Evaluating diverse electronic consultation programs with a common framework.

BACKGROUND: Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. METHODS: Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems' end-users. RESULTS: Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies. CONCLUSION: A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs.

A cohort study of a general surgery electronic consultation system: safety implications and impact on surgical yield.

BACKGROUND: Electronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case). METHODS: Retrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits. RESULTS: In 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits. CONCLUSION: Econsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.

Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange.

BACKGROUND: Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments. METHODS: All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments. An assessment was made of whether in-person visits were unnecessary by preconsultation exchange or whether the referrals remained unscheduled for other reasons. For the latter group, reasons why the referrals remained unscheduled were examined, and medical records were reviewed for actual patient harm when sufficient information was present in the chart or for potential harm when no further information about the referral complaint was available. RESULTS: Eighty-six (32%) of 266 not-scheduled referrals were resolved via preconsultation exchange. For another 96 (36%), patients were not ultimately considered to require appointments or were scheduled via other routes. Nine patients received unplanned care while awaiting scheduling decisions, 5 of whom had harm that was related to referral complaints, although scheduling of appointments may not have avoided this harm. Of 75 patients for whom further information was not available about the referral complaints, most were not seen back in primary care, and 55 (73%) had potential for major harm. CONCLUSION: Few adverse outcomes in electronic referrals not scheduled for in-person gastroenterology visits were found, and none were clearly due to communication lapses in the referral process. Contributors to the potential for harm in referrals that were unintentionally left unscheduled included discontinuity of care and lack of patient or provider follow-up.

Assessment of HBV preventive services in a medically underserved Asian and Pacific Islander population using provider and patient data.

BACKGROUND: Hepatitis B (HBV) represents a significant health disparity among medically underserved Asian and Hawaiian/Pacific Islander (API) populations. Studies evaluating adherence to HBV screening and vaccination guidelines in this population are limited. OBJECTIVE: The purpose of this study was to evaluate HBV screening and vaccination practices using both provider self-report and patient records. DESIGN: Medical records for 20,574 API adults were reviewed retrospectively and primary care providers were surveyed to evaluate rates and adherence to HBV screening and vaccination guidelines. PARTICIPANTS: The study included primary care providers and their adult API patients in the San Francisco safety-net healthcare system. MAIN MEASURES: Patient, practice, and provider factors, as well as HBV screening and vaccination practices, were assessed using provider survey constructs and patient laboratory and clinical data. Generalized linear mixed models and multivariate logistic regression analyses were used to identify factors associated with recommended HBV screening and vaccination. KEY RESULTS: The mean age of patients was 52 years, and 63.4 % of patients were female. Only 61.5 % underwent HBV testing, and 47.4 % of HBV-susceptible patients were vaccinated. Of 148 (44.8 %) responding providers, most were knowledgeable and had a favorable attitude towards screening, but 43.2 % were unfamiliar with HBV guidelines. HBV screening was positively associated with favorable provider attitude score (OR per unit 1.80, 95 % CI 1.18-2.74) and negatively associated with female patient sex (OR 0.82, 95 % CI 0.73-0.92), a higher number of clinic patients per week (OR per 20 patients 0.46, 95 % CI 0.28-0.76), and provider barrier score (OR per unit 0.45, 95 % CI 0.24-0.87). HBV vaccination was negatively associated with provider barrier score (OR per unit 0.48, 95 % CI 0.25-0.91). CONCLUSIONS: Rates of HBV screening and vaccination of API patients in this safety-net system are suboptimal, and provider factors play a significant role. Efforts to cultivate positive attitudes among providers and expand healthcare system resources to reduce provider barriers to HBV care are warranted.

Hepatitis B management in vulnerable populations: gaps in disease monitoring and opportunities for improved care.

