Know Thy User: Designing Digital Tools for Rheumatology Patients.

Imagine you are an ambitious technology innovator keen on advancing health care in the digital era. You could have chosen another industry, but you select health care because you want to make a difference in people's lives.

Toward an asthma patient-reported outcome measure for use in digital remote monitoring.

OBJECTIVE: To develop and test a patient-reported outcome measure (PROM) for suitability in digital remote asthma symptom monitoring to identify uncontrolled asthma. METHODS: We modified a 5-item PROM that does not require a license, the asthma control measure (ACM), from a one-month to one-week lookback period, and evaluated it using the 5-item asthma control questionnaire (ACQ-5). We recruited subjects with asthma through MTurk, an online platform. RESULTS: In a sample of 498 subjects, the ACM identified uncontrolled asthma with sensitivity 0.99 and specificity 0.65. The two measures correlated with r = 0.81. CONCLUSION: The ACM modified to a weekly lookback period can differentiate patients with well-controlled asthma from those with uncontrolled asthma. This PROM does not require a license and can be used in digital remote monitoring interventions.

Getting Value From Electronic Health Records: Research Needed to Improve Practice.

Electronic health records (EHRs) are now widely adopted in the United States, but health systems have barely begun using them to deliver high-value care. More directed and rigorous research is needed to fulfill the promise of EHRs to not only store information but also support the delivery of better care. This article describes 4 potential benefits of EHR-based research: improving clinical decisions, supporting triage decisions, enabling collaboration among the care team (including patients), and increasing productivity via automation of tasks. Six recommendations are made for conducting and reporting research to catalyze value creation: develop interventions systematically by using user-centered design and a building-block approach; assess value in terms of cost, quality, outcomes, and work required of providers and patients; consider the time horizon for the intervention; test best practices for implementation in a range of real-world contexts; assess subtleties of behavior change tools used to improve high-value behaviors; and report the intervention in enough detail that it can be replicated, including context. Just as research played a critical role in developing early EHR prototypes and demonstrating their value to justify dissemination, research will continue to be essential in the next phase: expanding EHR-based interventions and maximizing their role in creating value.

Trends in the use of computerized physician order entry by health-system affiliated ambulatory clinics in the United States, 2014-2016.

BACKGROUND: Computerized provider order entry (CPOE) can help providers deliver better quality care. We aimed to understand recent trends in use of CPOE by health system-affiliated ambulatory clinics. METHODS: We analyzed longitudinal data (2014-2016) for 19,109 ambulatory clinics that participated in all 3 years of the Healthcare Information and Management Systems Society Analytics survey to assess use of CPOE and identify characteristics of clinics associated with CPOE use. We calculated descriptive statistics to examine overall trends in use, location of order entry (bedside vs. clinical station), and system-level use CPOE across all clinics. We used linear probability models to explore the association between clinic characteristics (practice size, practice type, and health system type) and two outcomes of interest: CPOE use at any point between 2014 and 2016, and CPOE use beginning in 2015 or 2016. RESULTS: Between 2014 and 2016, use of CPOE increased more than 9 percentage points from 58 to 67%. Larger clinics and those affiliated with multi-hospital health systems were more likely to have reported use of CPOE. We found no difference in CPOE use by primary care versus specialty care clinics. When used, most clinics reported using CPOE for most or all of their orders. Health systems that used CPOE usually did so for all system-affiliated clinics. CONCLUSIONS: Small practice size or not being part of a multi-hospital system are associated with lower use of CPOE between 2014 and 2016. Less than optimal use in these environments may be harming patient outcomes.

Measuring Care Continuity: A Comparison of Claims-based Methods.

BACKGROUND: Assessing care continuity is important in evaluating the impact of health care reform and changes to health care delivery. Multiple measures of care continuity have been developed for use with claims data. OBJECTIVE: This study examined whether alternative continuity measures provide distinct assessments of coordination within predefined episodes of care. RESEARCH DESIGN AND SUBJECTS: This was a retrospective cohort study using 2008-2009 claims files for a national 5% sample of beneficiaries with congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. MEASURES: Correlations among 4 measures of care continuity-the Bice-Boxerman Continuity of Care Index, Herfindahl Index, usual provider of care, and Sequential Continuity of Care Index-were derived at the provider- and practice-levels. RESULTS: Across the 3 conditions, results on 4 claims-based care coordination measures were highly correlated at the provider-level (Pearson correlation coefficient r=0.87-0.98) and practice-level (r=0.75-0.98). Correlation of the results was also high for the same measures between the provider- and practice-levels (r=0.65-0.92). CONCLUSIONS: Claims-based care continuity measures are all highly correlated with one another within episodes of care.

