Using conceptual work products of health care to design health IT.

This paper introduces a new, model-based design method for interactive health information technology (IT) systems. This method extends workflow models with models of conceptual work products. When the health care work being modeled is substantially cognitive, tacit, and complex in nature, graphical workflow models can become too complex to be useful to designers. Conceptual models complement and simplify workflows by providing an explicit specification for the information product they must produce. We illustrate how conceptual work products can be modeled using standard software modeling language, which allows them to provide fundamental requirements for what the workflow must accomplish and the information that a new system should provide. Developers can use these specifications to envision how health IT could enable an effective cognitive strategy as a workflow with precise information requirements. We illustrate the new method with a study conducted in an outpatient multiple sclerosis (MS) clinic. This study shows specifically how the different phases of the method can be carried out, how the method allows for iteration across phases, and how the method generated a health IT design for case management of MS that is efficient and easy to use.

Predicting costs of care using a pharmacy-based measure risk adjustment in a veteran population.

BACKGROUND: Although most widely used risk adjustment systems use diagnosis data to classify patients, there is growing interest in risk adjustment based on computerized pharmacy data. The Veterans Health Administration (VHA) is an ideal environment in which to test the efficacy of a pharmacy-based approach. OBJECTIVE: To examine the ability of RxRisk-V to predict concurrent and prospective costs of care in VHA and compare the performance of RxRisk-V to a simple age/gender model, the original RxRisk, and two leading diagnosis-based risk adjustment approaches: Adjusted Clinical Groups and Diagnostic Cost Groups/Hierarchical Condition Categories. METHODS: The study population consisted of 161,202 users of VHA services in Washington, Oregon, Idaho, and Alaska during fiscal years (FY) 1996 to 1998. We examined both concurrent and predictive model fit for two sequential 12-month periods (FY 98 and FY 99) with the patient-year as the unit of analysis, using split-half validation. RESULTS: Our results show that the Diagnostic Cost Group /Hierarchical Condition Categories model performs best (R2 = 0.45) among concurrent cost models, followed by ADG (0.31), RxRisk-V (0.20), and age/sex model (0.01). However, prospective cost models other than age/sex showed comparable R2: Diagnostic Cost Group /Hierarchical Condition Categories R2 = 0.15, followed by ADG (0.12), RxRisk-V (0.12), and age/sex (0.01). CONCLUSIONS: RxRisk-V is a clinically relevant, open source risk adjustment system that is easily tailored to fit specific questions, populations, or needs. Although it does not perform better than diagnosis-based measures available on the market, it may provide a reasonable alternative to proprietary systems where accurate computerized pharmacy data are available.