Differences by Race in Outcomes of an In-Person Training Intervention on Use of an Inpatient Portal: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Differences in patient use of health information technologies by race can adversely impact equitable access to health care services. While this digital divide is well documented, there is limited evidence of how health care systems have used interventions to narrow the gap. Objective: To compare differences in the effectiveness of patient training and portal functionality interventions implemented to increase portal use among racial groups. Design, Setting, and Participants: This secondary analysis used data from a randomized clinical trial conducted from December 15, 2016, to August 31, 2019. Data were from a single health care system and included 6 noncancer hospitals. Participants were patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay. Data were analyzed from September 1, 2022, to October 31, 2023. Interventions: A 2 × 2 factorial design was used to compare the inpatient portal training intervention (touch, in-person [high] vs built-in video tutorial [low]) and the portal functionality intervention (technology, full functionality [full] vs a limited subset of functions [lite]). Main Outcomes and Measures: Primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and use of specific portal functions. A logistic regression model was used to test the association of the estimators with the comprehensiveness use measure. Outcomes are reported as incidence rate ratios (IRRs) for the frequency outcomes or odds ratios (ORs) for the comprehensiveness outcomes with corresponding 95% CIs. Results: Of 2892 participants, 550 (19.0%) were Black individuals, 2221 (76.8%) were White individuals, and 121 (4.2%) were categorized as other race (including African, American Indian or Alaska Native, Asian or Asian American, multiple races or ethnicities, and unknown race or ethnicity). Black participants had a significantly lower frequency (IRR, 0.80 [95% CI, 0.72-0.89]) of inpatient portal use compared with White participants. Interaction effects were not observed between technology, touch, and race. Among participants who received the full technology intervention, Black participants had lower odds of being comprehensive users (OR, 0.76 [95% CI, 0.62-0.91), but interaction effects were not observed between touch and race. Conclusions and Relevance: In this study, providing in-person training or robust portal functionality did not narrow the divide between Black participants and White participants with respect to their inpatient portal use. Health systems looking to narrow the digital divide may need to consider intentional interventions that address underlying issues contributing to this inequity. Trial Registration: ClinicalTrials.gov Identifier: NCT02943109.

Health system chief diversity officers: who are they and what do they do?

The Chief Diversity Officer, or CDO, is an increasingly common leadership role within U.S. health care delivery systems. Very little is known about the CDO role across hospitals and health systems. To map the responsibilities and characteristics of how CDOs are positioned within health care, we first searched the web pages of health systems to identify which systems have CDOs, or what we call "CDO-equivalents." Second, we expanded the search of public documents to new-hire announcements and the online social/professional media site, LinkedIn, to identify information regarding each identified leader's roles and responsibilities. Finally, text from these documents describing the leader's roles was uploaded to Atlas.ti, a qualitative analytic software, to identify common themes. There were 60 diversity leaders among 359 U.S. health care systems. Seven consistent roles and responsibilities were identified reflecting a very broad scope of work. Future research should focus on exploring the scope of this leadership role.

Were hospitals with sustained high performance more successful at reducing mortality during the pandemic's second wave?

