Text Analysis of Trends in Health Equity and Disparities From the Internal Revenue Service Tax Documentation Submitted by US Nonprofit Hospitals Between 2010 and 2019: Exploratory Study.

BACKGROUND: Many US hospitals are classified as nonprofits and receive tax-exempt status partially in exchange for providing benefits to the community. Proof of compliance is collected with the Schedule H form submitted as part of the annual Internal Revenue Service Form 990 (F990H), including a free-response text section that is known for being ambiguous and difficult to audit. This research is among the first to use natural language processing approaches to evaluate this text section with a focus on health equity and disparities. OBJECTIVE: This study aims to determine the extent to which the free-response text in F990H reveals how nonprofit hospitals address health equity and disparities, including alignment with public priorities. METHODS: We used free-response text submitted by hospital reporting entities in Part V and VI of the Internal Revenue Service Form 990 Schedule H between 2010 and 2019. We identified 29 main themes connected to health equity and disparities, and 152 related key phrases. We tallied occurrences of these phrases through term frequency analysis, calculated the Moran I statistic to assess geographic variation in 2018, analyzed Google Trends use for the same terms during the same period, and used semantic search with Sentence-BERT in Python to understand contextual use. RESULTS: We found increased use from 2010 to 2019 across all the 29 phrase themes related to health equity and disparities. More than 90% of hospital reporting entities used terms in 2018 and 2019 related to affordability (2018: 2117/2131, 99.34%; 2019: 1620/1627, 99.57%), government organizations (2018: 2053/2131, 96.33%; 2019: 1577/1627, 96.93%), mental health (2018: 1937/2131, 90.9%; 2019: 1517/1627, 93.24%), and data collection (2018: 1947/2131, 91.37%; 2019: 1502/1627, 92.32%). The themes with the largest relative increase were LGBTQ (lesbian, gay, bisexual, transgender, and queer; 1676%; 2010: 12/2328, 0.51%; 2019: 149/1627, 9.16%) and social determinants of health (958%; 2010: 68/2328, 2.92%; 2019: 503/1627, 30.92%). Terms related to homelessness varied geographically from 2010 to 2018, and terms related to equity, health IT, immigration, LGBTQ, oral health, rural, social determinants of health, and substance use showed statistically significant (P<.05) geographic variation in 2018. The largest percentage point increase was for terms related to substance use (2010: 403/2328, 17.31%; 2019: 1149/1627, 70.62%). However, use in themes such as LGBTQ, disability, oral health, and race and ethnicity ranked lower than public interest in these topics, and some increased mentions of themes were to explicitly say that no action was taken. CONCLUSIONS: Hospital reporting entities demonstrate an increasing awareness of health equity and disparities in community benefit tax documentation, but these do not necessarily correspond with general population interests or additional action. We propose further investigation of alignment with community health needs assessments and make suggestions for improvements to F990H reporting requirements.

Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care.

BACKGROUND: The US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process. METHODS: The objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager's adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function. DISCUSSION: This research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05256394 , Registered 25 February 2022.

Barriers, Facilitators, and Potential Solutions to Advancing Interoperable Clinical Decision Support: Multi-Stakeholder Consensus Recommendations for the Opioid Use Case.

With the advent of interoperability standards such as FHIR, SMART, CDS Hooks, and CQL, interoperable clinical decision support (CDS) holds great promise for improving healthcare. In 2018, the Agency for Healthcare Research and Quality (AHRQ)-sponsored Patient-Centered CDS Learning Network (PCCDS LN) chartered a Technical Framework Working Group (TechFWG) to identify barriers, facilitators, and potential solutions for interoperable CDS, with a specific focus on addressing the opioid epidemic. Through an open, multi-stakeholder process that engaged 54 representatives from healthcare, industry, and academia, the TechFWG identified barriers in 6 categories: regulatory environment, data integration, scalability, business case, effective and useful CDS, and care planning and coordination. Facilitators and key recommendations were also identified for overcoming these barriers. The key insights were also extrapolated to CDS-facilitated care improvement outside of the specific opioid use case. If applied broadly, the recommendations should help advance the availability and impact of interoperable CDS delivered at scale.

A qualitative framework-based evaluation of radiology clinical decision support initiatives: eliciting key factors to physician adoption in implementation.

OBJECTIVES: To illustrate key contextual factors that may have effects on clinical decision support (CDS) adoption and, ultimately, success. MATERIALS AND METHODS: We conducted a qualitative evaluation of 2 similar radiology CDS innovations for near-term endpoints affecting adoption and present the findings using an evaluation framework. We identified key contextual factors between these 2 innovations and determined important adoption differences between them. RESULTS: Degree of electronic health record integration, approach to education and training, key drivers of adoption, and tailoring of the CDS to the clinical context were handled differently between the 2 innovations, contributing to variation in their relative degrees of adoption and use. Attention to these factors had impacts on both near and later-term measures of success (eg, patient outcomes). DISCUSSION: CDS adoption is a well-studied early-term measure of CDS success that directly impacts outcomes. Adoption requires attention throughout the design phases of an intervention especially to key factors directly affecting it, including how implementation across multiple sites and systems complicates adoption, which prior experience with CDS matters, and that practice guidelines invariably require tailoring to the clinical context. CONCLUSION: With better planning for the capture of early-term measures of successful CDS implementation, especially adoption, critical adjustments may be made to ensure that the CDS is effectively implemented to be successful.

