Doctor of Philosophy

DissertationHealth information technology (HIT) in conjunction with quality improvement (QI) methodologies can promote higher quality care at lower costs. Unfortunately, most inpatient hospital settings have been slow to adopt HIT and QI methodologies. Successful adoption requires close attention to workflow. Workflow is the sequence of tasks, processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal. Assessing the impact on workflow is an important component of determining whether a HIT implementation will be successful, but little research has been conducted on the impact of eMeasure (electronic performance measure) implementation on workflow. One solution to addressing implementation challenges such as the lack of attention to workflow is an implementation toolkit. An implementation toolkit is an assembly of instruments such as checklists, forms, and planning documents. We developed an initial eMeasure Implementation Toolkit for the heart failure (HF) eMeasure to allow QI and information technology (IT) professionals and their team to assess the impact of implementation on workflow. During the development phase of the toolkit, we undertook a literature review to determine the components of the toolkit. We conducted stakeholder interviews with HIT and QI key informants and subject matter experts (SMEs) at the US Department of Veteran Affairs (VA). Key informants provided a broad understanding about the context of workflow during eMeasure implementation. Based on snowball sampling, we also interviewed other SMEs based on the recommendations of the key informants who suggested tools and provided information essential to the toolkit development. The second phase involved evaluation of the toolkit for relevance and clarity, by experts in non-VA settings. The experts evaluated the sections of the toolkit that contained the tools, via a survey. The final toolkit provides a distinct set of resources and tools, which were iteratively developed during the research and available to users in a single source document. The research methodology provided a strong unified overarching implementation framework in the form of the Promoting Action on Research Implementation in Health Services (PARIHS) model in combination with a sociotechnical model of HIT that strengthened the overall design of the study

Clinical Utility of Advanced Microbiology Testing Tools

Advanced microbiology technologies are rapidly changing our ability to diagnose infections, improve patient care, and enhance clinical workflow. These tools are increasing the breadth, depth, and speed of diagnostic data generated per patient, and testing is being moved closer to the patient through rapid diagnostic technologies, including point-of-care (POC) technologies. While select stakeholders have an appreciation of the value/importance of improvements in the microbial diagnostic field, there remains a disconnect between clinicians and some payers and hospital administrators in terms of understanding the potential clinical utility of these novel technologies. Therefore, a key challenge for the clinical microbiology community is to clearly articulate the value proposition of these technologies to encourage payers to cover and hospitals to adopt advanced microbiology tests. Specific guidance on how to define and demonstrate clinical utility would be valuable. Addressing this challenge will require alignment on this topic, not just by microbiologists but also by primary care and emergency room (ER) physicians, infectious disease specialists, pharmacists, hospital administrators, and government entities with an interest in public health. In this article, we discuss how to best conduct clinical studies to demonstrate and communicate clinical utility to payers and to set reasonable expectations for what diagnostic manufacturers should be required to demonstrate to support reimbursement from commercial payers and utilization by hospital systems

Designing Clinical Data Presentation Using Cognitive Task Analysis Methods

Despite the many decades of research on effective use of clinical systems in medicine, the adoption of health information technology to improve patient care continues to be slow especially in ambulatory settings. This applies to dentistry as well, a primary care discipline with approximately 137,000 practicing dentists in the United States. One critical reason is the poor usability of clinical systems, which makes it difficult for providers to navigate through the system and obtain an integrated view of patient data during patient care. Cognitive science methods have shown significant promise to meaningfully inform and formulate the design, development and assessment of clinical information systems. Most of these methods were applied to evaluate the design of systems after they have been developed. Very few studies, on the other hand, have used cognitive engineering methods to inform the design process for a system itself. It is this gap in knowledge – how cognitive engineering methods can be optimally applied to inform the system design process – that this research seeks to address through this project proposal. This project examined the cognitive processes and information management strategies used by dentists during a typical patient exam and used the results to inform the design of an electronic dental record interface. The resulting 'proof of concept' was evaluated to determine the effectiveness and efficiency of such a cognitively engineered and application flow design. The results of this study contribute to designing clinical systems that provide clinicians with better cognitive support during patient care. Such a system will contribute to enhancing the quality and safety of patient care, and potentially to reducing healthcare costs

Assessing the Relationship Between Automated Technology Expenditure and Revenue Cycle Performance