BACKGROUND: In 2019, the COVID-19 pandemic emerged. Variation in COVID-19 patient outcomes between hospitals was later reported. PURPOSE: This study aims to determine whether sustainers-hospitals with sustained high performance on Hospital Value-Based Purchasing Total Performance Score (HVBP-TPS)-more effectively responded to the pandemic and therefore had better patient outcomes. METHODOLOGY: We calculated hospital-specific risk-standardized event rates using deidentified patient-level data from the UnitedHealth Group Clinical Discovery Database. HVBP-TPS from 2016 to 2019 were obtained from Centers for Medicare & Medicaid Services. Hospital characteristics were obtained from the American Hospital Association Annual Survey Database (2019), and county-level predictors were obtained from the Area Health Resource File. We use a repeated-measures regression model assuming an AR(1) type correlation structure to test whether sustainers had lower mortality rates than nonsustainers during the first wave (spring 2020) and the second wave (October to December 2020) of the pandemic. RESULTS: Sustainers did not have significantly lower COVID-19 mortality rates during the first wave of the pandemic, but they had lower COVID-19 mortality rates during the second wave compared to nonsustainers. Larger hospitals, teaching hospitals, and hospitals with higher occupancy rates had higher mortality rates. CONCLUSION: During the first wave of the pandemic, mortality rates did not differ between sustainers and nonsustainers. However, sustainers had lower mortality rates than nonsustainers in the second wave, most likely because of their knowledge management capabilities and existing structures and resources that enable them to develop new processes and routines to care for patients in times of crisis. Therefore, a consistently high level of performance over the years on HVBP-TPS is associated with high levels of performance on COVID-19 patient outcomes. PRACTICE IMPLICATIONS: Investing in identifying the knowledge, processes, and resources that foster the dynamic capabilities needed to achieve superior performance in HVBP might enable hospitals to utilize these capabilities to adapt more effectively to future changes and uncertainty.

Promoting the Success and Sustainability of Coordinated Specialty Care Teams in Ohio.

Recent COVID-19-related federal legislation has resulted in time-limited increases in Mental Health Block Grant (MHBG) set-aside dollars for coordinated specialty care (CSC) throughout the United States. The state of Ohio has opted to apply these funds to establish a learning health network of Ohio CSC teams, promote efforts to expand access to CSC, and quantify the operating costs and rates of reimbursement from private and public payers for these CSC teams. These efforts may provide other states with a model through which they can apply increased MHBG funds to support the success of their own CSC programs.

Addressing Equity and Social Needs: The New Frontier of Patient Engagement Research.

Patient engagement has been a focus of patient-centered care in recent years, encouraging health care organizations to increase efforts to facilitate a patient's ability to participate in health care. At the same time, a growing body of research has examined the impact that social determinants of health (SDOH) have on patient health outcomes. Additionally, health care equity is increasingly becoming a focus of many organizations as they work to ensure that all patients receive equitable care. These three domains - patient engagement, SDOH, and health care equity - can intersect in the implementation of social needs screenings among health care organizations. We present a case study on a two-phase social needs screening implementation project and describe how this process focuses on equity. As health care organizations seek to increase patient engagement, address SDOH, and improve health equity, we highlight the need to move away from a siloed approach and view these efforts as interrelated. By approaching efforts to address these challenges and barriers as the duty of all those involved in the patient care process, there may be larger strides made toward equitable health care.

Multi-stakeholder perspectives on the implementation of a clinic-based food referral program for patients with chronic conditions: a qualitative examination.

Clinic-based food referral programs (FRPs) may help alleviate food insecurity and improve access to nutritious foods by systematically identifying and referring food-insecure primary care patients to community-based food resources. The purpose of this study was to examine the barriers to and facilitators of implementation of an FRP offered to primary care patients who screen positive for food insecurity and have a qualifying chronic condition. we used a multi-stakeholder approach to conduct semi-structured interviews with healthcare providers and administrators from an academic medical center (AMC) (n = 20), representatives of a regional foodbank and its affiliated pantries (n = 11), and patients referred to the FRP (n = 20), during the initial phase of FRP implementation from April to September 2020. Interviews were audio-recorded, transcribed verbatim, and coded using a deductive dominant approach that allowed for the identification of emergent themes. Seven major themes emerged across the two domains of analysis: barriers to and facilitators of FRP implementation. Key barriers were (a) provider time constraints and competing demands; (b) inadequate physician feedback regarding patient use of the program; (c) patient transportation barriers; and (d) stigma associated with food pantry use. Key facilitators of implementation included (a) program champions; (b) screening and referral coordination; and (c) addressing food pantry-related stigma. This study identifies factors that deter and facilitate the implementation of an AMC-based FRP. Our findings highlight opportunities for healthcare and community-based organizations to refine and optimize FRP models toward the ultimate aim of advancing health equity for food-insecure patients.

