Adoption of health information technology in community health centers: results of a national survey

To the extent that health information technology (IT) improves health care quality, differential adoption among providers that serve vulnerable populations may exacerbate health disparities. This first national survey of federally funded community health centers (CHCs) shows that although 26 percent reported some electronic health record (EHR) capacity and 13 percent have the minimal set of EHR functionalities, CHCs serving the most poor and uninsured patients were less likely to have a functional EHR. CHCs cited lack of capital as the top barrier to adoption. Ensuring comparable health IT capacity among providers that disproportionately serve disadvantaged patients will have increasing relevance for disparities; thus, monitoring adoption among such providers should be a priority.     

Adoption of health information technology for medication safety in U.S. Hospitals, 2006

Health information technology (IT) is regarded as an essential tool to improve patient safety, and a range of initiatives to address patient safety are under way. Using data from a comprehensive, national survey from HIMSS Analytics, we analyzed the extent of health IT adoption for medication safety in U.S. hospitals in 2006. Our findings indicate wide variation in health IT adoption by type of technology and geographic location. Hospital size, ownership, teaching status, system membership, payer mix, and accreditation status are associated with health IT adoption, although these relationships differ by type of technology. Hospitals in states with patient safety initiatives have greater adoption rates.     

There are important reasons for delaying implementation of the new ICD-10 coding system

Federal authorities have recently signaled that they would consider delaying some aspects of implementation of the newest version of the International Classification of Diseases, known as ICD-10-CM, a coding system used to define health care charges and diagnoses. Some industry groups have reacted with dismay, and many providers with relief. We are concerned that adopting this new classification system for reimbursement will be disruptive and costly and will offer no material improvement over the current system. Because the health care community is also working to integrate health information technology and federal meaningful-use specifications that require the adoption of other complex coding standardization systems (such as the system called SNOMED CT), we recommend that the Centers for Medicare and Medicaid Services consider delaying the adoption of ICD-10-CM. Policy makers should also begin planning now for ways to make the coming transition to ICD-11 as tolerable as possible for the health care and payment community.     

Re-engineering trust: the adoption and adaption of four models for external quality assurance of health care services in western European health care systems.

Accreditation, ISO, EFQLM and visitatie are, in essence, control mechanisms in health care systems. An analysis is provided of the way the four models have been adopted and adapted in European health care systems over the past decade. After a short discussion of the major reforms in the European health care systems in the direction of regulated markets, deregulation and decentralization, the features of the four models are highlighted and it is explained how each of them can help to fill the 'accountability gap' between health care providers on the one hand and patients, financiers and governments on the other. The quality system perspective of ISO, the quality management development perspective of EFQM, the health care organization perspective of accreditation and the professional perspective of visitatie can each be appropriate given the balance of power between parties in the health care system and the focus and scope of accountability. Although a general convergence between the four models can be observed, actual convergence will depend on their adoption in specific health system contexts. Potential pitfalls for further convergence are the differences in distribution of responsibilities for quality of care among the various European countries, the drift away from clinical decision making, bureaucratic tendencies and too much focus on efficiency and patient empowerment compared with attention to medical effectiveness.     

Beyond health outcomes: The benefits of health care

Most of the debate surrounding standards in medical care, issues of medical audit and what constitutes benefit from health care assumes that what is obtained from health care is health and only that. This is an assumption which most health economists at least implicitly appear to endorse. This paper questions that assumption. There are various outcomes beyond health and there are various processes involved in health care about which patients are not indifferent. This paper calls for a fuller investigation as to what it is that patients want from their health services and the adoption of a more pluralistic conception of health care benefits. It is further argued that the objectives of health care systems are those in which citizensqua citizens also have interests and which may be different from those of patients. It is yet less likely that citizens’ interests in health care will be restricted to health.     