BACKGROUND: Hepatitis B (HBV) is prevalent in certain US populations and regular HBV disease monitoring is critical to reducing associated morbidity and mortality. Adherence to established HBV monitoring guidelines among primary care providers is unknown. AIMS: The purpose of this study was to evaluate HBV disease monitoring patterns and factors associated with adherence to HBV management guidelines in the primary care setting. METHODS: Primary providers within the San Francisco safety net healthcare system were surveyed for HBV management practices, knowledge, attitudes, and barriers to HBV care. Medical records from 1,727 HBV-infected patients were also reviewed retrospectively. RESULTS: Of 148 (45 %) responding providers, 79 % reported ALT and 44 % reported HBV viral load testing every 6-12 months. Most providers were knowledgeable about HBV but 43 % were unfamiliar with HBV management guidelines. Patient characteristics included: mean age 51 years, 54 % male and 67 % Asian. Within the past year, 75 % had ALT, 24 % viral load, 21 % HBeAg tested, and 40 % of at-risk patients had abdominal imaging for HCC. Provider familiarity with guidelines (OR 1.02, 95 % CI 1.00-1.03), Asian patient race (OR 4.18, 95 % CI 2.40-7.27), and patient age were associated with recommended HBV monitoring. Provider HBV knowledge and attitudes were positively associated, while provider age and perceived barriers were negatively associated with HCC surveillance. CONCLUSIONS: Comprehensive HBV disease monitoring including HCC screening with imaging were suboptimal. While familiarity with AASLD guidelines and patient factors were associated with HBV monitoring, only provider and practice factors were associated with HCC surveillance. These findings highlight the importance of targeted provider education to improve HBV care.

Evaluation of language concordant, patient-centered drug label instructions.

BACKGROUND: Despite federal laws requiring language access in healthcare settings, most US pharmacies are unable to provide prescription (Rx) medication instructions to limited English proficient (LEP) patients in their native language. OBJECTIVE: To evaluate the efficacy of health literacy-informed, multilingual Rx instructions (the ConcordantRx instructions) to improve Rx understanding, regimen dosing and regimen consolidation in comparison to standard, language-concordant Rx instructions. DESIGN: Randomized, experimental evaluation. PARTICIPANTS: Two hundred and two LEP adults speaking five non-English languages (Chinese, Korean, Russian, Spanish, Vietnamese), recruited from nine clinics and community organizations in San Francisco and Chicago. INTERVENTION: Subjects were randomized to review Rx bottles with either ConcordantRx or standard instructions. MAIN MEASURES: Proper demonstration of common prescription label instructions for single and multi-drug medication regimens. Regimen consolidation was assessed by determining how many times per day subjects would take medicine for a multi-drug regimen. KEY RESULTS: Subjects receiving the ConcordantRx instructions demonstrated significantly greater Rx understanding, regimen dosing and regimen consolidation in comparison to those receiving standard instructions (incidence rate ratio [IRR]: 1.25, 95 % confidence interval [CI]: 1.06-1.48; P= 0.007 for Rx understanding, IRR: 1.19, 95 % CI: 1.03-1.39; P= 0.02 for regimen dosing and IRR: 0.76, 95 % CI: 0.64-0.90; P= 0.001 for regimen consolidation). In most cases, instruction type was the sole, independent predictor of outcomes in multivariate models controlling for relevant covariates. CONCLUSIONS: There is a need for standardized, multilingual Rx instructions that can be implemented in pharmacy practices to promote safe medication use among LEP patients. The ConcordantRx instructions represent an important step towards achieving this goal.

Evaluating electronic referrals for specialty care at a public hospital.

BACKGROUND: Poor communication between referring clinicians and specialists may lead to inefficient use of specialist services. San Francisco General Hospital implemented an electronic referral system (eReferral) that facilitates iterative pre-visit communication between referring and specialty clinicians to improve the referral process. OBJECTIVE: The purpose of the study was to determine the impact of eReferral (compared with paper-based referrals) on specialty referrals. DESIGN: The study was based on a visit-based questionnaire appended to new patient charts at randomly selected specialist clinic sessions before and after the implementation of eReferral. PARTICIPANTS: Specialty clinicians. MAIN MEASURES: The questionnaire focused on the self-reported difficulty in identifying referral question, referral appropriateness, need for and avoidability of follow-up visits. KEY RESULTS: We collected 505 questionnaires from speciality clinicians. It was difficult to identify the reason for referral in 19.8% of medical and 38.0% of surgical visits using paper-based methods vs. 11.0% and 9.5% of those using eReferral (p-value 0.03 and <0.001). Of those using eReferral, 6.4% and 9.8% of medical and surgical referrals using paper methods vs. 2.6% and 2.1% were deemed not completely appropriate (p-value 0.21 and 0.03). Follow-up was requested for 82.4% and 76.2% of medical and surgical patients with paper-based referrals vs. 90.1% and 58.1% of eReferrals (p-value 0.06 and 0.01). Follow-up was considered avoidable for 32.4% and 44.7% of medical and surgical follow-ups with paper-based methods vs. 27.5% and 13.5% with eReferral (0.41 and <0.001). CONCLUSION: Use of technology to promote standardized referral processes and iterative communication between referring clinicians and specialists has the potential to improve communication between primary care providers and specialists and to increase the effectiveness of specialty referrals.