Food insecurity can make the self-management of diet-related chronic conditions (e.g., diabetes, hypertension, and obesity) difficult. Clinic-based food referral programs (FRPs) can help address the diet-related needs of food-insecure primary care patients by improving access to nutritious foods. However, the factors contributing to successful FRP implementation in primary care settings are underexplored. The focus of this study was to explore the barriers to and facilitators of implementation of an FRP offered to food-insecure primary care patients with chronic conditions seen at an academic medical center using a multi-stakeholder approach. Competing clinical and patient demands, patient transportation barriers, and food pantry-related stigma were salient factors that prevented healthcare providers and patients from engaging fully with the FRP. Inadequate provider feedback about patients' use of the FRP was also cited as a deterrent to greater provider engagement with the FRP. Critical facilitators of implementation included support and encouragement from program champions and having a coordinated referral process. The intentional branding and presentation of the FRP to eligible patients may have helped encourage its use by destigmatizing the food pantry setting. The impact of optimizing FRP implementation on patient use and program effectiveness warrants further research.

Utilization Patterns of a Food Referral Program: Findings from the Mid-Ohio Farmacy.

INTRODUCTION: There is limited evidence describing utilization of clinic-based food referral programs intended to support healthy eating for food-insecure patients. To address this gap, this study aims to describe the utilization of the Mid-Ohio Farmacy (MOF). MOF is a partnership between a regional foodbank and local health care providers, including an academic medical center (AMC), that enables referrals of patients that experience food insecurity to a network of participating food pantries. METHODS: This observational study uses data from 2 AMC family medicine clinics that offered the MOF referral from September 2019 to November 2020. Patients who screened positive for food insecurity and had an eligible chronic disease (eg, diabetes, hypertension, obesity) were referred to the MOF. We compared demographic and clinical characteristics of patients that filled their referral (ie, visitors) to those that did not (ie, non-visitors). Among visitors, we also assessed patterns of pantry utilization. RESULTS: In total, 51% (164 of 322) of patients referred to the MOF visited a food pantry at least once. Visitors were more likely to be older, have diabetes, and have visited a food pantry before their referral. Patients with uncontrolled hypertension were less likely to visit a food pantry following their referral. Patients that had visited a food pantry before their referral had more visits in total and more produce-specific visits following their referral. CONCLUSIONS: Our results suggest that while the MOF can connect patients to food resources, further attention may be needed to encourage its use among patients who have not previously accessed pantries.

Defining safety net hospitals in the health services research literature: a systematic review and critical appraisal.

BACKGROUND: The aim of this study was to identify the range of ways that safety net hospitals (SNHs) have been empirically operationalized in the literature and determine the extent to which patterns could be identified in the use of empirical definitions of SNHs. METHODS: We conducted a PRISMA guided systematic review of studies published between 2009 and 2018 and analyzed 22 articles that met the inclusion criteria of hospital-level analyses with a clear SNH definition. RESULTS: Eleven unique SNH definitions were identified, and there were no obvious patterns in the use of a definition category (Medicaid caseload, DSH payment status, uncompensated care, facility characteristics, patient care mix) by the journal type where the article appeared, dataset used, or the year of publication. CONCLUSIONS: Overall, there is broad variability in the conceptualization of, and variables used to define, SNHs. Our work advances the field toward the development of standards in measuring, operationalizing, and conceptualizing SNHs across research and policy questions.

Care Team Perspectives About an Inpatient Portal: Benefits and Challenges of Patients' Portal Use During Hospitalization.