TOPSIS法与RSR法相结合对省级妇幼保健机构综合绩效评价

目的:运用本研究前期对妇幼保健机构综合绩效评价指标体系的研究结果,对省级妇幼保健机构综合绩效进行评估,并对绩效评价指标体系进行验证。方法:采用TOPSIS法与RSR法相结合对省级妇幼保健机构进行综合绩效评价和分档。结果:对8所省级妇幼保健机构综合绩效进行评价分档,4所机构被评为上档,3所被评为中档,1所被评为下档。结论:评价结果与实际情况较为吻合,评价指标体系较为合理。与疾病预防控制机构合并的妇幼保健机构绩效状况明显落后,提示政府部门应当谨慎看待将妇幼保健机构合并到疾病预防控制机构的做法。     

Electronic health records: postadoption physician satisfaction and continued use

One goal of public-policy makers in general and health care managers in particular is the adoption and efficient utilization of electronic health record (EHR) systems throughout the health care industry. Consequently, this investigation focused on the effects of known antecedents of technology adoption on physician satisfaction with EHR technology and the continued use of such systems. The American Academy of Family Physicians provided support in the survey of 453 physicians regarding their satisfaction with their EHR use experience. A conceptual model merging technology adoption and computer user satisfaction models was tested using structural equation modeling. Results indicate that effort expectancy (ease of use) has the most substantive effect on physician satisfaction and the continued use of EHR systems. As such, health care managers should be especially sensitive to the user and computer interface of prospective EHR systems to avoid costly and disruptive system selection mistakes.     

The impact of health system membership on patient safety initiatives

BACKGROUND: Research in configurations and strategic groups has a rich history of revealing performance differences for hospitals and health care systems. PURPOSES: To assess the relationship between hospital-led health system configurations and the adoption of patient safety practices. In particular, the adoption of computerized physician order entry (CPOE) and intensive care unit physician staffing (IPS) is analyzed. METHODOLOGY: Analysis of variance was used to detect differences in patient safety measures based on health networks and systems' initial configuration clustering, and regression was used to assess group membership, controlling for hospital-level characteristics. The 2002 American Hospital Association survey and the first 3 years of the Leapfrog Group annual survey (2003-2005) are used for the analyses. RESULTS: There were significant differences in CPOE and IPS adoption and implementation levels based on health systems' configurations. Centralized physician/insurance health systems and moderately centralized health systems were the highest configurations in terms of CPOE adoption. Group membership was not positively related to the use of IPS relative to hospitals that are not classified using the taxonomy. In fact, there is a significant and negative adoption rate for both patient safety measures in facilities classified in the independent hospital systems category. CONCLUSION: There are systematic differences in the adoption of CPOE and IPS patient safety measures based on health system configurations. The configuration with an insurance company as part of its structure was more likely than other groups to be adopting CPOE. PRACTITIONER IMPLICATIONS: Given the durability of group membership, the Leapfrog Group and other patient safety initiatives could explicitly target configurations most likely to adopt and implement patient safety programs.     

Reconsidering patient-centred care: Authority,expertise and abandonment

Patient-centred care is commonly framed as a means to guard against the problem of medical paternalism, exemplified in historical attitudes of ‘doctor knows best’. In this sense, patient-centred care (PCC) is often regarded as a moral imperative. Reviews of its adoption in healthcare settings do not find any consistent improvement in health outcomes; however, these results are generally interpreted as pointing to the need for more or ‘better’ training for staff, rather than raising more fundamental questions. Patient autonomy is generally foregrounded in conceptualizations of PCC, to be actualized through the exercising of choice and control. But examining healthcare interaction in practice shows that when professionals attempt to enact these underpinnings, it often results in the sidelining of medical expertise that patients want or need. The outcome is that patients can feel abandoned to make decisions they feel unqualified to make, or even that care standards may not be met. This helps to explain why PCC has not produced the hoped-for improvement in health outcomes. It also suggests that, rather than focusing on scoring individual consultations, we need to consider how medical expertise can be rehabilitated for a 21st century public, and how patient expertise can be better incorporated into co-design and co-production of services and resources rather than being seen as something to be expressed through a binary notion of control.

Patient and Public Contribution

This viewpoint draws on research conducted by the author across a range of settings in health and social care, all of which incorporated patient and public involvement when it was conducted.     

