Perceptions of factors influencing use of an electronic record for case management of persons living with HIV.

Case managers (CMs) facilitate continuity of care for persons living with HIV (PLWH) by coordination of resources and referrals to social services and medical care. The complexity of the management of HIV drives the need for more coordination, which can be achieved through the use of health information technology (HIT). However, HIT has not been well studied in the context of HIV services. The primary aim of this qualitative study was to assess CMs' perceptions regarding factors that influence acceptance and use of an electronic continuity of care record (CCR) for PLWH. Focus group methodology was used to gather perceptions from 37 CMs. Major themes related to factors for CCR adoption and use included: predisposing (system functionality and confidentiality), enabling (user training and computer access), reinforcing (work efficiency, continuity of care, information quality, and communication). Electronic CCRs have the potential to improve coordination of services and information sharing for PLWH. Careful attention must be paid to factors that predispose, enable, and reinforce use of HIT such as CCRs so that potential benefits in terms of quality and efficiency can be realized.

The development and implementation of a user-friendly priority setting tool for HIV care and treatment services in New York City.

The Ryan White Human Immunodeficiency Virus (HIV) Program is the largest federal program designed to provide medical and social support services for HIV infected persons who are uninsured or underinsured. In 2008, the Ryan White budget was $2.2 billion, of which over $100 million went to the New York City (NYC) eligible metropolitan area (EMA), which receives the largest Ryan White allocation targeted to any EMA. The NYC Department of Health and Mental Hygiene (DOHMH) is the grantee for the EMA. To implement HIV care and treatment programs funded by this grant, the DOHMH works closely with the NYC Ryan White Planning Council, a local community planning body that assesses needs, plans for service delivery and sets priorities for funds. This article describes priority setting principles, practices, findings and lessons learned. It also outlines how the legislatively mandated community planning body has developed and implemented a user-friendly priority setting process and tool.

Feasibility of using audio computer-assisted self-interview (ACASI) screening in routine HIV care.

We evaluated the feasibility of implementing audio computer-assisted self-interviews (ACASI) as part of routine clinical care at two community hospital-based HIV clinics in New York City. Between June 2003 and August 2006, 215 patients completed 1001 ACASI sessions in English or Spanish prior to their scheduled clinical appointments. Topics covered included antiretroviral therapy adherence, depression symptoms, alcohol and drug use, and condom use. Patients and providers received feedback reports immediately after each session. Feasibility was evaluated by quantitative analysis of ACASI responses, medical chart reviews, a brief patient questionnaire administered at the conclusion of each computer session, patient focus groups, and semi-structured provider interviews. ACASI interviews frequently identified inadequate medication adherence and depression symptoms: at baseline, 31% of patients reported < or =95% adherence over the past three days and 52% had symptoms of depression (CES-D score > or =16). Substance abuse problems were identified less frequently. Patients were comfortable with the ACASI and appreciated it as an additional communication route with their providers; however, expectations about the level of communication achieved were sometimes higher than actual practice. Providers felt the summary feedback information was useful when received in a timely fashion and when they were familiar with the clinical indicators reported. Repeated ACASI sessions did not have a favorable impact on adherence, depression, or substance use outcomes. No improvements in HIV RNA suppression were observed in comparison to patients who did not participate in the study. We conclude that it is feasible to integrate an ACASI screening tool into routine HIV clinical care to identify patients with inadequate medication adherence and depression symptoms. Repeated screening was not associated with improved clinical outcomes. ACASI screening should be considered in HIV clinical care settings to assist providers in identifying patients with the greatest need for targeted psychosocial services including adherence support and depression care.

Exploring factors related to the adoption and acceptance of an internet-based electronic personal health management tool (EPHMT) in a low income, special needs population of people living with HIV and AIDS in New York City.