Usage and effect of health information exchange: a systematic review.

BACKGROUND: Health information exchange (HIE) is increasing in the United States, and it is incentivized by government policies. PURPOSE: To systematically review and evaluate evidence of the use and effect of HIE on clinical care. DATA SOURCES: Selected databases from 1 January 2003 to 31 May 2014. STUDY SELECTION: English-language hypothesis-testing or quantitative studies of several types of data exchange among unaffiliated organizations for use in clinical care that addressed health outcomes, efficiency, utilization, costs, satisfaction, HIE usage, sustainability, and attitudes or barriers. DATA EXTRACTION: Data extraction was done in duplicate. DATA SYNTHESIS: Low-quality evidence from 12 hypothesis-testing studies supports an effect of HIE use on reduced use or costs in the emergency department. Direct evidence that HIEs were used by providers was reported in 21 studies involving 13 distinct HIE organizations, 6 of which were located in New York, and generally showed usage in less than 10% of patient encounters. Findings from 17 studies of sustainability suggest that approximately one quarter of existing HIE organizations consider themselves financially stable. Findings from 38 studies about attitudes and barriers showed that providers, patients, and other stakeholders consider HIE to be valuable, but barriers include technical and workflow issues, costs, and privacy concerns. LIMITATION: Publication bias, possible selective reporting of outcomes, and a dearth of reporting on context and implementation processes. CONCLUSION: Health information exchange use probably reduces emergency department usage and costs in some cases. Effects on other outcomes are unknown. All stakeholders claim to value HIE, but many barriers to acceptance and sustainability exist. A small portion of operational HIEs have been evaluated, and more research is needed to identify and understand success factors. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs. (PROSPERO registration number: CRD42014007469).

Health information technology: an updated systematic review with a focus on meaningful use.

BACKGROUND: Incentives offered by the U.S. government have spurred marked increases in use of health information technology (IT). PURPOSE: To update previous reviews and examine recent evidence that relates health IT functionalities prescribed in meaningful use regulations to key aspects of health care. DATA SOURCES: English-language articles in PubMed from January 2010 to August 2013. STUDY SELECTION: 236 studies, including pre-post and time-series designs and clinical trials that related the use of health IT to quality, safety, or efficiency. DATA EXTRACTION: Two independent reviewers extracted data on functionality, study outcomes, and context. DATA SYNTHESIS: Fifty-seven percent of the 236 studies evaluated clinical decision support and computerized provider order entry, whereas other meaningful use functionalities were rarely evaluated. Fifty-six percent of studies reported uniformly positive results, and an additional 21% reported mixed-positive effects. Reporting of context and implementation details was poor, and 61% of studies did not report any contextual details beyond basic information. LIMITATION: Potential for publication bias, and evaluated health IT systems and outcomes were heterogeneous and incompletely described. CONCLUSION: Strong evidence supports the use of clinical decision support and computerized provider order entry. However, insufficient reporting of implementation and context of use makes it impossible to determine why some health IT implementations are successful and others are not. The most important improvement that can be made in health IT evaluations is increased reporting of the effects of implementation and context. PRIMARY FUNDING SOURCE: Office of the National Coordinator.

Clinical Visit Frequencies in Rheumatology: A Systematic Literature Review.

OBJECTIVE: Clinical visits are a fundamental aspect of rheumatic disease care, but recommendations for appropriate visit frequencies are largely absent from guidelines, scarcely studied, and inconsistently reported. The aim of this systematic review was to summarize the evidence pertaining to visit frequencies for major rheumatic diseases. METHODS: This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Title/abstract screening, full-text screening, and extraction were carried out by 2 independent authors. Annual visit frequencies were either extracted or calculated and stratified by disease type and country of study. Weighted mean annual visit frequencies were calculated. RESULTS: A total of 273 relevant manuscript records were screened, and 28 were included after applying selection criteria. The included studies were equally divided between US and non-US and were published between 1985 and 2021. Most (n = 16) focused on rheumatoid arthritis (RA), systemic lupus erythematosus (SLE; n = 5), and fibromyalgia (FM; n = 4). For RA, the average annual visit frequencies were 5.25 for US rheumatologists, 4.80 for US non-rheumatologists, 3.29 for non-US rheumatologists, and 2.74 for non-US non-rheumatologists. For SLE, annual visit frequencies for non-rheumatologists were much higher than for US rheumatologists (12.3 versus 3.24). For FM, annual visit frequencies were 1.80 for US rheumatologists and 0.40 for non-US rheumatologists. There was a decreasing trend of visit frequency to rheumatologists from 1982 to 2019. CONCLUSION: Evidence for rheumatology clinical visits was limited and heterogeneous on a global scale. However, general trends suggest more frequent visits in the US and less frequent visits in recent years.

Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality: A Randomized Clinical Trial.

Importance: Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations. Objective: To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits. Design, Setting, and Participants: Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023. Interventions: In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips. Main outcomes and measures: The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted. Results: There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians' advice even when inconsistent with educational materials. Conclusions and Relevance: In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships. Trial Registration: ClinicalTrials.gov Identifier: NCT04902664.

A Mobile Health Application Integrated in the Electronic Health Record for Rheumatoid Arthritis Patient-Reported Outcomes: A Controlled Interrupted Time-Series Analysis of Impact on Visit Efficiency.

OBJECTIVE: Patient-reported outcome (PRO) collection between visits for rheumatoid arthritis (RA) could improve visit efficiency, reducing in-person visits for patients with stable symptoms while facilitating access for those with symptoms. We examined whether a mobile health PRO application integrated in the electronic health record (EHR) could reduce visit volume for those with RA. METHODS: We developed an application for RA that prompted patients every other day to complete brief PRO questionnaires. Results of the application were integrated into the EHR. We tested the application in a controlled interrupted time-series analysis between 2020 and 2023. Rheumatologists received EHR-based messages based on PRO results recommending the patient receive a visit earlier or later than scheduled. The primary outcome was monthly visit volume during the year before versus the year after initiation. RESULTS: A total of 150 patients with RA consented and used the application. The median age was 62 years, 83% were female, 7% had fewer than 2 years of disease, and 50% were seropositive; 150 controls were well matched. Among those in the application cohort, the estimated monthly median visit volume in the year before use of the application was 31.2 (95% confidence interval [95% CI] 28.0-34.3); in controls, this was 30.4 (95% CI 27.3-33.6). In the year using the application, the estimated monthly visit volume was 36.8 (95% CI 33.4-40.3) compared to 38.7 (95% CI 35.2-42.3) in controls. The difference in the differences between the cohorts was not statistically significant (-2.7 visits, 95% CI -9.3 to 4.0). No differences were noted in flare rates or visit delays. CONCLUSION: In this initial trial of a PRO application intervention to improve visit efficiency, we found no association with reduced visit volume.

Why APIs? Anticipated value, barriers, and opportunities for standards-based application programming interfaces in healthcare: perspectives of US thought leaders.

Objective: Improving health data interoperability through application programming interfaces (APIs) is a focus of US policy initiatives and could have tremendous impact on many aspects of care delivery, such as innovation, operational efficiency, and patient-centered care. To better understand the landscape of API use cases, we interviewed US thought leaders involved in developing and implementing standard-based APIs. Materials and Methods: We conducted semi-structured virtual interviews with US subject matter experts (SMEs) on APIs. SMEs were asked to describe API use cases along with value and barriers for each use case. Written summaries were checked by the SME and analyzed by the study team to identify findings and themes. Results: We interviewed 12 SMEs representing diverse sectors of the US healthcare system, including academia, industry, public health agencies, electronic health record vendors, government, and standards organizations. Use cases for standards-based APIs fell into six categories: patient-facing, clinician-facing, population health and value-based care, public health, administrative, and social services. The value across use cases was viewed as unrealized to date, and barriers to the use of APIs varied by use case. Conclusions: SMEs identified a diverse set of API use cases where standard-based APIs had the potential to generate value. As policy efforts seek to increase API adoption, our work provides an early look at the landscape of API use cases, value propositions, and barriers. Additional effort is needed to better understand the barriers and how to overcome them to create value, such as through demonstration projects and rigorous evaluations for specific use cases.

Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient-Doctor Communication.

BACKGROUND: Low-value medical testing is a major component of health care overuse, both directly and through the potential for borderline and/or incidental results to trigger cascades (downstream services of uncertain value). The costs and harms from marginal test results and their cascades can add up. It is thus important to both prevent low-value tests at the outset and mitigate cascades when they arise. METHODS: Informed by a framework for understanding and reducing overuse of care, this study employed user-centered design methods (focus groups and 1:1 design meetings) with patients and primary care physicians (PCPs) to understand the problem and iteratively develop an intervention. RESULTS: Design meetings with 15 PCPs, 12 patients, and 3 patient focus groups revealed myriad drivers for medical test overuse and cascades. Patients commonly believed that all medical tests yield definitive results and lack downsides. PCPs cited expert recommendations, limited time during visits, fear of lawsuits, and desire to be responsive to patients as reasons for ordering potentially low-value medical tests. To address these issues, an intervention was designed using patient pre-visit educational materials, clinician reference materials on test interpretation and incidental findings, and clinician peer comparison on test overuse. CONCLUSION: Overuse of medical testing is driven by a range of factors related to PCPs, patients, and their interactions. Multipronged interventions may have the potential to address these drivers after they are rigorously tested.