Despite evidence that the automation of administrative processes may lead to both cost reductions and performance benefits, there was little to no empirical evidence that holistically examined the impact of technology within the healthcare revenue cycle. The purpose of the current quantitative study was to examine the relationship between automated technology expenditure and revenue cycle performance. Correlational analyses were used to determine the relationship between automated technology expenditure and labor, revenue, and denials, respectively, within the revenue cycle of a single, multi entity health system in California. Regression analysis was used to determine the relationship between variables over a 4-year timeframe. The results from correlational analyses revealed a weak, negative relationship between automated technology expenditure and labor that was not statistically significant; however, strong, positive, statistically significant relationships were found between automated technology expenditure and revenue as well as automated technology expenditure and denials. The impact of automation within healthcare administration should be addressed and subsequently adopted on a larger scale than what the nation has in place today. When new technology is introduced, employees tend to view the change with skepticism and have heightened anxiety around job security. As such, findings from the current study may support positive social change through informed decision making when investing in automated technology. Finally, results may aid support open dialogue around the impact of automated technology within the workforce and with respect to financial metrics, aid in the communication of shared goals at all levels, and subsequently support social change at the organizational level

Revenue Cycle Management

The healthcare industry continues to navigate through legislative changes requiring a change from the fee-for-service model to a value-based model. Healthcare is required to balance quality care of the patient and financial viability. The general problem to be addressed is the inefficient adoption of a revenue integrity program within the revenue cycle management process resulting in a revenue deficit for healthcare providers. The purpose of this qualitative case study was to add to the body of knowledge exploring the possible inefficient insurance denial management process within non-profit hospital-owned physician practices resulting in revenue deficits for the provider clinics. The study achieved this purpose by exploring barriers to the revenue cycle management process. The researcher conducted a qualitative case study with 14 participants. Based on the identified themes the researcher shared implications and strategies to improve general business practices. Additionally, this study shared recommendations for future research. To improve revenue cycle process healthcare organizations can consider improved communications, increase knowledge and skill set, focus on staff resources and retention efforts, review data analytics, and consider a revenue integrity adoption program

Organizational Climate and Physician Office Staff: A Grounded Theory Study of Patients’ Perspectives of Staff Stress and the Influence on Personal Health Behaviors

Healthcare in the US has been in an extended state of accelerated change since the passing of the Affordable Care Act in 2010. Sweeping policies designed to reduce cost per capita, improve the patient experience of care (including quality and satisfaction), and improve the health of populations are being implemented at the macro and micro levels of healthcare services. Chronic illness is a leading factor in the rising costs of healthcare. This issue is driving more patient care from the hospital to the outpatient setting, such as physician practices, to reduce costs. Additionally, this paradigm shift is transitioning the patient from one of consumer of services to a co-manager of their own health. Managing chronic illness is a team endeavor with multiple healthcare players and support staff in concert with the patient. The ensuing relationship is a key element of success to the goal of living well. This qualitative constructivist grounded theory study of 11 patients with chronic illness explains their perceptions of organizational climate in physician office practices and conceptualizes perspectives of developing the patient-staff relationship. The major thematic construct is a model which demonstrates how chronically ill patients’ perceive the significance of the patient-staff relationship as proxy to their physicians. This emerging model informs healthcare leaders and practitioners how organizational climate influences patients’ perceptions and their health behaviors, and the significance placed on their patient-staff relationships

Diffusion of Electronic Health Records in Rural Primary Care Clinics

By the end of 2015, Medicare-eligible physicians at primary care practices (PCP) who do not use an electronic health record (EHR) system will incur stiff penalties if they fail to meet the deadline for using EHRs. Yet, less than 30% of rural primary clinics have fully functional EHR systems. The purpose of this phenomenology study was to explore rural primary care physicians and physician assistants\u27 experiences regarding overcoming barriers to implementing EHRs. Complex adaptive systems formed the conceptual framework for this study. Data were collected through face-to-face interviews with a purposeful sample of 21 physicians and physician assistants across 2 rural PCPs in the southeastern region of Missouri. Participant perceptions were elicited regarding overcoming barriers to implementing EHRs under the American Recovery and Reinvestment Act, Health Information Technology for Economic and Clinical Health, and the Patient Protection and Affordable Care Act legislation. Interview questions were transcribed and processed through qualitative software to discern themes of how rural PCP physicians and physician assistants might overcome barriers to implementing electronic health records. Through the exploration of the narrative segments, 4 emergent themes were common among the participants: (a) limited finances to support EHRs, (b) health information exchange issues, (c) lack of business education, and (d) lack of transformation at rural medical practices. The implications for positive social change include the potential implementation of EHRs particularly in physician practices in rural communities, which could provide cost-efficient health care services for those communities and a more sustainable future at primary care practices