Not perfect, but better: primary care providers' experiences with electronic referrals in a safety net health system.

BACKGROUND: Electronic referrals can improve access to subspecialty care in safety net settings. In January 2007, San Francisco General Hospital (SFGH) launched an electronic referral portal that incorporated subspecialist triage, iterative communication with referring providers, and existing electronic health record data to improve access to subspecialty care. OBJECTIVE: We surveyed primary care providers (PCPs) to assess the impact of electronic referrals on workflow and clinical care. DESIGN: We administered an 18-item, web-based questionnaire to all 368 PCPs who had the option of referring to SFGH. MEASUREMENTS: We asked participants to rate time spent submitting a referral, guidance of workup, wait times, and change in overall clinical care compared to prior referral methods using 5-point Likert scales. We used multivariate logistic regression to identify variables associated with perceived improvement in overall clinical care. RESULTS: Two hundred ninety-eight PCPs (81.0%) from 24 clinics participated. Over half (55.4%) worked at hospital-based clinics, 27.9% at county-funded community clinics, and 17.1% at non-county-funded community clinics. Most (71.9%) reported that electronic referrals had improved overall clinical care. Providers from non-county-funded clinics (AOR 0.40, 95% CI 0.14-0.79) and those who spent > or =6 min submitting an electronic referral (AOR 0.33, 95%CI 0.18-0.61) were significantly less likely than other participants to report that electronic referrals had improved clinical care. CONCLUSIONS: PCPs felt electronic referrals improved health-care access and quality; those who reported a negative impact on workflow were less likely to agree. While electronic referrals hold promise as a tool to improve clinical care, their impact on workflow should be considered.

Frequent Emergency Department Users: Focusing Solely On Medical Utilization Misses The Whole Person.

Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus <0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.

The legal framework for language access in healthcare settings: Title VI and beyond.

Over the past few decades, the number and diversity of limited English speakers in the USA has burgeoned. With this increased diversity has come increased pressure--including new legal requirements--on healthcare systems and clinicians to ensure equal treatment of limited English speakers. Healthcare providers are often unclear about their legal obligations to provide language services. In this article, we describe the federal mandates for language rights in health care, provide a broad overview of existing state laws and describe recent legal developments in addressing language barriers. We conclude with an analysis of key policy initiatives that would substantively improve health care for LEP patients.

Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature.

OBJECTIVE: To determine if professional medical interpreters have a positive impact on clinical care for limited English proficiency (LEP) patients. DATA SOURCES: A systematic literature search, limited to the English language, in PubMed and PsycINFO for publications between 1966 and September 2005, and a search of the Cochrane Library. STUDY DESIGN: Any peer-reviewed article which compared at least two language groups, and contained data about professional medical interpreters and addressed communication (errors and comprehension), utilization, clinical outcomes, or satisfaction were included. Of 3,698 references, 28 were found by multiple reviewers to meet inclusion criteria and, of these, 21 assessed professional interpreters separately from ad hoc interpreters. Data were abstracted from each article by two reviewers. Data were collected on the study design, size, comparison groups, analytic technique, interpreter training, and method of determining the participants' need for an interpreter. Each study was evaluated for the effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care. PRINCIPAL FINDINGS: In all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers. CONCLUSIONS: Published studies report positive benefits of professional interpreters on communication (errors and comprehension), utilization, clinical outcomes and satisfaction with care.

Specialty Care Access in the Safety Net-the Role of Public Hospitals and Health Systems.

Access to specialty care in the United States safety net, already strained, is fac-ing increasing pressure with an influx of patients following the passage of the Affordable Care Act (ACA). We surveyed 18 public hospitals and health systems across the country to describe the current state of specialty care delivery in safety-net systems. We elicited information regarding challenges, provider models, metrics of access and productivity, and strategies for improving access. Based on our findings, we propose a framework for assessing and improving specialty care access with a focus on population health planning.

Effect of awareness of language law on language access in the health care setting.