While current research about inpatient portals has focused largely on the patient perspective, it is also critical to consider the care team point of view, as support from these individuals is essential to successful portal implementation and use. We held brief in-person interviews with 433 care team members across a six-hospital health system to explore opinions about patients' use of an inpatient portal as perceived by care team members. Using the Inpatient Portal Evaluation Framework, we characterized benefits and challenges of portal use that care team members reported affected patients, themselves, and the collaborative work of these care teams with their patients. Interviewees noted inpatient portals can improve patient care and experience and also indicated room for improvement in portal use for hospitalized patients. Further understanding of the care team perspective is critical to inform approaches to inpatient portal implementation that best benefit both patients and providers.

A Community Health Worker Home Visit Program: Facilitators and Barriers of Program Implementation.

Home visit programs have long been used as a means of intervention specifically among vulnerable, at-risk populations including: chronically ill, impoverished, rural, or homebound individuals. Understanding barriers and facilitators to the implementation of home visit programs is essential to inform these efforts. Home visit programs led by community health workers (CHWs) are becoming more common and pose specific challenges. The Ohio Infant Mortality Reduction Initiative is a home visit program led by CHWs with the purpose of reducing infant mortality among high-risk populations. The intervention included health education, referrals to health services, and provision of supplies and social support to expectant mothers. This study examined qualitative interviews with program managers and administrators to describe facilitators and barriers associated with this home visit program from a managerial perspective. Findings highlight the importance of initial and ongoing CHW training, appropriate caseloads, effective communication, and adequate funding, which can inform future CHW programs.

Exploring the Digital Divide: Age and Race Disparities in Use of an Inpatient Portal.

Background: Age and race disparities in the use of new technologies-the digital divide-may be limiting the potential of patient-facing health information technology to improve health and health care. Objective: To investigate whether disparities exist in the use of patient portals designed specifically for the inpatient environment. Methods: Patients admitted to the six hospitals affiliated with a large, Midwestern academic medical center from July 2017 to July 2018 were provided with access to a tablet equipped with an inpatient portal and recruited to participate in the study (n = 842). Demographic characteristics of study enrollees were obtained from patients' electronic health records and surveys given to patients during their hospital stay. Log files from the inpatient portal were used to create a global measure of use and calculate use rates for specific portal features.Results: We found both age and race disparities in use of the inpatient portal. Patients aged 60-69 (45.3% difference, p < 0.001) and those over age 70 (36.7% difference, p = 0.04) used the inpatient portal less than patients aged 18-29. In addition, African American patients used the portal less than White patients (40.4% difference, p = 0.004).Discussion: These findings suggest that the availability of the technology alone may be insufficient to overcome barriers to use and that additional intervention may be needed to close the digital divide. Conclusions: We identified lower use of the inpatient portal among African American and older patients, relative to White and younger patients, respectively.

Primary Care Provider Understanding of Hair Care Maintenance as a Barrier to Physical Activity in African American Women.

INTRODUCTION: African American (AA) women have reported hair maintenance as a barrier to regular exercise; however, to our knowledge, this study is the first to identify primary care provider thoughts, attitudes, beliefs, and knowledge regarding hair as a barrier to increased physical activity among AA females. METHODS: A 13-question electronic survey was sent via email to 151 clinicians working within a department of family medicine's 8 ambulatory clinics within a large urban academic medical center. RESULTS: A total of 62 primary care clinicians completed the survey, which is a response rate of 41%. The vast majority of respondents (95%) sometimes/often engage in discussions with AA female patients regarding physical activity. However, 76% of respondents have never included a hairstyling or maintenance assessment in that discussion and only 34% noted being comfortable discussing this topic. Among a list of potential barriers to exercise, hair maintenance/scalp perspiration was rarely endorsed as important by clinicians. DISCUSSION: This study highlights a need for increased education among primary care providers regarding AA hair care and maintenance practices as a barrier to increased physical activity in AA women. If specific barriers to increasing healthy habits among AA women are to be addressed, there must be a baseline knowledge of hair care and maintenance barriers, an understanding of the strong influence of cultural norms and practices as it relates to physical activity and exercise, and an increased comfortability when engaging in difficult cross-cultural conversations to ultimately improve health outcomes in AA females.

