Minnesota Electronic Health Record Consortium COVID-19 Project: Informing Pandemic Response Through Statewide Collaboration Using Observational Data.

OBJECTIVE: Robust disease and syndromic surveillance tools are underdeveloped in the United States, as evidenced by limitations and heterogeneity in sociodemographic data collection throughout the COVID-19 pandemic. To monitor the COVID-19 pandemic in Minnesota, we developed a federated data network in March 2020 using electronic health record (EHR) data from 8 multispecialty health systems. MATERIALS AND METHODS: In this serial cross-sectional study, we examined patients of all ages who received a COVID-19 polymerase chain reaction test, had symptoms of a viral illness, or received an influenza test from January 3, 2016, through November 7, 2020. We evaluated COVID-19 testing rates among patients with symptoms of viral illness and percentage positivity among all patients tested, in aggregate and by zip code. We stratified results by patient and area-level characteristics. RESULTS: Cumulative COVID-19 positivity rates were similar for people aged 12-64 years (range, 15.1%-17.6%) but lower for adults aged ≥65 years (range, 9.3%-10.7%). We found notable racial and ethnic disparities in positivity rates early in the pandemic, whereas COVID-19 positivity was similarly elevated across most racial and ethnic groups by the end of 2020. Positivity rates remained substantially higher among Hispanic patients compared with other racial and ethnic groups throughout the study period. We found similar trends across area-level income and rurality, with disparities early in the pandemic converging over time. PRACTICE IMPLICATIONS: We rapidly developed a distributed data network across Minnesota to monitor the COVID-19 pandemic. Our findings highlight the utility of using EHR data to monitor the current pandemic as well as future public health priorities. Building partnerships with public health agencies can help ensure data streams are flexible and tailored to meet the changing needs of decision makers.

SPUR: psychometric properties of a patient-reported outcome measure of medication adherence in type 2 diabetes.

INTRODUCTION: Poor medication adherence is associated with worsening patient health outcomes and increasing healthcare costs. A holistic tool to assess both medication adherence and drivers of adherence behaviour has yet to be developed. This study aimed to examine SPUR, a multifactorial patient-reported outcome measure of medication adherence in patients living with type 2 diabetes, with a view to develop a suitable model for psychometric analysis.Furthermore, the study aimed to explore the relationship between the SPUR model and socio-clinical factors of medication adherence. RESEARCH DESIGN AND METHODS: The study recruited 378 adult patients living with type 2 diabetes from a mix of community and secondary-care settings to participate in this non-interventional cross-sectional study. The original SPUR-45 tool was completed by participants with other patient-reported outcome measures for comparison, in addition to the collection of two objective adherence measures; HbA1c and the medication possession ratio (MPR). RESULTS: Factor and reliability analysis conducted on SPUR-45 produced a revised and more concise version (27-items) of the tool, SPUR-27, which was psychometrically assessed. SPUR-27 observed strong internal consistency with significant correlations to the other psychometric measures (Beliefs about Medication Questionnaire, Diabetes Treatment Satisfaction Questionnaire, Medicine Adherence Rating Scale) completed by participants. Higher SPUR-27 scores were associated with lower HbA1c values and a higher MPR, as well as other predicted socio-clinical factors such as higher income, increased age and lower body mass index. CONCLUSIONS: SPUR-27 demonstrated strong psychometric properties. Further work should look to examine the test-retest reliability of the model as well as examine transferability to other chronic conditions and broader population samples. Overall, the initial findings suggest that SPUR-27 is a reliable model for the multifactorial assessment of medication adherence among patients living with type 2 diabetes.

Trends in Pediatric Viral Symptoms, Influenza Testing, and SARS-CoV-2 Testing From a Statewide Electronic Health Record Consortium, January 2017 to July 2021.

