Marshfield Clinic: Health Information Technology Paves the Way for Population Health Management

Highlights Fund-defined attributes of an ideal care delivery system and best practices, including an internal electronic health record, primary care teams, physician quality metrics and mentors, and standardized care processes for chronic care management

HITECH Revisited

Assesses the 2009 Health Information Technology for Economic and Clinical Health Act, which offers incentives to adopt and meaningfully use electronic health records. Recommendations include revised criteria, incremental approaches, and targeted policies

Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial

BACKGROUND: Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. METHODS: In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. DISCUSSION: While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered 23 February 2016

Information and Communications Technology in Chronic Disease Care: Why is Adoption So Slow and Is Slower Better?

Unlike the widespread adoption of information and communications technology (ICT) in much of the economy, adoption of ICT in clinical care is limited. We examine how a number of not previously emphasized features of the health care and ICT markets interact and exacerbate each other to create barriers for adoption. We also examine how standards can address these barriers and the key issues to consider before investing in ICT. We conclude that the ICT market exhibits a number of unique features that may delay or completely prevent adoption, including low product differentiation, high switching costs, and lack of technical compatibility. These barriers are compounded by the many interlinked markets in health care, which substantially blunt the use of market forces to influence adoption. Patient heterogeneity also exacerbates the barriers by wide variation in needs and ability for using ICT, by high demands for interoperability, and by higher replacement costs. Technical standards are critical for ensuring optimal use of the technology. Careful consideration of the socially optimal time to invest is needed. The value of waiting in health care is likely to be so much greater than in other sectors because the costs of adopting the wrong type of ICT are so much higher.

The Evidence for the Economic Value of eHealth in the United States Today: A Systematic Review

The United States healthcare system continues to face increasing costs, with year-over-year projected cost increases that now exceed the rate of increase of the gross domestic product. The rapid expansion and integration of eHealth within the United States healthcare system is driven primarily by a perceived ability to increase access in a cost-efficient manner. However, there is little economic research that addresses the large diversity of eHealth products being integrated into this healthcare landscape. The goal of this study is to evaluate the published economic evidence for eHealth in the United States, analyse how well it supports the growth of the current eHealth environment, and suggest what evidence is needed. This systematic literature review, conducted through the PubMed and The Cochrane Library databases, found that few studies addressed today’s eHealth environment. The current landscape is broader and less tailored to the traditional telemedicine initiatives represented by existing studies. We suggest more rigour in the design and scope of economic studies and that current eHealth technologies be identified for analysis. These studies must be comprehensive from the healthcare system’s perspective and conducted for relevant initiatives and patient groups to allow for evidence-based discussions on the cost-effectiveness of eHealth

Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) in western Kenya: a study protocol of a cluster randomized trial

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease (CVD), yet treatment and control rates for hypertension are very low in low- and middle-income countries (LMICs). Lack of effective referral networks between different levels of the health system is one factor that threatens the ability to achieve adequate blood pressure control and prevent CVD-related morbidity. Health information technology and peer support are two strategies that have improved care coordination and clinical outcomes for other disease entities in other settings; however, their effectiveness and cost-effectiveness in strengthening referral networks to improve blood pressure control and reduce CVD risk in low-resource settings are unknown. METHODS/DESIGN: We will use the PRECEDE-PROCEED framework to conduct transdisciplinary implementation research, focused on strengthening referral networks for hypertension in western Kenya. We will conduct a baseline needs and contextual assessment using a mixed-methods approach, in order to inform a participatory, community-based design process to fully develop a contextually and culturally appropriate intervention model that combines health information technology and peer support. Subsequently, we will conduct a two-arm cluster randomized trial comparing 1) usual care for referrals vs 2) referral networks strengthened with our intervention. The primary outcome will be one-year change in systolic blood pressure. The key secondary clinical outcome will be CVD risk reduction, and the key secondary implementation outcomes will include referral process metrics such as referral appropriateness and completion rates. We will conduct a mediation analysis to evaluate the influence of changes in referral network characteristics on intervention outcomes, a moderation analysis to evaluate the influence of baseline referral network characteristics on the effectiveness of the intervention, as well as a process evaluation using the Saunders framework. Finally, we will analyze the incremental cost-effectiveness of the intervention relative to usual care, in terms of costs per unit decrease in systolic blood pressure, per percentage change in CVD risk score, and per disability-adjusted life year saved. DISCUSSION: This study will provide evidence for the implementation of innovative strategies for strengthening referral networks to improve hypertension control in LMICs. If effective, it has the potential to be a scalable model for health systems strengthening in other low-resource settings worldwide