Access to personal health information assists efforts to improve health outcomes and creates a population of active and informed health consumers. Understanding this significance, Healthy People 2020 retained, as a Focus Area, the need for improved interactive Health Communication and HIT. Attainment of this goal includes increasing the use of Internet-based electronic personal health management tools (EPHMT). Health information management, essential for favorable health outcomes, can be problematic in low income, special needs populations with complex chronic illnesses such as HIV/AIDS. Furthermore, barriers to the adoption and acceptance of an EPHMT in such populations have not been well explored. The current study seeks to explore the usability of an EPHMT entitled MyHealthProfile and to identify perceived health information needs in a vulnerable population of people living with HIV and AIDS (PLWH) that have access to an EPHMT through their Medicaid Special Needs Plan.

Perceptions of predisposing, enabling, and reinforcing factors influencing the use of a continuity of care document in special needs PLWH.

The provision of personal health information through electronic personal health management tools (EPHMT) has the potential to improve health outcomes. However, little is known about factors that affect EPHMT use in special needs people living with HIV/AIDS (PLWH). The purpose of this study was to describe PLWH perceptions of predisposing, enabling, and reinforcing factors affecting use of one type of EPHMT, a continuity of care document (CCD). Data were collected through focus groups and qualitative interviews with PLWH (n=35), health care providers (N=19) and care site managers (N=5). All participant types identified predisposing barriers to CCD use including literacy, privacy, and technology access and enabling factors to promote CCD use including user support and password simplicity. People living with HIV/AIDS also identified reinforcing factors for recurring CCD use including emergent situations and reducing test redundancy. Results inform methods to promote use of the CCD and other EPHMT by special needs PLWH.

Event detection: a clinical notification service on a health information exchange platform.

Notifying ambulatory providers when their patients visit the hospital is a simple concept but potentially a powerful tool for improving care coordination. A health information exchange (HIE) can provide automatic notifications to its members by building services on top of their existing infrastructure. NYCLIX, Inc., a functioning HIE in New York City, has developed a system that detects hospital admissions, discharges and emergency department visits and notifies their providers. The system has been in use since November 2010. Out of 63,305 patients enrolled 6,913 (11%) had one or more events in the study period and on average there were 238 events per day. While event notifications have a clinical value, their use also involves non-clinical care coordination; new workflows should be designed to incorporate a broader care team in their use. This paper describes the user requirements for the notification system, system design, current status, lessons learned and future directions.

Barriers and Facilitators of Implementing Electronic Data Summaries in HIV/AIDS Care.

The purpose of this study was to describe case managers' perceptions of the barriers and facilitators to implementing two different electronic data summaries (EDS), a USB-based and Web-based Continuity of Care Document (CCD) for patients living with HIV/AIDS (PLWH) in New York City. The primary aim of this descriptive qualitative study was to understand case managers' perceptions of the two systems. Focus group methodology was used to gather perceptions from 48 participants. Major themes by factor included: barriers (technical difficulties, quality of data, and confidentiality breaches), and facilitators (training/ user support, work efficiency, and improved coordination of care). EDSs may be particularly useful in improving coordination of services and information sharing for HIV case managers. Careful attention must be paid to barriers and facilitators for use of these EDSs so that they can best meet the healthcare and social service needs of PLWH.

Employing the FITT framework to explore HIV case managers' perceptions of two electronic clinical data (ECD) summary systems.

PURPOSE: Case managers facilitate continuity of care for persons living with HIV (PLWH) by coordination of resources and referrals to social services and medical care. The complexity of HIV care and associated comorbidities drives the need for medical and psychosocial care coordination, which may be achieved through health information exchange (HIE) systems. However, the use of HIE has not been well studied in the context of HIV services. The purpose of this descriptive qualitative study is to explore factors influencing case managers' adoption of electronic clinical data (ECD) summaries as an HIE strategy in HIV care through application of the "fit between individuals, task and technology" (FITT) framework. METHODS: Focus group methodology was used to gather perceptions from 48 participants who provided direct case management services for PLWH in New York City. Questions addressed current quality and efficiency challenges to HIE utilization in the context of case management of PLWH as well as barriers and enablers to use of an ECD summary. Analysis of the data was guided by the FITT framework. RESULTS: Major themes by interaction type were: (1) task-technology fit - resources, time and workflow; (2) individual-task fit - training and technical support; and 3) individual-technology fit - ECD summary functionality, technical difficulties and the need of a computer for each end-user. CONCLUSIONS: Our findings provide evidence for the applicability of the FITT framework to explore case managers' perceptions of factors influencing the adoption of ECD summary systems for HIV care prior to actual implementation. Assessment of fit among individual, task, and technology and addressing the concerns identified prior to implementation is critical to successful adoption of health information technology as a strategy to improve quality and efficiency in health care.

