Market power and contract form: evidence from physician group practices

Physicians, Contracts, Market power, I11, L13, L14,

Factors Influencing Electronic Clinical Information Exchange in Small Medical Group Practices

Purpose: The purpose of this study was to identify the organizational factors that influence electronic health information exchange (HIE) by medical group practices in rural areas. Methods: A purposive sample of 8 small medical group practices in 3 experimental HIE regions were interviewed to determine the extent of clinical information exchange with other health care providers and to identify the factors influencing those patterns. Findings: HIE was found to be largely limited to exchanging immunization data through the state health department and exchanging clinical information within owned provider systems. None of the clinics directly exchange clinical information with non-owned clinics or hospitals. Conclusions: While regional HIE networks may be a laudable goal, progress is slow and significant technical, political, and financial obstacles remain. Limiting factors include data protection concerns, competition among providers, costs, and lack of compatible electronic health record (EHR) systems

Factors Influencing Electronic Clinical Information Exchange in Small Medical Group Practices

Purpose: The purpose of this study was to identify the organizational factors that influence electronic health information exchange (HIE) by medical group practices in rural areas. Methods: A purposive sample of 8 small medical group practices in 3 experimental HIE regions were interviewed to determine the extent of clinical information exchange with other health care providers and to identify the factors influencing those patterns. Findings: HIE was found to be largely limited to exchanging immunization data through the state health department and exchanging clinical information within owned provider systems. None of the clinics directly exchange clinical information with non-owned clinics or hospitals. Conclusions: While regional HIE networks may be a laudable goal, progress is slow and significant technical, political, and financial obstacles remain. Limiting factors include data protection concerns, competition among providers, costs, and lack of compatible electronic health record (EHR) systems

A Day in the Life of an Urban Emergency Department

Importance: The annual number of patient visits to emergency departments (EDs) continues to increase. Patients seen in the ED for nonemergent conditions potentially increase the cost of health care and lead to overcrowding in EDs. Objective: To gain insights into the factors leading to nonemergent use of hospital EDs. Design, Setting, and Participants: During a 24-hour period, we interviewed 67 patients in an urban ED. A total of 232 patients were seen in the ED and the hospital provided all claims data. Intervention: None. Main Outcomes and Measures: Elicit and record patient-stated reasons for seeking care in the ED. Results: Interview results showed that 90% of patients had a primary care clinic although 23% of those clinics were not affiliated with the hospital. Of the 67 interviewed patients, 72% reported they came to the ED because their condition was an emergency, 79% had spoken to someone prior to going to the ED, but only 30% consulted medical personnel. Conclusions and Relevance: Patients did not go to the ED because they lacked a primary care clinic. Most patients did not discuss their condition with medical personnel prior to going to the ED. Informing patients of clinic and hospital affiliations may improve continuity of care and access to electronic health records

The Transition of Primary Care Group Practices to Next Generation Models: Satisfaction of Staff, Clinicians, and Patients

Introduction: Restructuring primary care is essential to achieve the triple aim. This case study examines the human factors of extensive redesign on 2 midsized primary care clinics (clinics A and B) in the Midwest United States that are owned by a large health care system. The transition occurred when while the principles for patient-centered medical home were being rolled out nationally, and before the Affordable Care Act. Methods: After the transition, interviews and discussions were conducted with 5 stakeholder groups: health system leaders, clinic managers, clinicians, nurses, and reception staff. Using a culture assessment instrument, the responses of personnel at clinics A and B were compared with comparison clinics from another health system that had not undergone transition. Patient satisfaction scores are presented. Results: Clinics A and B were similar in size and staffing. Three human factor themes emerged from interviews: responses to change, professional and personal challenges due to role redefinition, and the importance of communication. The comparison clinics had an equal or higher mean culture scores compared with the transition clinics (A and B). Patient satisfaction in improved in Clinic A. Conclusions: The transition took more time than expected. Health system leaders underestimated the stress and the role adjustments for clinicians and nurses. Change leaders need to anticipate the challenge of role redefinition until health profession schools graduate trainees with more experience in new models of team-based care. Incorporating experience with team based, interprofessional care into training is essential to properly prepare future health professionals

