The face of Canadian medicare is going to look much different following this federal budget

The federal government has attempted to downplay the effect its recent budget will have on health care, but observers ranging from provincial governments to health care organizations say there will be a huge impact. Premier Bob Rae said that from 1996 to 1998 Ontario's loss will total $3.6 billion for health care, education and social services, an amount that almost equals the combined total annual expenditures for its drug-benefit program, nearly all cancer treatment in the province and the cost of running almost all 20 hospitals in the city of Toronto. Dr. Léo-Paul Landry, the CMA secretary general, says the budget “is probably the beginning of the end of medicare as we know it.”     

Leveraging health information technology to achieve the “triple aim” of healthcare reform

Objective To investigate experiences with leveraging health information technology (HIT) to improve patient care and population health, and reduce healthcare expenditures.Materials and methods In-depth qualitative interviews with federal government employees, health policy, HIT and medico-legal experts, health providers, physicians, purchasers, payers, patient advocates, and vendors from across the United States.Results The authors undertook 47 interviews. There was a widely shared belief that Health Information Technology for Economic and Clinical Health (HITECH) had catalyzed the creation of a digital infrastructure, which was being used in innovative ways to improve quality of care and curtail costs. There were however major concerns about the poor usability of electronic health records (EHRs), their limited ability to support multi-disciplinary care, and major difficulties with health information exchange, which undermined efforts to deliver integrated patient-centered care. Proposed strategies for enhancing the benefits of HIT included federal stimulation of competition by mandating vendors to open-up their application program interfaces, incenting development of low-cost consumer informatics tools, and promoting Congressional review of the The Health Insurance Portability and Accountability Act (HIPPA) to optimize the balance between data privacy and reuse. Many underscored the need to “kick the legs from underneath the fee-for-service model” and replace it with a data-driven reimbursement system that rewards high quality care.Conclusions The HITECH Act has stimulated unprecedented, multi-stakeholder interest in HIT. Early experiences indicate that the resulting digital infrastructure is being used to improve quality of care and curtail costs. Reform efforts are however severely limited by problems with usability, limited interoperability and the persistence of the fee-for-service paradigm—addressing these issues therefore needs to be the federal government’s main policy target.     

Informatics,evidence-based care,and research; implications for national policy: a report of an American Medical Informatics Association health policy conference

There is an increased level of activity in the biomedical and health informatics world (e-prescribing, electronic health records, personal health records) that, in the near future, will yield a wealth of available data that we can exploit meaningfully to strengthen knowledge building and evidence creation, and ultimately improve clinical and preventive care. The American Medical Informatics Association (AMIA) 2008 Health Policy Conference was convened to focus and propel discussions about informatics-enabled evidence-based care, clinical research, and knowledge management. Conference participants explored the potential of informatics tools and technologies to improve the evidence base on which providers and patients can draw to diagnose and treat health problems. The paper presents a model of an evidence continuum that is dynamic, collaborative, and powered by health informatics technologies. The conference''s findings are described, and recommendations on terminology harmonization, facilitation of the evidence continuum in a “wired” world, development and dissemination of clinical practice guidelines and other knowledge support strategies, and the role of diverse stakeholders in the generation and adoption of evidence are presented.     

“Not all my friends need to know”: a qualitative study of teenage patients,privacy, and social media

Background

The literature describes teenagers as active users of social media, who seem to care about privacy, but who also reveal a considerable amount of personal information. There have been no studies of how they manage personal health information on social media.

Objective

To understand how chronically ill teenage patients manage their privacy on social media sites.

Design

A qualitative study based on a content analysis of semistructured interviews with 20 hospital patients (12–18 years).

Results

Most teenage patients do not disclose their personal health information on social media, even though the study found a pervasive use of Facebook. Facebook is a place to be a “regular”, rather than a sick teenager. It is a place where teenage patients stay up-to-date about their social life—it is not seen as a place to discuss their diagnosis and treatment. The majority of teenage patients don''t use social media to come into contact with others with similar conditions and they don''t use the internet to find health information about their diagnosis.

Conclusions

Social media play an important role in the social life of teenage patients. They enable young patients to be “regular” teenagers. Teenage patients'' online privacy behavior is an expression of their need for self-definition and self-protection.     

