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

Successful Billing Strategies in the Hospital Industry

Failure to collect reimbursement because of changing regulations negatively impacts hospital profitability. A multiple case study approach was used to explore the successful strategies billing managers employed to collect reimbursement for all legitimate Medicare claims. The target population for this study included 5 hospital billing managers from 3 organizations in the Northern New Jersey region. The complexity theory was used as a framework for assessing changing Medicare regulations and how the managers adapted to them. The data collection process for this study involved gathering data from participant interviews, documentation from the organizations of the participants, and government documented regulations and manuals. The logical and sequential order of data analysis for this study embraced Yin\u27s 5-steps data analysis that includes compiling data, disassembling data, reassembling data, interpreting the data, and concluding. The successful strategies billing managers used that emerged as themes were remaining up to date with Medicare changing compliance regulations; enhancing communication with staff, multiple departments, and Medicare; and adopting a robust billing system and other systems that compliment billing. The implications of this study for social change include the potential to ensure access to patient care for benefiting families and communities through the sharing of successful strategies for Medicare claims

Health Information Exchange Use in Primary Care

Indiana University-Purdue University Indianapolis (IUPUI)The United States has invested over $40 billion in digitizing the health care system, yet the anticipated gains in improved care coordination, quality, and cost savings remain largely unrealized. This is due in part to limited interoperability and low rates of health information exchange (HIE) use, which can support care coordination and improve provider decision-making. Primary care providers are central to the US health care delivery system and frequently function as care coordinators, yet capability and HIE use gaps among these providers limit the potential of these digital systems to achieve their intended goals. I study HIE use in the context of primary care to examine 1) factors associated with provider HIE use, 2) the extent and nature of team-based HIE use, and 3) differences in HIE system use patterns across discrete groups of system users. First, I use a national sample of primary care providers to analyze market and practice factors related to HIE use for patient referrals. Overall, I find that only 43% of primary care provider referrals used HIE. Furthermore, I find substantial variation in HIE use rates across electronic health record (EHR) vendors. Second, I use HIE system log data to understand the breadth and depth of HIE use among teams, a care model underpinning primary care delivery reform efforts. I find that although use of HIE systems remains low, in primary care settings it overwhelmingly takes place in a manner consistent with team-based care workflows. Furthermore, team-based use does not differ in breadth from single provider HIE use, but illustrates less depth before and after visits. Third, I apply cluster analysis to 16 HIE use measures representing 7 use attributes, and identify 5 discrete user groups. I then compare two of these user groups and find user-level variation in volume and efficiency of use, both of which have implications for HIE system design and usability improvements. Ultimately, these findings help to inform how HIE use can be increased and improved in primary care, moving the US health care system closer to realizing the coordination, quality, and cost savings made possible by a digitized delivery system

Visiting Nurses\u27 Knowledge, Attitudes and Beliefs Regarding Telehealth to Promote Medication Compliance in the Elderly Population

Introduction: Medication noncompliance in the elderly home dwelling adult is a persistent problem resulting in decreased quality of life, hospital readmission within a 30-day period and increased morbidity. Visiting nurses are in a key position to assist the elderly population to employ medication compliance strategies that are tailor-made to fit their individual needs and abilities. The introduction of telehealth technology, while meant to aid elderly home dwelling individuals, may negatively impact the infusion of medication compliance strategies and thus increase medication noncompliance if visiting nurses are not effective in employing this technology. Aim: The aim of this study is to evaluate visiting nurses’ knowledge, attitudes, and beliefs of incorporating telehealth technology while using medication compliance strategies. Once factors are identified future work can seek to design programs to improve the use of telehealth technology in the home care environment by visiting nurses. Materials and Methods: The study employed a qualitative research approach using semi-structured interviews to hear the voices of the visiting nurses. The Diffusion of Innovation theory (DOI) and the Knowledge, Attitudes and Behavior (KAB) model were used as lenses through which to design interview guide questions that could assess visiting nurse’s knowledge, attitudes and beliefs regarding employing telehealth technology in the home care environment to assist the elderly dwelling patient with medication management strategies. One on one interviews were conducted via Teams platform for a max of 60 minutes. Participants were visiting nurses who were employed at home health agencies working with elderly dwelling adults, and who use telehealth technology to advance medication compliance strategies. Results: 10 interviews were conducted at which time data saturation occurred. The PI coded all data manually and intercoder agreement was obtained. Several themes emerged from the data. This study provided evidence that visiting nurses accept telehealth technology, are supportive of its continued use, and are willing to be educated on future advances in this technology to assist the elderly home care patient with medication compliance strategies. Visiting nurses enjoy utilizing telehealth technology, state that they find it convenient and easy to use. Telehealth technology enables nurses to fill the visit void related to limited staff and financial restraints. Conclusion: Given the aging population of patients in the US requiring home health services the health care system must provide opportunities for nurses to continue to explore and adopt new technologies to advance medication compliance in the elderly population. Specifically, Universities and home health agencies must ensure that nurses are prepared to utilize telehealth technologies in order to promote the use of telehealth in the home care environment with the elderly patient to reduce medication non-compliance issues

Electronic Health Record (EHR) Data Quality and Type 2 Diabetes Mellitus Care

Indiana University-Purdue University Indianapolis (IUPUI)Due to frequent utilization, high costs, high prevalence, and negative health outcomes, the care of patients managing type 2 diabetes mellitus (T2DM) remains an important focus for providers, payers, and policymakers. The challenges of care delivery, including care fragmentation, reliance on patient self-management behaviors, adherence to care management plans, and frequent medical visits are well-documented in the literature. T2DM management produces numerous clinical data points in the electronic health record (EHR) including laboratory test values and self-reported behaviors. Recency or absence of these data may limit providers’ ability to make effective treatment decisions for care management. Increasingly, the context in which these data are being generated is changing. Specifically, telehealth usage is increasing. Adoption and use of telehealth for outpatient care is part of a broader trend to provide care at-a-distance, which was further accelerated by the COVID-19 pandemic. Despite unknown implications for patients managing T2DM, providers are increasingly using telehealth tools to complement traditional disease management programs and have adapted documentation practices for virtual care settings. Evidence suggests the quality of data documented during telehealth visits differs from that which is documented during traditional in-person visits. EHR data of differential quality could have cascading negative effects on patient healthcare outcomes. The purpose of this dissertation is to examine whether and to what extent levels of EHR data quality are associated with healthcare outcomes and if EHR data quality is improved by using health information technologies. This dissertation includes three studies: 1) a cross-sectional analysis that quantifies the extent to which EHR data are timely, complete, and uniform among patients managing T2DM with and without a history of telehealth use; 2) a panel analysis to examine associations between primary care laboratory test ages (timeliness) and subsequent inpatient hospitalizations and emergency department admissions; and 3) a panel analysis to examine associations between patient portal use and EHR data timeliness

Federal Register

Daily publication of the U.S. Office of the Federal Register contains rules and regulations, proposed legislation and rule changes, and other notices, including "Presidential proclamations and Executive Orders, Federal agency documents having general applicability and legal effect, documents required to be published by act of Congress, and other Federal agency documents of public interest" (p. ii). Table of Contents starts on page iii