OBJECTIVE: The heterogeneous implementation and uptake of nonpharmaceutical interventions (NPIs) during the coronavirus disease 2019 (COVID-19) pandemic amplified the need for locally responsive disease surveillance mechanisms. Using data from a newly developed statewide electronic health record (EHR) consortium in Minnesota, we sought to characterize trends in pediatric viral symptoms, influenza testing, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing. METHODS: We conducted a serial cross-sectional analysis of EHR data from 1/1/2017 to 7/30/2021 across 8 large health systems in Minnesota. We included patients ≤18 years of age with any SARS-CoV-2 test, influenza test, or documented diagnostic code which met our viral symptom definition. We plotted week-by-week trends in viral symptoms, SARS-CoV-2 and influenza testing, and test positivity, stratified between children (0-11 years) and adolescents (12-18 years). RESULTS: We identified 1,079,924 patients ≤18 years of age with viral symptoms or testing; 880,669 (81.5%) were children ≤11 years. Influenza testing and influenza test positivity remained well below historical averages from March 2020 through mid-May 2021. Peaks in viral symptoms during this time were concomitant with peaks in SARS-CoV-2 testing and test positivity, whereas influenza testing and test positivity remained stagnant. Influenza test positivity rates increased substantively among children from May through July 2021. CONCLUSIONS: Viral illness and influenza testing among pediatric patients were below historical averages throughout the COVID-19 pandemic. Ongoing increases in influenza test positivity may merit clinical and public health awareness and intervention. Future NPI policies can be better targeted with insights from collaborative EHR-based surveillance, which enhances real-time, locally sensitive measurement of disease outbreaks.

Professional roles and relationships during the COVID-19 pandemic: a qualitative study among US clinicians.

OBJECTIVE: The COVID-19 pandemic has transformed healthcare delivery in the USA, but there has been little empirical work describing the impact of these changes on clinicians. We conducted a study to address the following question: how has the pandemic impacted US clinicians' professional roles and relationships? DESIGN: Inductive thematic analysis of semi-structured interviews. SETTING: Clinical settings across the USA in April and May of 2020. PARTICIPANTS: Clinicians with leadership and/or clinical roles during the COVID-19 pandemic. MEASURES: Emergent themes related to professional roles and relationships. RESULTS: Sixty-one clinicians participated in semi-structured interviews. Study participants were practising in 15 states across the USA, and the majority were White physicians from large academic centres. Three overlapping and inter-related themes emerged from qualitative analysis of interview transcripts: (1) disruption: boundaries between work and home life became blurred and professional identity and usual clinical roles were upended; (2) constructive adaptation: some clinicians were able to find new meaning in their work and described a spirit of collaboration, shared goals, open communication and mutual respect among colleagues; and (3) discord and estrangement: other clinicians felt alienated from their clinical roles and experienced demoralising work environments marked by division, value conflicts and mistrust. CONCLUSIONS: Clinicians encountered marked disruption of their professional roles, identities and relationships during the pandemic to which they and their colleagues responded in a range of different ways. Some described a spirit of collaboration and camaraderie, while others felt alienated by their new roles and experienced work environments marked by division, value conflicts and mistrust. Our findings highlight the importance of effective teamwork and efforts to support clinician well-being during the COVID-19 pandemic.

Sustainable care coordination: a qualitative study of primary care provider, administrator, and insurer perspectives.

BACKGROUND: Care coordination has been a common tool for practices seeking to manage complex patients, yet there remains confusion about the most effective and sustainable model. Research exists on opinions of providers of care coordination but there is limited information on perspectives of those in the insurance industry about key elements. We sought to gather opinions from primary care providers and administrators in Minnesota who were involved in a CMS (Center for Medicare and Medicaid Services) transformational grant implementing COMPASS (Care Of Mental, Physical And Substance-use Syndromes), an evidence-based model of care coordination for depressed patients comorbid with diabetes and/or cardiovascular disease. We then sought to compare these views with those of private insurance representatives in Minnesota. METHODS: We used qualitative methods to conducted forty-two key informant interviews with primary care providers (n = 15); administrators (n = 15); and insurers (n = 12). We analyzed the recorded and transcribed data, once de-identified, using a frameworks analysis approach. RESULTS: We identified six primary themes: 1) a defined scope, rationale, and key partnerships for building comprehensive care coordination programs, 2) effective information exchange, 3) a trained and available workforce, 4) the need for a business model and a financially justifiable program, 5) a need for evaluation and ongoing improvement of care coordination, and 6) the importance of patient and family engagement. Overall consensus across stakeholder groups was high including a call for payment reform to support a valued service. Despite their role in paying for care, insurance representatives did not stress reduced utilization as more important than other outcomes. CONCLUSIONS: Primary care providers and administrators from different organizations and backgrounds, all with experience in COMPASS, in large part agreed with insurance representatives on the main elements of a sustainable model and the need for health reform to sustain this service.