Health Information Exchange Participation by Minnesota Primary Care Practices

Background The American Recovery and Reinvestment Act of 2009 will provide $36 billion to promote electronic health records and the formation of regional centers that foster community-wide electronic health information exchange (HIE) with the ultimate goal of a nationwide health information network. Minnesota\u27s e-Health Law, passed in 2007, mandates electronic health record and HIE participation by all clinics and hospitals. To achieve these goals, small primary care practices must participate. Factors that motivate or prevent them from doing so are examined. Methods From November 10, 2008, through February 20, 2009, we gathered data (through questionnaires and interviews) from 9 primary care practices in Minnesota with fewer than 20 physicians and with varying degrees of electronic health records and HIE involvement. Results No practice was fully involved in a regional HIE, and HIE was not part of most practices\u27 short-term strategic plans. External motivators for HIE included state and federal mandates, payer incentives, and increasing expectations for quality reporting. Internal motivators were anticipated cost savings, quality, patient safety, and efficiency. The most frequently cited barriers were lack of interoperability, cost, lack of buy-in for a shared HIE vision, security and privacy, and limited technical infrastructure and support. Conclusions Currently, small practices do not have the means or motivation to fully participate in regional HIEs, but many are exchanging health data in piecemeal arrangements with stakeholders with whom they are not directly competing for patients. To achieve more comprehensive HIE, regional health information organizations must provide leadership and financial incentives for community-wide meaningful use of interoperable electronic health records

Health Information Exchange in Small Primary Care Practices

Context: The future of health care includes electronic health records (EHR) and Health Information Exchange (HIE) with the goal of creating a National Health Information Network. Efforts to date have been based in hospitals or large ambulatory care settings, with far less written about HIE in smaller primary care clinics. Objective: The goal of this project was to assess the benefits and barriers that influence the participation of primary care practices in community-wide HIE. Design: Clinics’ background data regarding practice composition and use of EHR/HIE was collected with an on-line questionnaire. On-site structured interviews with at least three key informants were conducted at each clinic. Interviews were audio-taped, transcribed and analyzed for themes by the researchers. Setting: Nine ambulatory clinics with fewer than 20 primary care physicians in three geographic regions of Minnesota. Participants: Six clinics were rural and three urban, all but one were not-for-profit, three were federally qualified health centers. Six clinics were using a purchased EHR, one had created a relational database system, and two were in the process of acquiring an EHR. Two clinics participated in a Regional Health Information Organization (RHIO). Key informants included clinic administrators, medical directors, nurse managers, IT support staff, and physician IT champions. Results: Clinics using EHR/HIE described improvements in timeliness of communication, quality of care, and patient data tracking. Strategic planning that involved staged implementation of EHR/HIE and having clinician champions who were knowledgeable about IT were important factors for success. Cost was a barrier, with several of the clinics overcoming this with federal and state funding mechanisms. Other barriers include political, liability and patient privacy challenges. Conclusions: HIE is developing by incremental steps within small practices. It is important to consider the successes and challenges faced by such practices when setting over-arching policies about HIE

Health Information Exchange in Small Primary Care Practices

Context: The future of health care includes electronic health records (EHR) and Health Information Exchange (HIE) with the goal of creating a National Health Information Network. Efforts to date have been based in hospitals or large ambulatory care settings, with far less written about HIE in smaller primary care clinics. Objective: The goal of this project was to assess the benefits and barriers that influence the participation of primary care practices in community-wide HIE. Design: Clinics’ background data regarding practice composition and use of EHR/HIE was collected with an on-line questionnaire. On-site structured interviews with at least three key informants were conducted at each clinic. Interviews were audio-taped, transcribed and analyzed for themes by the researchers. Setting: Nine ambulatory clinics with fewer than 20 primary care physicians in three geographic regions of Minnesota. Participants: Six clinics were rural and three urban, all but one were not-for-profit, three were federally qualified health centers. Six clinics were using a purchased EHR, one had created a relational database system, and two were in the process of acquiring an EHR. Two clinics participated in a Regional Health Information Organization (RHIO). Key informants included clinic administrators, medical directors, nurse managers, IT support staff, and physician IT champions. Results: Clinics using EHR/HIE described improvements in timeliness of communication, quality of care, and patient data tracking. Strategic planning that involved staged implementation of EHR/HIE and having clinician champions who were knowledgeable about IT were important factors for success. Cost was a barrier, with several of the clinics overcoming this with federal and state funding mechanisms. Other barriers include political, liability and patient privacy challenges. Conclusions: HIE is developing by incremental steps within small practices. It is important to consider the successes and challenges faced by such practices when setting over-arching policies about HIE