Processes and outcomes of developing a continuity of care document for use as a personal health record by people living with HIV/AIDS in New York City.

PURPOSE: To describe the processes and outcomes of developing and implementing a Continuity of Care Document (CCD), My Health Profile, as a personal health record for persons living with HIV (PLWH) in an HIV/AIDS Special Needs Plan in New York City. METHODS: Multiple qualitative and quantitative data sources were used to describe the processes and outcomes of implementing My Health Profile including focus groups, Audio Computer Assisted Self Interview (ACASI) surveys, administrative databases, chart abstraction, usage logs, and project management records. Qualitative data were thematically analyzed. Quantitative data analytic methods included descriptive and multivariate statistics. Data were triangulated and synthesized using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework. RESULTS: Reach - SNP members are predominantly African American or Hispanic/Latino and about one-third are female. A larger proportion of African Americans and smaller proportions of Hispanics/Latinos and Whites were trained to use My Health Profile.Efficacy/Effectiveness - CCDs were produced for 8249 unique members and updated on a monthly basis, 509 members were trained to use My Health Profile. Total number of member logins for 112 active users was 1808 and the longest duration of use was 1008 days. There were no significant differences between users and non-users of My Health Profile in clinical outcomes, perceptions of the quality of medical care, or health service utilization. Adoption -My Health Profile was well-matched to organizational mission, values, and priorities related to coordination of care for a high-risk population of PLWH. Implementation - Pre-implementation focus group participants identified potential barriers to use of My Health Profile including functional and computer literacy, privacy and confidentiality concerns, potential reluctance to use technology, and cognitive challenges. Key strategies for addressing barriers included a dedicated bilingual coach for recruitment, training, and support; basic computer and My Health Profile training; transparent audit trail revealing clinician and case manager access of My Health Profile, time-limited passwords for sharing My Health Profile with others at the point of need, and emergency access mechanism. Maintenance -My Health Profile was integrated into routine operational activities and its sustainability is facilitated by its foundation on standards for Health Information Exchange (HIE). CONCLUSIONS: Although potential barriers exist to the use of personal health records (PHRs) such as My Health Profile, PLWH with complex medical needs, low socioeconomic status, and limited computer experience will use such tools when a sufficient level of user support is provided and privacy and confidentiality concerns are addressed.

HIV patients' willingness to share personal health information electronically.

OBJECTIVE: To assess the attitudes of persons living with HIV/AIDS (PLWH) towards having their personal health information (PHI) stored and shared electronically. METHODS: PLWH (n = 93) in New York City completed surveys using audio computer-assisted self-interview (ACASI) that assessed willingness to share their PHI with various people and entities via a secure electronic network. The survey also included questions on satisfaction with and trust of health care providers, current health, HIV-associated stigma, and frequency of internet access. Data were analyzed with descriptive and multivariate statistical methods. RESULTS: The majority (84%) of individuals were willing to share their PHI with clinicians involved in their care. Fewer individuals (39%) were as willing to share with non-clinical staff. Willingness to share PHI was positively associated with trust and respect of clinicians. CONCLUSION: PLWH accepted clinicians' need for access to accurate information. Patients' trust in their primary care providers highlights the importance of the clinician-patient relationship which can be used to engage patients support for health information exchange initiatives. PRACTICE IMPLICATIONS: As electronic storage and sharing of PHI is increasing, clinicians and PLWH should discuss patients' attitudes towards sharing PHI electronically.