The Imperative for Patient-Centered Clinical Decision Support.

This commentary introduces the Patient-Centered Clinical Decision Support (PCCDS) Learning Network, which is collaborating with AcademyHealth to publish "Better Decisions Together" as part of eGEMs. Patient-centered clinical decision support (CDS) is an important vehicle to address broad issues in the U.S. health care system regarding quality and safety while also achieving better outcomes and better patient and provider satisfaction. Defined as CDS that supports individual patients and their care givers and/or care teams in health-related decisions and actions, PCCDS is an important step forward in advancing endeavors to move patient-centered care forward. The PCCDS Learning Network has developed a framework, referred to as the Analytic Framework for Action (AFA), to organize thinking and activities around PCCDS. A wide array of activities the PCCDS Learning Network is engaging in to inform and connect stakeholders is discussed.

Evaluation of a Quality Improvement Resource for Public Health Practitioners.

OBJECTIVES: Quality improvement is a critical mechanism to manage public health agency performance and to strengthen accountability for public funds. The objective of this study was to evaluate a relatively new quality improvement resource, the Public Health Quality Improvement Exchange (PHQIX), a free online communication platform dedicated to making public health quality improvement information accessible to practitioners. METHODS: We conducted an internet-based survey of registered PHQIX users (n = 536 respondents) in 2013 and key informant interviews with PHQIX frequent users (n = 21) in 2014, in the United States. We assessed use of the PHQIX website, user engagement and satisfaction, communication and knowledge exchange, use of information, and impact on quality improvement capacity and accreditation readiness. RESULTS: Of 462 respondents, 369 (79.9%) browsed quality improvement initiatives, making it the most commonly used site feature, and respondents described PHQIX as a near-unique source for real-world quality improvement examples. Respondents were satisfied with the quality and breadth of topics and relevance to their settings (average satisfaction scores, 3.9-4.1 [where 5 was the most satisfied]). Of 407 respondents, 237 (58.2%) said that they had put into practice information learned on PHQIX, and 209 of 405 (51.6%) said that PHQIX had helped to improve quality improvement capacity. Fewer than half of respondents used the commenting function, the Community Forum, and the Ask an Expert feature. CONCLUSIONS: Findings suggest that PHQIX, particularly descriptions of the quality improvement initiatives, is a valued resource for public health practitioners. Users reported sharing information with colleagues and applying what they learned to their own work. These findings may relate to other efforts to disseminate quality improvement knowledge.

Using health information exchanges to calculate clinical quality measures: A study of barriers and facilitators.

BACKGROUND: A key motivation for the large national investment in electronic health record systems is to promote electronic reporting of quality measures that can be used as the basis for moving to value-based payment. Given the fragmented delivery system, robust quality reporting requires aggregating data across sites of care. Health information exchanges (HIEs) have emerged to facilitate exchange of clinical data across provider organizations and, therefore, should be well-positioned to support clinical quality measure reporting. METHODS: By interviewing representatives from 36 HIEs across the United States, we aimed to determine whether HIEs are capable of computing National Quality Forum measures for 6 cardiovascular disease preventive services. RESULTS: Eleven HIEs (30%) reported computing at least one CQM; six computed one or more of the measures, and no HIE computed a measure in each of the 6 areas. Barriers to computing CQMs included data quality, completeness, sharing, and transmission issues; organizational structure, maturity, and sustainability issues; and vendor issues. CONCLUSIONS: The ability to compute CQMs at the HIE level is still yet to be developed; currently, very few HIEs are able to do so for a variety of reasons. As HIE services expand and HIEs mature organizationally, the viability and utility of CQM reporting at the HIE level will increase. IMPLICATIONS: As the healthcare system migrates towards a value-based payment system these broad challenges will need to be addressed. LEVEL OF EVIDENCE: Cross-sectional semi-structured qualitative interviews.

Beacon communities' public health initiatives: a case study analysis.

INTRODUCTION: The Beacon Communities for Public Health (BCPH) project was launched in 2011 to gain a better understanding of the range of activities currently being conducted in population- and public health by the Beacon Communities. The project highlighted the successes and challenges of these efforts with the aim of sharing this information broadly among the public health community. BACKGROUND: The Beacon Community Program, designed to showcase technology-enabled, community-based initiatives to improve outcomes, focused on: building and strengthening health information technology (IT) infrastructure and exchange capabilities; translating investments in health IT to measureable improvements in cost, quality, and population health; and, developing innovative approaches to performance measurement, technology, and care delivery. METHODS: Four multimethod case studies were conducted based on a modified sociotechnical framework to learn more about public health initiative implementation and use in the Beacon Communities. Our methodological approach included using document review and semistructured key informant interviews. NACCHO Model Practice Program criteria were used to select the public health initiatives included in the case studies. FINDINGS: Despite differences among the case studies, common barriers and facilitators were found to be present in all areas of the sociotechnical framework application including structure, people, technology, tasks, overarching considerations, and sustainability. Overall, there were many more facilitators (range = 7-14) present for each Beacon compared to barriers (range = 4-6). DISCUSSION: Four influential promising practices were identified through the work: forging strong and sustainable partnerships; ensuring a good task-technology fit and a flexible and iterative design; fostering technology acceptance; and, providing education and demonstrating value. CONCLUSIONS: A common weakness was the lack of a framework or model for the Beacon Communities evaluation work. Sharing a framework or approach to evaluation at the beginning of implementation made the work more effective. Supporting evaluation to inform future implementations is important.