Vulnerability in health care – reflections on encounters in every day practice

Vulnerability is a human condition and as such a constant human experience. However, patients and professional health care providers may be regarded as more vulnerable than people who do not suffer or witness suffering on a regular basis. Acquiring a deeper understanding of vulnerability would thus be of crucial importance for health care providers. This article takes as its point of departure Derek Sellman's and Havi Carel's discussion on vulnerability in this journal. Through different examples from the authors' research focusing on the interaction between health professionals and patients, existential, contextual, and relational dimensions of vulnerability are illuminated and discussed. Two main strategies in the professionals' interactions with patients are described. The strategy that aims at understanding the patients or families from the professional's own personal perspective oftentimes ends in excess attention to the professional's own reactions, thereby impairing the ability to help. The other strategy attempts to understand the patients or families from the patients' or families' own perspective. This latter strategy seems to make vulnerability bearable or even transform it into strength. Being sensitive to the vulnerability of the other may be a key to acting ethically.     

Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project

Many commentators view the conversion of small, independent primary care practices into patient-centered medical homes as a vital step in creating a better-performing health care system. The country's first national medical home demonstration, which ran from June 1, 2006, to May 31, 2008, and involved thirty-six practices, showed that this transformation can be lengthy and complex. Among other features, the transformation process requires an internal capability for organizational learning and development; changes in the way primary care clinicians think about themselves and their relationships with patients as well as other clinicians on the care team; and awareness on the part of primary care clinicians that they will need to make long-term commitments to change that may require three to five years of external assistance. Additionally, transforming primary care requires synchronizing practice redesign with development of the health care "neighborhood," which is made up of a broad range of health and health care resources available to patients. It also requires payment reform that supports practice development and a policy environment that sets reasonable expectations and time frames for the adoption of appropriate innovations.     

Promoting health information technology: is there a case for more-aggressive government action?

Health information technology (HIT) could save $81-$162 billion or more annually while greatly reducing morbidity and mortality. However, gaining these benefits requires broad adoption, effective implementation, and associated changes in health care processes and structures. The policy options that could speed the adoption of HIT and the realization of these benefits include incentives to promote standard-based electronic medical record (EMR) system adoption; subsidies to develop information-exchange networks; and programs to measure, report, and reward performance. Investments in these and other identified policy options should pay for themselves while also laying the foundation for needed transformation of the U.S. health care system.     

Competencies necessary to conduct patient and self-care education in the medical setting

The education of patients has recently taken on increasing importance in the medical community due to the following factors: The escalation in the costs associated with health care The competition for patients The realization that it is wiser to prevent illness and disease than to treat them once they occur The recognition that patients need to access the health care system less frequently if they know how to provide self-care This article presents the rationale for patient and self-care education. It also describes the settings in which patient and self-care education occur, with particular emphasis on private practice medical care. Specific guidelines for the selection of patient educators are also recommended. Finally, implications of the adoption of these recommendations are explored.     

Pharmakoökonomie und Public Health

The main purpose of Public health is improvement of the health state of the population. Thereby necessary coasts have to be considered. Public Health research is directly practice-related because of the development and implementation of health policy strategies. Important aims of the public health research are the realization of interventions in practice and their reevaluation. Health economy is an essential point of Public health. The public health research aims at analyzing the medical care and control systems. Further aims of the health economy are the individual processes of decisions of participating persons (e.g. physicians, patients)are object of research. Pharmacoeconomic aspects belong to an optimal therapy, that means the quality assurance and improvement with regard to circumstances. Quality assurance is not possible without the consideration of the state of knowledge. Only on the basis of actual data from the medical care system specific interventions on the political and individual level may be established. Subsequently these programs can be evaluated according to quality and cost outcomes. Drug information services and pharmacotherapy circles (Peer review groups)can contribute to an optimization in medical treatment. As a result these interventions are of consequence for health economy and medical care.     

The determinants of medical technology adoption in different decisional systems: A systematic literature review

Studies of determinants of adoption of new medical technology have failed to coalesce into coherent knowledge. A flaw obscuring strong patterns may be a common habit of treating a wide range of health care innovations as a generic technology. We postulate three decisional systems that apply to different medical technologies with distinctive expertise, interest, and authority: medical-individualistic, fiscal-managerial, and strategic-institutional decisional systems. This review aims to examine the determinants of the adoption of medical technologies based on the corresponding decision-making system. We included quantitative and qualitative studies that analyzed factors facilitating or inhibiting the adoption of medical technologies. In total, 65 studies published between 1974 and 2014 met our inclusion criteria. These studies contained 688 occurrences of variables that were used to examine the adoption decisions, and we subsequently condensed these variables to 62 determinants in four main categories: organizational, individual, environmental, and innovation-related. The determinants and their empirical association with adoption were grouped and analyzed by the three decision-making systems. Although we did not identify substantial differences across the decision-making systems in terms of the direction of the determinants’ influence on adoption, a clear pattern emerged in terms of the categories of determinants that were targeted in different decision-making systems.     

Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patient-centered medical home

In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.     

The influence of payer mix on electronic health record adoption by physicians

BACKGROUND: Numerous studies have examined the relationship between physician practice characteristics and electronic health record (EHR) adoption. Little is known about how payer mix influences physicians' decisions to implement EHR systems. PURPOSE: This study examines how different proportions of Medicare, Medicaid, and privately insured patients in physicians' practices influence EHR adoption. METHODOLOGY: Data from a large-scale survey of physician's use of information technologies in Florida were analyzed. Physicians were categorized based on their responses to questions regarding the proportion of patients in their practice that use Medicare, Medicaid, or private insurance products. The binary dependent variable of interest was EHR adoption among physicians. Adjusted odds ratios (ORs) were computed using logistic regression modeling techniques. The model examined the effect of changes in each payer type on EHR adoption, controlling for various practice characteristics. FINDINGS: Physicians with the highest percentage of Medicaid patients in their practices were significantly less likely to indicate using an EHR system when compared with those in the low-volume Medicaid group (OR = 0.690; 95% confidence interval [CI] = 0.50-0.95). No differences in EHR adoption were detected among physicians in the low, median, and high Medicare volume classifications. Among the private payer classifications, physicians whose practices were in the median group indicated significantly greater EHR use than those with relatively low levels of privately insured patients (OR = 1.62; 95% CI = 1.16-2.27). Those in the high-volume private payer group were also more likely than the low-volume group to have an EHR system, but this trend did not reach statistical significance (OR = 1.44; 95% CI = 0.96-2.16). PRACTICE IMPLICATIONS: Governmental insurance programs are either not influencing or negatively influencing EHR adoption among physicians in Florida. Given the quality and cost benefits associated with EHR use (particularly for health care payers), policymakers should consider strategies to incentivize or reward EHR adoption among doctors who care for Medicare and Medicaid patients.     

Achieving U.S. Health information technology adoption: the need for a third hand

The U.S. health care information technology (HIT) market is broken; broad-scale adoption of HIT is not occurring despite considerable evidence of its impact on the quality of care and patient safety. Although adoption of HIT will not cure all that ails health care, it is an important step toward transformation of the U.S. health care delivery system. In this commentary I describe several critical issues pertaining to the HIT market failure and several ways in which the federal government may act as a deft and gentle "Third Hand" to assist the Invisible Hand of Adam Smith.     

A review of methods for controlling medical costs from the point of view of cost-effectiveness

Cost-effectiveness analysis is a method used to evaluate the outcomes and costs of treatments or interventions designed to improve health. It has been widely regarded as an important aid to providing health care services efficiently. This paper reviews several measures for controlling medical costs in Japan, where a fee-for-service system is employed to remunerate for medical services provision. From the point of view of cost-effectiveness, the first step in health care reform for controlling medical costs should be minimizing useless medical services because the cost-effectiveness ratio of these tends to infinity. For the purpose of minimizing unserviceable provision in the field of medicine, two approaches must be considered. One is establishing a system so that physicians can act as perfect agencies for their patients. The other is encouraging academic research on the effectiveness of medical services.     

我国医保支付方式改革的有效性边界研究

从理论角度阐述我国医保支付方式改革对医疗服务结果影响的作用机制,并分析医保支付方式在医改中的功能定位及该项改革工作在实现预期效果方面的有效前提。结果表明,支付方式改革可视作公立医院改革的重要抓手,但不是改革的核心。我国医保支付方式改革要实现预期目标,需要同时满足内外部多个传导前提:(1)区域内公共医疗保障程度需达到一定水平;(2)医疗服务供方的筹资体系相对处于封闭状态;(3)需要辅以取消药品加成政策;(4)需要与医院分配制度改革相衔接。按病种支付可以缓解当前医疗费用过快增长的压力,但无法从根本上避免公立医院的逐利倾向。同时改革过程中警惕异地就医可能带来的跨域性医保财政逆向转移的陷阱。