A randomized trial of population-based clinical decision support to manage health and resource use for Medicaid beneficiaries.

To determine whether a clinical decision support system can favorably impact the delivery of emergency department and hospital services. Randomized clinical trial of three clinical decision support delivery modalities: email messages to care managers (email), printed reports to clinic administrators (report) and letters to patients (letter) conducted among 20,180 Medicaid beneficiaries in Durham County, North Carolina with follow-up through 9 months. Patients in the email group had fewer low-severity emergency department encounters vs. controls (8.1 vs. 10.6/100 enrollees, p < 0.001) with no increase in outpatient encounters or medical costs. Patients in the letter group had more outpatient encounters and greater outpatient and total medical costs. There were no treatment-related differences for patients in the reports group. Among patients <18 years, those in the email group had fewer low severity (7.6 vs. 10.6/100 enrollees, p < 0.001) and total emergency department encounters (18.3 vs. 23.5/100 enrollees, p < 0.001), and lower emergency department ($63 vs. $89, p = 0.002) and total medical costs ($1,736 vs. $2,207, p = 0.009). Patients who were ≥18 years in the letter group had greater outpatient medical costs. There were no intervention-related differences in patient-reported assessments of quality of life and medical care received. The effectiveness of clinical decision support messaging depended upon the delivery modality and patient age. Health IT interventions must be carefully evaluated to ensure that the resultant outcomes are aligned with expectations as interventions can have differing effects on clinical and economic outcomes.

Population-based clinical decision support: a clinical and economic evaluation.

Governments are investing in health information technologies (HIT) to improve care quality and reduce medical costs. However, evidence of these benefits is limited. We conducted a randomized trial of three clinical decision support (CDS) interventions in 20,180 patients: email to care managers (n=3329), reports to primary care administrators (n=3368), letters to patients (n=3401), and controls (10,082). At 7-month follow-up, the letters to patients group had greater use of outpatient services and higher outpatient and total medical costs; whereas, the other groups had no change in clinical events or medical costs. As our CDS interventions were associated with no change or an increase in medical costs, it appears that investments in HIT without consideration for organizational context may not be sufficient to achieve improvements in clinical and economic outcomes.

Proactive population health management in the context of a regional health information exchange using standards-based decision support.

The clinic-based healthcare model does not deliver high quality, cost-effective care to populations of patients. Despite public perception that aggressive investment in information technology will lead to improvements in the safety and quality of healthcare delivery, there is little evidence that health information technology can be used to promote population-based health management. This paper describes the use of a standards-based clinical decision support system to facilitate proactive population health management using data from a regional health information exchange (HIE) network. The initial release of this system was designed to detect ten sentinel health events related to hospitalization, emergency department (ED) utilization, and care coordination in a population of 36,000 individuals. In an analysis of 11,899 continuously enrolled patients from a single county over a six-month period, 2,285 unique patients experienced 7,226 sentinel health events. The most common events were ED utilization for low severity conditions (2,546), two or more missed appointments within a 60-day period (1,728), ED encounters for patients with asthma (1,220), and three or more ED encounters within 90 days (731). Logistic regression analysis identified patients aged 19-64 as the population most likely to have sentinel health events. In addition to presenting data demonstrating the feasibility of population health management in the context of an HIE, this paper also includes lessons learned from the development, implementation, and operational support of the population health management system.

Perceptions of Medicaid beneficiaries regarding the usefulness of accessing personal health information and services through a patient Internet portal.

Increasing emphasis is being placed on the importance of information technology to improve the safety and quality of healthcare. However, concern is growing that these potential benefits will not be equally distributed across the population because of a widening digital divide along racial and socioeconomic lines. In this pilot study, we surveyed 31 Medicaid beneficiaries to ascertain their interest in and projected use of a healthcare patient Internet portal. We found that most Medicaid beneficiaries (or their parents/guardians) were very interested in accessing personal health information about themselves (or their dependents) online. Additionally, they were interested in accessing healthcare services online. We also found that many Medicaid beneficiaries have Internet access, including a slight majority with access to high-speed Internet connections. Our study revealed significant concern about the privacy of online health information.

Perceptions about use of a patient Internet portal among Medicaid beneficiaries.

Patient Internet portals that allow patients to access their personal health information are an emerging form of enabling technology. The purported benefits from increasing use of information technology in healthcare, however, may not be universal because of a widening digital divide along racial and socioeconomic lines. In this pilot study, we surveyed 31 Medicaid beneficiaries to ascertain their interest in and projected use of a healthcare patient Internet portal. We found that most Medicaid beneficiaries were very interested in accessing personal health information about themselves or their dependents online. Moreover, ninety percent of respondents reported that they have access to the Internet, and sixty-eight percent of those with Internet access use the Internet once a week or more.