Development and Testing of an Electronic Health Record-Integrated Patient-Reported Outcome Application and Intervention to Improve Efficiency of Rheumatoid Arthritis Care.

OBJECTIVE: Many patients with rheumatoid arthritis (RA) have difficulty finding clinicians to treat them because of workforce shortages. We developed an app to address this problem by improving care efficiency. The app collects patient-reported outcomes (PROs) and can be used to inform visit timing, potentially reducing the volume of low-value visits. We describe the development process, intervention design, and planned study for testing the app. METHODS: We employed user-centered design, interviewing patients and clinicians, to develop the app. To improve visit efficiency, symptom tracking logic alerts clinicians to PRO trends: worsening PROs generate alerts suggesting an earlier visit, and stable or improving PROs generate notifications that scheduled visits could be delayed. An interrupted time-series analysis with a nonrandomized control population will allow assessment of the impact of the app on visit frequency. RESULTS: Patient interviews identified several of the following needs for effective app and intervention design: the importance of a simple user interface facilitating rapid answering of PROs, the availability of condensed summary information with links to more in-depth answers to common questions regarding RA, and the need for clinicians to discuss the PRO data during visits with patients. Clinician interviews identified the following user needs: PRO data must be easy to view and use during the clinical workflow, and there should be reduced interval visits when PROs are trending worse. Some clinicians believed visits could be delayed for patients with stable PROs, whereas others raised concerns. CONCLUSION: PRO apps may improve care efficiency in rheumatology. Formal evaluation of an integrated PRO RA app is forthcoming.

Barriers to using clinical decision support in ambulatory care: Do clinics in health systems fare better?

OBJECTIVE: We quantify the use of clinical decision support (CDS) and the specific barriers reported by ambulatory clinics and examine whether CDS utilization and barriers differed based on clinics' affiliation with health systems, providing a benchmark for future empirical research and policies related to this topic. MATERIALS AND METHODS: Despite much discussion at the theoretic level, the existing literature provides little empirical understanding of barriers to using CDS in ambulatory care. We analyze data from 821 clinics in 117 medical groups, based on in Minnesota Community Measurement's annual Health Information Technology Survey (2014-2016). We examine clinics' use of 7 CDS tools, along with 7 barriers in 3 areas (resource, user acceptance, and technology). Employing linear probability models, we examine factors associated with CDS barriers. RESULTS: Clinics in health systems used more CDS tools than did clinics not in systems (24 percentage points higher in automated reminders), but they also reported more barriers related to resources and user acceptance (26 percentage points higher in barriers to implementation and 33 points higher in disruptive alarms). Barriers related to workflow redesign increased in clinics affiliated with health systems (33 points higher). Rural clinics were more likely to report barriers to training. CONCLUSIONS: CDS barriers related to resources and user acceptance remained substantial. Health systems, while being effective in promoting CDS tools, may need to provide further assistance to their affiliated ambulatory clinics to overcome barriers, especially the requirement to redesign workflow. Rural clinics may need more resources for training.

User-centered design of a scalable, electronic health record-integrated remote symptom monitoring intervention for patients with asthma and providers in primary care.

OBJECTIVE: To determine user and electronic health records (EHR) integration requirements for a scalable remote symptom monitoring intervention for asthma patients and their providers. METHODS: Guided by the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, we conducted a user-centered design process involving English- and Spanish-speaking patients and providers affiliated with an academic medical center. We conducted a secondary analysis of interview transcripts from our prior study, new design sessions with patients and primary care providers (PCPs), and a survey of PCPs. We determined EHR integration requirements as part of the asthma app design and development process. RESULTS: Analysis of 26 transcripts (21 patients, 5 providers) from the prior study, 21 new design sessions (15 patients, 6 providers), and survey responses from 55 PCPs (71% of 78) identified requirements. Patient-facing requirements included: 1- or 5-item symptom questionnaires each week, depending on asthma control; option to request a callback; ability to enter notes, triggers, and peak flows; and tips pushed via the app prior to a clinic visit. PCP-facing requirements included a clinician-facing dashboard accessible from the EHR and an EHR inbox message preceding the visit. PCP preferences diverged regarding graphical presentations of patient-reported outcomes (PROs). Nurse-facing requirements included callback requests sent as an EHR inbox message. Requirements were consistent for English- and Spanish-speaking patients. EHR integration required use of custom application programming interfaces (APIs). CONCLUSION: Using the NASSS framework to guide our user-centered design process, we identified patient and provider requirements for scaling an EHR-integrated remote symptom monitoring intervention in primary care. These requirements met the needs of patients and providers. Additional standards for PRO displays and EHR inbox APIs are needed to facilitate spread.