Large-Scale Implementation of Collaborative Care Management for Depression and Diabetes and/or Cardiovascular Disease.

BACKGROUND: Collaborative care models have been shown to improve mental and physical health, but their effectiveness varies. Implementation science frameworks identify measures at the structural (eg, sociocultural context, public policies), organizational, provider, innovation, and patient levels that may facilitate or impede collaborative care effectiveness. OBJECTIVE: To describe commonalities and variation in multilevel measures associated with the implementation of Care of Mental, Physical, and Substance-Use Syndromes (COMPASS), a large-scale collaborative care intervention for depression, diabetes, and cardiovascular disease. DESIGN: Qualitative study using semistructured descriptive data obtained from annual site visit reports and supplemental site surveys. PARTICIPANTS: COMPASS care teams from 8 health care systems serving 3854 patients with active depression and poorly controlled diabetes and/or cardiovascular disease. INTERVENTION: COMPASS included weekly case reviews with a consulting physician and psychiatrist, a patient-tracking registry, and monitoring of hospital and emergency department use. MAIN MEASURES: Site visit reports were analyzed with Atlas.ti software to qualitatively describe implementation measures and their variation across sites. KEY RESULTS: Nine measures were identified that impacted implementation efforts across health systems: (1) challenges in health systems' organizational environments, (2) prior care coordination experience, (3) physician engagement, (4) care team trust and cohesion, (5) care manager training and experience, (6) patient enrollment length, attainment of clinical targets, and frequency/content of care manager contacts, (7) patient-tracking registries, (8) quality improvement and outcomes monitoring reports, and (9) patients' social needs. CONCLUSIONS: Understanding multilevel measures impacting COMPASS implementation could increase the success of future collaborative care implementation efforts.

Potentially Preventable Hospital and Emergency Department Events: Lessons from a Large Innovation Project.

INTRODUCTION: There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department (ED) visits. To facilitate strategy development, we documented these events among complex patients and the factors that contribute to them in a large care-improvement initiative. METHODS: Observational study with retrospective audits and selective interviews by the patients' care managers among 12 diverse medical groups in California, Minnesota, Pennsylvania, and Washington that participated in an initiative to implement collaborative care for patients with both depression and either uncontrolled diabetes, uncontrolled hypertension, or both. We reviewed information about 373 adult patients with the required conditions who belonged to these medical groups and had experienced 389 hospitalizations or ED visits during the 12-month study period from March 30, 2014, through March 29, 2015. The main outcome measures were potentially preventable hospitalizations or ED visit events. RESULTS: Of the studied events, 28% were considered to be potentially preventable (39% of ED visits and 14% of hospitalizations) and 4.6% of patients had 40% of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with potentially preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events. CONCLUSION: Among these complex patients, patient characteristics, disease control, and the presence of ambulatory care-sensitive conditions were not associated with likelihood of ED visits or hospital admissions, including those considered to be potentially preventable. The current focus on using ambulatory care-sensitive conditions as a proxy for potentially preventable events needs further evaluation.

The Challenges of Collecting and Using Patient Care Data From Diverse Care Systems: Lessons From COMPASS.

The ability to aggregate clinical data across multiple diverse organizations and to use it for performance measurement, quality improvement, evaluation, and research is rapidly becoming a national necessity, but there are few examples of how to do that. This article uses lessons from a national effort to implement the collaborative care management model for patients with both depression and diabetes or heart disease across 8 partner organizations, 18 medical groups, and more than 170 clinics in 8 states to identify the challenges and provide experience-based recommendations for those tasks. The challenges are divided into those needed for (1) collecting similar data, (2) aggregating those data across care systems, and (3) using the data to both improve and evaluate care. Start with agreement on goals, methods, transparency, and a data system integrated into the electronic medical record while promptly addressing all the legal, regulatory, and human subject requirements.