A cost minimisation analysis in teledermatology: model-based approach

<p>Abstract</p> <p>Background</p> <p>Although store-and-forward teledermatology is increasingly becoming popular, evidence on its effects on efficiency and costs is lacking. The aim of this study, performed in addition to a clustered randomised trial, was to investigate to what extent and under which conditions store-and-forward teledermatology can reduce costs from a societal perspective.</p> <p>Methods</p> <p>A cost minimisation study design (a model based approach) was applied to compare teledermatology and conventional process costs per dermatology patient care episode. Regarding the societal perspective, total mean costs of investment, general practitioner, dermatologists, out-of-pocket expenses and employer costs were calculated. Uncertainty analysis was performed using Monte Carlo simulation with 31 distributions in the used cost model. Scenario analysis was performed using one-way and two-way sensitivity analyses with the following variables: the patient travel distance to physician and dermatologist, the duration of teleconsultation activities, and the proportion of preventable consultations.</p> <p>Results</p> <p>Total mean costs of teledermatology process were €387 (95%CI, 281 to 502.5), while the total mean costs of conventional process costs were €354.0 (95%CI, 228.0 to 484.0). The total mean difference between the processes was €32.5 (95%CI, -29.0 to 74.7). Savings by teledermatology can be achieved if the distance to a dermatologist is larger (> = 75 km) or when more consultations (> = 37%) can be prevented due to teledermatology.</p> <p>Conclusions</p> <p>Teledermatology, when applied to all dermatology referrals, has a probability of 0.11 of being cost saving to society.</p> <p>In order to achieve cost savings by teledermatology, teledermatology should be applied in only those cases with a reasonable probability that a live consultation can be prevented.</p> <p>Trail Registration</p> <p>This study is performed partially based on PERFECT D Trial (Current Controlled Trials No.ISRCTN57478950).</p

Cost-effectiveness of Skin Cancer Referral and Consultation Using Teledermoscopy in Australia

Importance: International literature has shown that teledermoscopy referral may be a viable method for skin cancer referral, however no economic investigations have occurred in Australia. Objective: To assess the cost-effectiveness of teledermoscopy as a referral mechanism for skin cancer diagnosis and management in Australia. Design: Cost-effectiveness analysis using a decision-analytic model. Setting: Primary care. Participants: Australian general population (modelled). Intervention: We compared the costs of teledermoscopy referral (electronic referral containing digital dermoscopic images) versus usual care (a written referral letter) for specialist dermatologist review of a suspected skin cancer. Main outcome measures: Cost and time in ‘days to clinical resolution’, where clinical resolution was defined as diagnosis by a dermatologist or excision by a general practitioner. Probabilistic sensitivity analysis was performed to examine the uncertainty of the main results. Results: Time to clinical resolution was 26 days earlier with teledermoscopy referral compared with usual care alone (95%Credible interval (CrI) 13 to 38). The estimated mean cost difference between teledermoscopy referral ($318.39) versus usual care ($263.75) was $54.64 (95$22.69 to $97.35) per person. The incremental cost per day saved to clinical resolution was$2.10 (95%CrI $0.87 to$5.29). Conclusion and Relevance: Using teledermoscopy for skin cancer referral and triage in Australia will cost $54.64 extra per case on average, but will result in clinical resolution 26 days sooner than usual care. Implementation recommendations depend on the preferences of the Australian health system decision makers for either lower cost or expedited clinical resolution. Further research around the clinical significance of expedited clinical resolution and its importance for patients could inform implementation recommendations for the Australian setting

Telecare for managing diabetes in Saudi Arabia

Saudi Arabia is struggling to provide quality healthcare services in light of the growing population, rapid spread of chronic diseases, and limited resources available. In addition to these obstacles, the Saudi society is a highly conservative one, and certain traditions may sometimes limit how healthcare services can be offered. This work examines the impact of a Telecare solution on the healthcare system at the National Guard Health Affairs (NGHA). It focuses on diabetes, and the challenges faced by both the healthcare officials at NGHA, and the patients. These challenges also include social factors that may pose at obstacle in delivering healthcare services. The ‘Telecare for Managing Diabetes – TeMaD’ system is designed and developed using the Soft Systems Methodology. It was then integrated into the hospital information systems at King Abdulaziz Medical City in the Central Region, and consisted of 52 participating patients, and four involved Diabetic Educators. HbA1c levels of all patients were recorded prior to commencement of the study. Patients were required to use TeMaD for a 3-month period, then, had their HbA1c levels recorded again after completion of the study. Overall observation of the results showed a reduction in the HbA1c levels of 83% of the patients. Participating patients expressed their acceptance of the system, indicating that TeMaD allowed them to overcome some obstacles such as lack of transportation. It also assisted the majority of participants to better manage their diabetes and ease communication with their diabetic educators. Most patients requested that the system be offered permanently at the clinic. Diabetic educators were in favour of integrating TeMaD into the current healthcare system at NGHA, and they were enthusiastic about its numerous benefits. Telecare solutions can be used to enhance the quality of healthcare services, meet current demands, and address obstacles faced by the healthcare system in Saudi Arabia, including social factors that are unique. They can be adopted by neighbouring Gulf States which share common obstacles in healthcare