Assessment of Variation in Electronic Health Record Capabilities and Reported Clinical Quality Performance in Ambulatory Care Clinics, 2014-2017.

Importance: Electronic health records (EHRs) are widely promoted to improve the quality of health care, but information about the association of multifunctional EHRs with broad measures of quality in ambulatory settings is scarce. Objective: To assess the association between EHRs with different degrees of capabilities and publicly reported ambulatory quality measures in at least 3 clinical domains of care. Design, Setting, and Participants: This cross-sectional and longitudinal study was conducted using survey responses from 1141 ambulatory clinics in Minnesota, Washington, and Wisconsin affiliated with a health system that responded to the Healthcare Information and Management Systems Society Annual Survey and reported performance measures in 2014 to 2017. Statistical analysis was performed from July 10, 2019, through February 26, 2021. Main Outcomes and Measures: A composite measure of EHR capability that considered 50 EHR capabilities in 7 functional domains, grouped into the following ordered categories: no functional EHR, EHR underuser, EHR, neither underuser or superuser, EHR superuser; as well as a standardized composite of ambulatory clinical performance measures that included 3 to 25 individual measures (median, 13 individual measures). Results: In 2014, 381 of 746 clinics (51%) were EHR superusers; this proportion increased in each subsequent year (457 of 846 clinics [54%] in 2015, 510 of 881 clinics [58%] in 2016, and 566 of 932 clinics [61%] in 2017). In each cross-sectional analysis year, EHR superusers had better clinical quality performance than other clinics (adjusted difference in score: 0.39 [95% CI, 0.12-0.65] in 2014; 0.29 [95% CI, -0.01 to 0.59] in 2015; 0.26 [95% CI, -0.05 to 0.56] in 2016; and 0.20 [95% CI, -0.04 to 0.45] in 2017). This difference in scores translates into an approximately 9% difference in a clinic's rank order in clinical quality. In longitudinal analyses, clinics that progressed to EHR superuser status had only slightly better gains in clinical quality between 2014 and 2017 compared with the gains in clinical quality of clinics that were static in terms of their EHR status (0.10 [95% CI, -0.13 to 0.32]). In an exploratory analysis, different types of EHR capability progressions had different degrees of associated improvements in ambulatory clinical quality (eg, progression from no functional EHR to a status short of superuser, 0.06 [95% CI, -0.40 to 0.52]; progression from EHR underuser to EHR superuser, 0.18 [95% CI, -0.14 to 0.50]). Conclusions and Relevance: Between 2014 and 2017, ambulatory clinics in Minnesota, Washington, and Wisconsin with EHRs having greater capabilities had better composite measures of clinical quality than other clinics, but clinics that gained EHR capabilities during this time had smaller increases in clinical quality that were not statistically significant.

Lessons Learned from the MAVEN Project Pilot: Using Physician Volunteers to Increase Access to Care via Telehealth.

The Medical Alumni Volunteer Expert Network (MAVEN) Project was one of the first programs in the United States to create a corps of experienced volunteer physicians to provide consults to providers in rural and inner-city safety-net clinics through telehealth. In the fall of 2015, the MAVEN Project started offering telehealth visits, with the expectation of serving three safety-net clinics in Massachusetts and California for a six-month period. RAND Corporation researchers aimed to conduct a qualitative evaluation of the pilot, describing the program's strengths and limitations to inform quality-improvement efforts within the program itself, and to provide lessons learned for other telehealth initiatives under development in the United States. They obtained data from MAVEN Project administrators on telehealth visit volume and site characteristics. They also conducted 13 semistructured interviews with volunteers, on-site referring physicians, and administrators across the three pilot sites and, for comparison, three representatives of additional telehealth programs that link physician volunteers to underserved communities. They identified themes in the interview data and developed recommendations for addressing program challenges or limitations. They conclude that, although stakeholders involved in the pilot were pleased with many of its features, further formative development and experimentation will be needed to address identified barriers to implementation and to establish sustainable and scalable processes. Because the demand for such services on the part of community health centers, as well as the supply of physicians interested in volunteering, will continue to grow, this model, when fully developed, has the potential to increase access to care for underserved populations.