A deep learning model for pediatric patient risk stratification.

OBJECTIVES: Current models for patient risk prediction rely on practitioner expertise and domain knowledge. This study presents a deep learning model-a type of machine learning that does not require human inputs-to analyze complex clinical and financial data for population risk stratification. STUDY DESIGN: A comparative predictive analysis of deep learning versus other popular risk prediction modeling strategies using medical claims data from a cohort of 112,641 pediatric accountable care organization members. METHODS: "Skip-Gram," an unsupervised deep learning approach that uses neural networks for prediction modeling, used data from 2014 and 2015 to predict the risk of hospitalization in 2016. The area under the curve (AUC) of the deep learning model was compared with that of both the Clinical Classifications Software and the commercial DxCG Intelligence predictive risk models, each with and without demographic and utilization features. We then calculated costs for patients in the top 1% and 5% of hospitalization risk identified by each model. RESULTS: The deep learning model performed the best across 6 predictive models, with an AUC of 75.1%. The top 1% of members selected by the deep learning model had a combined healthcare cost $5 million higher than that of the group identified by the DxCG Intelligence model. CONCLUSIONS: The deep learning model outperforms the traditional risk models in prospective hospitalization prediction. Thus, deep learning may improve the ability of managed care organizations to perform predictive modeling of financial risk, in addition to improving the accuracy of risk stratification for population health management activities.

Moving Organizational Culture from Volume to Value: A Qualitative Analysis of Private Sector Accountable Care Organization Development.

OBJECTIVE: The concept of shifting from volume (i.e., billing for as many patients and services as possible) to value (i.e., reducing costs while improving quality) has been a key underpinning of the development of accountable care organizations (ACOs), yet the cultural change necessary to make this shift has been previously unexplored. DATA SOURCES/STUDY SETTING: Primary data collected through site visits to four private sector ACOs. STUDY DESIGN: Cross-sectional, semi-structured interview study with analysis done at the ACO level to learn about ACO development. DATA COLLECTION: One hundred and forty-eight interviews recorded and transcribed verbatim followed by rigorous qualitative analysis using a grounded theory approach. PRINCIPAL FINDINGS: The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost-benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided. CONCLUSIONS: We found that moving from volume to value is central to the culture change required of an ACO. Our findings can inform future efforts that aim to create a more effective value-based health care system.

Implementing Accountable Care Organizations: Lessons From a Qualitative Analysis of Four Private Sector Organizations.

EXECUTIVE SUMMARY: Accountable care organizations (ACOs) are emerging across the healthcare marketplace and now include Medicare, Medicaid, and private sector payers covering more than 24 million lives. However, little is known about the process of organizational change required to achieve cost savings and quality improvements from the ACO model. This study applies the complex innovation implementation framework to understand the challenges and facilitators associated with the ACO implementation process. We conducted four case studies of private sector ACOs, selected to achieve variation in terms of geography and organizational maturity. Across sites, we used semistructured interviews with 68 key informants to elicit information regarding ACO implementation. Our analysis found challenges and facilitators across all domains in the conceptual framework. Notably, our findings deviated from the framework in two ways. First, findings from the financial resource availability domain revealed both financial and nonfinancial (i.e., labor) resources that contributed to implementation effectiveness. Second, a new domain, patient engagement, emerged as an important factor in implementation effectiveness. We present these deviations in an adapted framework. As the ACO model proliferates, these findings can support implementation efforts, and they highlight the importance of focusing on patients throughout the process. Importantly, this study extends the complex innovation implementation framework to incorporate consumers into the implementation framework, making it more patient centered and aiding future efforts.