BACKGROUND: Federal law obligates health care providers receiving federal funding to ensure language access to limited English-proficient (LEP) individuals who cannot communicate with their provider. OBJECTIVE: To determine whether LEP individual awareness of this law improved language access through interpreter utilization. DESIGN, SETTING, AND PARTICIPANTS: In June 2003, a telephone survey of 1,200 Californians was conducted in 11 non-English languages. MEASUREMENTS: The survey included items on English proficiency, awareness of language law, health care utilization, and communication methods. Language access was defined as having a provider who speaks the individual's language (language-concordant) or utilizing an interpreter. RESULTS: There were 1,000 LEP participants, of whom 371 (37%) were aware of the language law. Four hundred and ninety-one (49%) of LEP participants had a language-concordant provider. Of the remaining 509 LEP participants without a language-concordant provider, 111 (22%) reported interpreter utilization in the health care setting. After controlling for age, gender, education, income, insurance status, years in the United States, health care utilization, and level of English proficiency, awareness of law was not associated with interpreter utilization (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.38, 1.17; P=.16), but was associated with having a language-concordant provider (OR 1.64; 95% CI 1.19, 2.26; P=.003). CONCLUSION: Awareness of language law is not sufficient to resolve language barriers for LEP individuals. Provider and organization level barriers to language access must be addressed.

Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering.

BACKGROUND: Displaying radiation exposure and cost information at electronic order entry may encourage clinicians to consider the value of diagnostic imaging. METHODS: An urban safety-net health system displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. We assessed whether there were differences in numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians' responses to the intervention. RESULTS: There were 23 171 outpatient CTs, 15 052 MRIs and 43 266 ultrasounds from 2011 to 2014. The ratio of CTs to ultrasounds decreased by 15% (95% CI 9% to 21%), from 58.2 to 49.6 CTs per 100 ultrasounds; the ratio of MRIs to ultrasounds declined by 13% (95% CI 7% to 19%), from 37.5 to 32.5 per 100. Of 300 invited, 190 (63%) completed the web-based survey in 17 clinics. 154 (81%) noticed the radiation exposure information and 158 (83.2%) noticed the cost information. Clinicians believed radiation exposure information was more influential than cost information: when unsure clinically about ordering a test (radiation=69.7%; cost=46.4%), when a patient wanted a test not clinically indicated (radiation=77.5%; cost=54.8%), when they had a choice between imaging modalities (radiation=77.9%; cost=66.6%), in patient care discussions (radiation=71.9%; cost=43.2%) and in trainee discussions (radiation=56.5%; cost=53.7%). Resident physicians and nurse practitioners were more likely to report that the cost information influenced them (p<0.05). CONCLUSIONS: Displaying radiation exposure and cost information at order entry may improve clinician awareness about diagnostic imaging safety risks and costs. More clinicians reported the radiation information influenced their clinical practice.

Changes in research on language barriers in health care since 2003: A cross-sectional review study.

BACKGROUND: Understanding how to mitigate language barriers is becoming increasingly important for health care providers around the world. Language barriers adversely affect patients in their access to health services; comprehension and adherence; quality of care; and patient and provider satisfaction. In 2003, the United States (US) government made a major change in national policy guidance that significantly affected limited English proficient patients' ability to access language services. OBJECTIVE: The objectives of this paper are to describe the state of the language barriers literature inside and outside the US since 2003 and to compare the research that was conducted before and after a national policy change occurred in the US. We hypothesize that language barrier research would increase inside and outside the US but that the increase in research would be larger inside the US in response to this national policy change. METHODS: We reviewed the research literature on language barriers in health care and conducted a cross sectional analysis by tabulating frequencies for geographic location, language group, methodology, research focus and specialty and compared the literature before and after 2003. RESULTS: Our sample included 136 studies prior to 2003 and 426 studies from 2003 to 2010. In the 2003-2010 time period there was a new interest in studying the providers' perspective instead of or in addition to the patients' perspective. The methods remained similar between periods with greater than 60% of studies being descriptive and 12% being interventions. CONCLUSIONS: There was an increase in research on language barriers inside and outside the US and we believe this was larger due to the change in the national policy. We suggest that researchers worldwide should move away from simply documenting the existence of language barriers and should begin to focus their research on documenting how language concordant care influences patient outcomes, providing evidence for interventions that mitigate language barriers, and evaluating the cost effectiveness of providing language concordant care to patients with language barriers. We think this is possible if funding agencies around the world begin to request proposals for these types of research studies. Together, we can begin document meaningful ways to provide high quality health care to patients with language barriers.