Enhancing laboratory report contents to improve outpatient management of test results

In today''s environment, providers are extremely time-constrained. Assembling relevant contextual data to make decisions on laboratory results can take a significant amount of time from the day. The Regenstrief Institute has created a system which leverages data within Indiana Health Information Exchange''s (IHIE''s) repository, the Indiana Network for Patient Care (INPC), to provide well-organized and contextual information on returning laboratory results to outpatient providers. The system described here uses data extracted from INPC to add historical test results, medication-dispensing events, visit information, and clinical reminders to traditional laboratory result reports. These “Enhanced Laboratory Reports” (ELRs) are seamlessly delivered to outpatient practices connected through IHIE via the DOCS4DOCS clinical messaging service. All practices, including those without electronic medical record systems, can receive ELRs. In this paper, the design and implementation issues in creating this system are discussed, and generally favorable preliminary results of attitudes by providers towards ELRs are reported.     

Electronic consultations and clinician burnout: An antidote to our emotional pandemic?

Health information technology is a major source of clinician burnout due to increased administrative burden and inefficient work processes. Electronic consultations (eConsults) represent a promising innovation to improve access to specialty care by reducing wait times for specialist visits and reducing unnecessary in-person specialist visits. While eConsults have clear benefits for patients and healthcare systems, their potential effects on provider burnout should be considered. Using a framework which outlines that the loss of autonomy, competence, and relatedness as the main contributing factors to clinician “amotivation” and burnout, we discuss the use of eConsults and their potential to mitigate or exacerbate burnout for primary care providers and specialists, as well as recommendations for implementation of eConsults to reduce burnout.     

Computerized Physician Order Entry: Helpful or Harmful?

Computerized physician order entry (CPOE) is touted as a major improvement in patient safety, primarily as a result of the Institute of Medicine''s 1999 report on medical errors and the subsequent formation of the “Leapfrog Group” of companies to preferentially direct their employees'' health care to those institutions that install such systems (as part of directives that “Leapfrog” feels will improve patient care). Although the literature suggests that such systems have the potential to improve patient outcomes through decrease of adverse drug events, actual improvements in medical outcomes have not been documented. Installation of such systems could actually increase the number of adverse drug events and result in higher overall medical costs, particularly in the first few years of their adoption.In the last five years, hospitals, including our own, have begun to use computerized systems that require physicians and other health care providers to electronically enter patient care orders.¹ Before this time, only a handful of hospitals used such systems. These computer programs contain algorithms that alert health care providers to potentially harmful therapeutic decisions before orders are processed. The installation of these systems is costly (millions of dollars) and requires major behavioral changes, not only by physicians, but also by the entire health care organization.² In January 2003, Cedars-Sinai Health System in Los Angeles removed its recently installed computerized physician order entry (CPOE) system from use after almost unanimous protest from the medical staff. Why are hospitals and other health care organizations pursuing this avenue at this time? Does the literature support the premise that these systems are beneficial for patient care? Do such systems decrease total health care costs? The answers to these questions are still evolving. In this forum, we address these questions and describe some of the pertinent medical literature on this subject.     

Impact of event notification services on timely follow-up and rehospitalization among primary care patients at two Veterans Affairs Medical Centers

ObjectiveTo examine the effectiveness of event notification service (ENS) alerts on health care delivery processes and outcomes for older adults.Materials and methodsWe deployed ENS alerts in 2 Veterans Affairs (VA) medical centers using regional health information exchange (HIE) networks from March 2016 to December 2019. Alerts targeted VA-based primary care teams when older patients (aged 65+ years) were hospitalized or attended emergency departments (ED) outside the VA system. We employed a concurrent cohort study to compare postdischarge outcomes between patients whose providers received ENS alerts and those that did not (usual care). Outcome measures included: timely follow-up postdischarge (actual phone call within 7 days or an in-person primary care visit within 30 days) and all-cause inpatient or ED readmission within 30 days. Generalized linear mixed models, accounting for clustering by primary care team, were used to compare outcomes between groups.ResultsCompared to usual care, veterans whose primary care team received notification of non-VA acute care encounters were 4 times more likely to have phone contact within 7 days (AOR = 4.10, P < .001) and 2 times more likely to have an in-person visit within 30 days (AOR = 1.98, P = .007). There were no significant differences between groups in hospital or ED utilization within 30 days of index discharge (P = .057).DiscussionENS was associated with increased timely follow-up following non-VA acute care events, but there was no associated change in 30-day readmission rates. Optimization of ENS processes may be required to scale use and impact across health systems.ConclusionGiven the importance of ENS to the VA and other health systems, this study provides guidance for future research on ENS for improving care coordination and population outcomes.Trial RegistrationClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT02689076","term_id":"NCT02689076"}}NCT02689076. “Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization.” Registered February 23, 2016.     