Clinician burnout and satisfaction with resources in caring for complex patients.

OBJECTIVE: To describe primary care clinicians' self-reported satisfaction, burnout and barriers for treating complex patients. METHODS: We conducted a survey of 1554 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states prior to the implementation of a collaborative model of care for patients with depression and diabetes and/or cardiovascular disease. RESULTS: Of the clinicians who responded to the survey (n=709; 46%), we found that a substantial minority (31%) were experiencing burnout that was associated with lower career satisfaction (P<.0001) and lower satisfaction with resources to treat complex patients (P<.0001). Less than 50% of clinicians rated their ability to treat complex patients as very good to excellent with 21% rating their ability as fair to poor. The majority of clinicians (72%) thought that a collaborative model of care would be very helpful for treating complex patients. CONCLUSIONS: Burnout remains a problem for primary care clinicians and is associated with low job satisfaction and low satisfaction with resources to treat complex patients. A collaborative care model for patients with mental and physical health problems may provide the resources needed to improve the quality of care for these patients.

Impact of A National Collaborative Care Initiative for Patients With Depression and Diabetes or Cardiovascular Disease.

(Reprinted with permission from General Hospital Psychiatry 44 (2017) 77-85).

Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease.

OBJECTIVE: The spread of evidence-based care is an important challenge in healthcare. We evaluated spread of an evidence-based large-scale multisite collaborative care model for patients with depression and diabetes and/or cardiovascular disease (COMPASS). METHODS: Primary care patients with depression and comorbid diabetes or cardiovascular disease were recruited. Collaborative care teams used care management tracking systems and systematic case reviews to track and intensify treatment for patients not improving. Targeted outcomes were depression remission and response (assessed with the Patient Health Questionnaire-9) and control of diabetes (assessed by HbA1c) and blood pressure. Patients and clinicians were surveyed about satisfaction with care. RESULTS: Eighteen care systems and 172 clinics enrolled 3609 patients across the US. Of those with uncontrolled disease at enrollment, 40% achieved depression remission or response, 23% glucose control and 58% blood pressure control during a mean follow-up of 11 months. There were large variations in outcomes across medical groups. Patients and clinicians were satisfied with COMPASS care. CONCLUSIONS: COMPASS was successfully spread across diverse care systems and demonstrated improved outcomes for complex patients with previously uncontrolled chronic disease. Future large-scale implementation projects should create robust processes to identify and reduce expected variation in implementation to consistently provide improved care.

The COMPASS initiative: description of a nationwide collaborative approach to the care of patients with depression and diabetes and/or cardiovascular disease.

OBJECTIVE: To describe a national effort to disseminate and implement an evidence-based collaborative care management model for patients with both depression and poorly controlled diabetes and/or cardiovascular disease across multiple, real-world diverse clinical practice sites. METHODS: Goals for the initiative were as follows: (1) to improve depression symptoms in 40% of patients, (2) to improve diabetes and hypertension control rates by 20%, (3) to increase provider satisfaction by 20%, (4) to improve patient satisfaction with their care by 20% and (5) to demonstrate cost savings. A Care Management Tracking System was used for collecting clinical care information to create performance measures for quality improvement while also assessing the overall accomplishment of these goals. RESULTS: The Care of Mental, Physical and Substance-use Syndromes (COMPASS) initiative spread an evidence-based collaborative care model among 18 medical groups and 172 clinics in eight states. We describe the initiative's evidence-base and methods for others to replicate our work. CONCLUSIONS: The COMPASS initiative demonstrated that a diverse set of health care systems and other organizations can work together to rapidly implement an evidence-based care model for complex, hard-to-reach patients. We present this model as an example of how the time gap between research and practice can be reduced on a large scale.

Translation of obesity practice guidelines: measurement and evaluation.