Working with an Electronic Medical Record in Ambulatory Care: A Study of Patient Perceptions of Intrusiveness

OBJECTIVE: To assess patient perceptions of electronic medical record (EMR) intrusiveness during ambulatory visits to clinics associated with a large academic medical center. METHOD: We conducted a survey of patients seen at any of 98 academic medical center clinics. The survey assessed demographics, visit satisfaction, computer use, and perceived intrusiveness of the computer. RESULTS: Of 7,058 patients, slightly more than 80 percent reported that the physician had used the computer while in the room, but only 24 percent were shown results in the EMR. Most patients were very satisfied or satisfied with their visit and did not find the computer intrusive (83 percent). Younger respondents, those shown results, and those who reported that the physician used the computer were more likely to perceive the computer as intrusive. Qualitative comments suggest different perceptions related to computer intrusiveness than to EMR use more generally. DISCUSSION: Patients were generally accepting of EMRs and therefore use of computers in the exam room. However, subgroups of patients may require greater study to better understand patient perceptions related to EMR use and intrusiveness. CONCLUSION: Results suggest the need for greater focus on how physicians use computers in the exam room in a manner that facilitates maintaining good rapport with patients.

What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Academic Medical Center?

Crew Resource Management (CRM) training has been used successfully within hospital units to improve quality and safety. This article presents a description of a health system-wide implementation of CRM focusing on the return on investment (ROI). The costs included training, programmatic fixed costs, time away from work, and leadership time. Cost savings were calculated based on the reduction in avoidable adverse events and cost estimates from the literature. Between July 2010 and July 2013, roughly 3000 health system employees across 12 areas were trained, costing $3.6 million. The total number of adverse events avoided was 735-a 25.7% reduction in observed relative to expected events. Savings ranged from a conservative estimate of $12.6 million to as much as $28.0 million. Therefore, the overall ROI for CRM training was in the range of $9.1 to $24.4 million. CRM presents a financially viable way to systematically organize for quality improvement.

Meaningful Engagement of ACOs With Communities: The New Population Health Management.

OBJECTIVES: Population health management (PHM) activities within health care organizations have traditionally focused on coordinating services for populations who present for care in physicians' offices. With the recent proliferation of Accountable Care Organizations (ACOs), however, the reach of PHM has expanded. We aimed to study ACOs' evolving definitions of their patient populations, and how these definitions might be linked to different types of PHM activities pursued by ACOs. METHODS: Over a 2-year period, we conducted in-depth case studies of 4 ACOs operating in the private sector, including 149 interviews with 89 informants. Although the main study focused on the ACO implementation process, our use of both inductive and deductive qualitative methods enabled us to study emergent topics such as we report here about PHM. RESULTS: Interviewees across sites described their ACO populations using terms indicating both panel management and community/neighborhood involvement in the context of PHM. Further, all 4 sites reported conducting PHM activities that extended beyond traditional provider-based PHM; these ranged from wellness registries to school-based clinics. Executives at all 4 ACOs also discussed providing, or planning to provide, health care services to all community members in local settings. CONCLUSIONS: Administrators and physicians in private sector ACOs were proponents of ACO-led programs delivered in community settings that provided health care to all members of the community, and reported their ACOs engaged in multisector collaborations designed to improve neighborhood health. These community engagement activities point to a distinction from 90s era managed and integrated care organizations and may contribute to the sustainability of the ACO model.

Patient Safety Errors: Leveraging Health Information Technology to Facilitate Patient Reporting.

Patient safety continues to be a national challenge not only for providers but for patients and families as well. In an attempt to standardize processes and systems, we have lost opportunities for improvement. For instance, current patient safety reporting systems tend to favor capturing details around events that are classified as highly clinically significant (i.e., sentinel-level and never events); yet little to no effort is spent on capturing information about less evident errors or near misses, nor simply about concerns that are more experiential in nature. As a result, patients' experiences and observations are relegated to the notion of satisfaction, real-time reporting remains illusive, and the ability to learn across incidents remains anecdotal rather than systematic. Herein we propose an alternative, real-time, innovative model that merges syndromic surveillance and patient engagement to embrace patient-initiated reporting of patient safety events and concerns. The result would be a patient safety system where patients are partners, in both the conduct of their care, and in the quality of the healthcare delivered.