaningful use: insights from hospitals that successfully received Centers for Medicare and Medicaid Services payments in 2011.

OBJECTIVE: In an effort to understand better the federal electronic health record (EHR) incentive programme's challenges, this study compared hospitals that did and did not receive meaningful use (MU) payments in the programme's first year based on the challenges they anticipated a year before. MATERIALS AND METHODS: This cross-sectional study used 2010 American Hospital Association survey data and 2011 Centers for Medicare and Medicaid Services data that identify hospitals receiving MU payments. Multivariate regression analysis assessed differences in 2010 anticipated challenges to MU for hospitals that were successful in earning 2011 MU payment compared to hospitals that intended to participate in the programme but were not yet successful. RESULTS: The study sample consisted of 2475 hospitals, 313 of which received MU payments in 2011. Controlling for standard hospital characteristics, hospitals that reported the computerized provider order entry (CPOE) MU criterion as a primary challenge were 18% less likely to receive a 2011 MU payment compared to hospitals that reported other criteria as primary challenges. DISCUSSION: CPOE was the main challenge among hospitals that failed to achieve MU in the first year of the programme. In order to maximize the incentive programme's effectiveness, policymakers, healthcare organizations, and EHR vendors may benefit from increased attention to hospitals' challenges with CPOE. CONCLUSION: As the EHR incentive programme matures, policymakers and other stakeholders should consider strategies that maintain the critical elements of MU while adequately supporting hospitals that desire to become MU but are impeded by specific technological, cultural, and organizational adoption and use challenges.

Reflections on US health care information technology policy from a global perspective.

PURPOSE: Health information technology (HIT) has been lauded as a foundation upon which the development of an integral solution to cost and quality problems facing many nations is predicated. Countries throughout the world have taken differing approaches in their efforts to advance that foundation through policy, financial, and cultural systems that come to support or hinder adoption. As we explore potential opportunities to learn from the experience of others, we pause to consider the environmental, regulatory, financial, and social dynamics that define the US context. DESIGN/METHODOLOGY/APPROACH: This chapter outlines the framework for a comparative approach through four dimensions--environmental, regulation, financial, and social--through which comparative HIT studies should be explored. FINDINGS: With such markedly different contexts in which their HIT is embedded, it is important to not simply look at other countries as a yardstick upon which we compare our failures and successes. Rather, we must look critically at these examples understanding that the dynamics at play in each context have created opportunities and obligations that have come to define each country's implementation. ORIGINALITY/VALUE: The need for a common framework through which scholars can explore comparative HIT systems, while remaining grounded in the US context is an important aspect of effective knowledge translation in adoption.

Hospital characteristics related to the intention to apply for meaningful use incentive payments.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provides incentives for hospitals to fully adopt and use electronic health records (EHRs). We used data from the 2009 American Hospital Association (AHA) Annual Survey Information Technology Supplement and the Centers for Medicare and Medicaid Services (CMS) 2008 Hospital Cost Reports to examine how various hospital characteristics are associated with the intention to pursue meaningful use incentives. Overall, 86 percent of hospitals indicated an intent to pursue HITECH incentives. However, hospitals that already have an EHR system, are larger, and are located in urban areas are more likely to indicate an intention to pursue incentives. Despite a high interest in HITECH incentives, certain hospital characteristics, including current EHR use, increase the proclivity for some hospitals to pursue meaningful use. Given these differences, there is the potential for the HITECH Act to inadvertently increase the digital divide between hospitals with certain characteristics and their counterparts without those characteristics. Policy makers should consider ways to alleviate barriers, especially for nonusers of EHRs, to realize the maximum benefits of the HITECH Act.

Mandatory insurance coverage and hospital productivity in Massachusetts: bending the curve?

OBJECTIVE: The aim of this study was to examine whether universal insurance coverage mandates lead to a more productive use of hospital resources. DATA SOURCES: The American Hospital Association's Annual Survey and the Centers for Medicare and Medicaid Services' case mix index for fiscal years 2005 through 2008 were used. STUDY DESIGN: A Malmquist approach was used to assess hospitals' productivity in the United States and Massachusetts over the sample period. Propensity score matching is used to "simulate" a randomized control group of hospitals from other markets to compare with Massachusetts. Comparisons are then made to examine if productivity differences are due to universal health insurance coverage mandate. PRINCIPAL FINDINGS: In the early stages, Massachusetts' coverage mandates lead to a significant drop in hospitals' productivity relative to comparable facilities in other states. In 2008, Massachusetts functioned 3.53% below its 2005 level, whereas facilities across the United States have seen a 4.06% increase over the same period. CONCLUSIONS: If the individual mandate is implemented nationwide, the Massachusetts' experience indicates that a near-term decrease in overall hospital productivity will occur. As such, current cost estimates of the Patient Protection and Affordable Care Act's impact on overall health spending are potentially understated.

Effective US health system websites: establishing benchmarks and standards for effective consumer engagement.

Hospitals and health systems are playing increasingly important roles as care coordination hubs and consumer information sources. In particular, the accountable care organization (ACO) and medical home models promoted in the Affordable Care Act place hospitals at the center of many activities related to health information exchange. Therefore, it is important for these organizations to have effective websites, and the need for a social media presence to connect with consumers is growing quickly. The purpose of this study is to assess the websites of hospitals and health systems on four dimensions: accessibility, content, marketing, and technology. In addition, an overall score is calculated to identify the top 25 hospital and health system websites. Specific website elements that healthcare managers can inspect visually are described for each dimension in the discussion section. Generally, hospital and health system websites can be more effective from an end user's perspective. In particular, hospitals and health systems lagged on the accessibility scale that measures the education level required to understand the language used on a site. The scale also assesses the extent to which web pages are designed for ease of movement from page to page using embedded links. Given that healthcare consumers come from every demographic and stratum of society, it is important that user-friendliness be optimized for a broadly defined audience. Hospital and health system websites can also be improved on the technology scale, as many sites do not return clear descriptions of links to search engines such as Google and Bing that use webcrawlers to collect information.