OBJECTIVE(S): A public health nurse (PHN) in the Midwestern United States (U.S.) led a collaborative system-level intervention to translate the Institute of Clinical Systems Improvement (ICSI) Adult Obesity Guideline into interprofessional practice. This study (1) evaluated the extent of guideline translation across organizations and (2) assessed the Omaha System as a method for translating system-level interventions and measuring outcomes. DESIGN AND SAMPLE: This retrospective, mixed methods study was conducted with a purposeful sample of one administrator (n = 10) and two to three clinicians (n = 29) from each organization (n = 10). MEASURES: Omaha System Problem Rating Scale for Outcomes Knowledge, Behavior, and Status (KBS). KBS ratings gathered from semi-structured interviews and Omaha System documentation were analyzed using standard descriptive and inferential statistics and triangulated findings with participant quotes. RESULTS: KBS ratings and participant quotes revealed intervention effectiveness in creating sustained system-level changes. Self-reported and observed KBS ratings demonstrated improvement across organizations. There was moderate to substantial agreement regarding benchmark attainment within organizations. On average, self-reported improvement exceeded observer improvement. CONCLUSIONS: System-level PHN practice facilitator interventions successfully translated clinical obesity guidelines into interprofessional use in health care organizations. The Omaha System Problem Rating Scale for Outcomes reliably measured system-level outcomes.

Translation of obesity practice guidelines: interprofessional perspectives regarding the impact of public health nurse system-level intervention.

OBJECTIVE: The purpose of the study was to investigate the perceptions of administrators and clinicians regarding a public health facilitated collaborative supporting the translation into practice of the Institute for Clinical Systems Improvement (ICSI) Adult Obesity Guideline. DESIGN AND SAMPLE: This qualitative study was conducted with 10 health care organizations participating in a voluntary, interprofessional obesity management collaborative. A purposive sample of 39 participants included two to three clinicians and an administrator from each organization. Interview analysis focused on how the intervention affected participants and their practices. RESULTS: Four themes described participant experiences of obesity guideline translation: (1) a shift from powerlessness to positive motivation, (2) heightened awareness coupled with improved capacity to respond, (3) personal ownership and use of creativity, and (4) a sense of the importance of increased interprofessional collaboration. CONCLUSIONS: The investigation of interprofessional perspectives illuminates the feelings and perceptions of clinician and administrator participants regarding obesity practice guideline translation. These themes suggest that positive motivation, improved capacity, personal creative ownership, and interprofessional collaboration may be conducive to successful evidence-based obesity guideline implementation. Further research is needed to evaluate these findings relative to translating the ICSI obesity guideline and other guidelines into practice in diverse clinical settings.

Feasibility of encoding the Institute for Clinical Systems Improvement Depression Guideline using the Omaha System.

Evidence-based clinical guidelines are being developed to bridge the gap between research and practice with the goals of improving health care quality and population health. However, disseminating, implementing, and ensuring ongoing use of clinical guidelines in practice settings is challenging. The purpose of this study was to demonstrate the feasibility of encoding evidence-based clinical guidelines using the Omaha System. Clinical documentation with Omaha System-encoded guidelines generates individualized, meaningful data suitable for program evaluation and health care quality research. The use of encoded guidelines within the electronic health record has potential to reinforce use of guidelines, and thus improve health care quality and population health. Research using Omaha System data generated by clinicians has potential to discover new knowledge related to guideline use and effectiveness.

How can continuing professional development better promote shared decision-making? Perspectives from an international collaboration.

BACKGROUND: Shared decision-making is not widely implemented in healthcare. We aimed to set a research agenda about promoting shared decision-making through continuing professional development. METHODS: Thirty-six participants met for two days. RESULTS: Participants suggested ways to improve an environmental scan that had inventoried 53 shared decision-making training programs from 14 countries. Their proposed research agenda included reaching an international consensus on shared decision-making competencies and creating a framework for accrediting continuing professional development initiatives in shared decision-making. CONCLUSIONS: Variability in shared decision-making training programs showcases the need for quality assurance frameworks.