A systems approach to accepted standards of care: Shifting the blame

In healthcare, from a legal perspective, the standard of acceptable practice has been generally set by the courts and defined as healthcare professionals acting in a manner that is widely accepted by their peers as meeting an acceptable standard of care. This view, however, reflects the state of how practice “is” rather than what it “ought to be”. What is ought to be depends on whether you take a “person” or “system” oriented approach to practice.The increasing pressures of lack of money and resources, and an ever–increasing need for care are bringing pressure on the health services to move to a system approach and this is gaining acceptance both with clinicians and thus eventually the courts.A systems-type approach to healthcare will, by necessity, embrace clinical protocols and guidelines supported by clinical information systems. It will also see blame for errors shifting from clinicians to the organisations that employ them.This paper argues that a continued use of a person-based approach to healthcare, developed through an historical record of practice by individual clinicians, is no longer adequate defence in a case of supposed negligence.When the healthcare system has codified clinical guidelines and digital data gathered across thousands of clinicians and their patients, it is possible to compute adequate levels of care and expect clinicians and the healthcare system in general to meet these minimum standards.Future negligence decisions will rely on a systems-based best practice standard of care determined through evidence rather than opinion     

Breaching the Security of the Kaiser Permanente Internet Patient Portal: the Organizational Foundations of Information Security

This case study describes and analyzes a breach of the confidentiality and integrity of personally identified health information (e.g. appointment details, answers to patients’ questions, medical advice) for over 800 Kaiser Permanente (KP) members through KP Online, a web-enabled health care portal. The authors obtained and analyzed multiple types of qualitative data about this incident including interviews with KP staff, incident reports, root cause analyses, and media reports. Reasons at multiple levels account for the breach, including the architecture of the information system, the motivations of individual staff members, and differences among the subcultures of individual groups within as well as technical and social relations across the Kaiser IT program. None of these reasons could be classified, strictly speaking, as “security violations.” This case study, thus, suggests that, to protect sensitive patient information, health care organizations should build safe organizational contexts for complex health information systems in addition to complying with good information security practice and regulations such as the Health Insurance Portability and Accountability Act (HIPAA) of 1996.     

An approach to predicting patient experience through machine learning and social network analysis

ObjectiveImproving the patient experience has become an essential component of any healthcare system’s performance metrics portfolio. In this study, we developed a machine learning model to predict a patient’s response to the Hospital Consumer Assessment of Healthcare Providers and Systems survey’s “Doctor Communications” domain questions while simultaneously identifying most impactful providers in a network.Materials and MethodsThis is an observational study of patients admitted to a single tertiary care hospital between 2016 and 2020. Using machine learning algorithms, electronic health record data were used to predict patient responses to Hospital Consumer Assessment of Healthcare Providers and Systems survey questions in the doctor domain, and patients who are at risk for responding negatively were identified. Model performance was assessed by area under receiver-operating characteristic curve. Social network analysis metrics were also used to identify providers most impactful to patient experience.ResultsUsing a random forest algorithm, patients’ responses to the following 3 questions were predicted: “During this hospital stay how often did doctors. 1) treat you with courtesy and respect? 2) explain things in a way that you could understand? 3) listen carefully to you?” with areas under the receiver-operating characteristic curve of 0.876, 0.819, and 0.819, respectively. Social network analysis found that doctors with higher centrality appear to have an outsized influence on patient experience, as measured by rank in the random forest model in the doctor domain.ConclusionsA machine learning algorithm identified patients at risk of a negative experience. Furthermore, a doctor social network framework provides metrics for identifying those providers that are most influential on the patient experience.     

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes

BackgroundThe 21st Century Cures Act mandates patients’ access to their electronic health record (EHR) notes. To our knowledge, no previous work has systematically invited patients to proactively report diagnostic concerns while documenting and tracking their diagnostic experiences through EHR-based clinician note review.ObjectiveTo test if patients can identify concerns about their diagnosis through structured evaluation of their online visit notes.MethodsIn a large integrated health system, patients aged 18–85 years actively using the patient portal and seen between October 2019 and February 2020 were invited to respond to an online questionnaire if an EHR algorithm detected any recent unexpected return visit following an initial primary care consultation (“at-risk” visit). We developed and tested an instrument (Safer Dx Patient Instrument) to help patients identify concerns related to several dimensions of the diagnostic process based on notes review and recall of recent “at-risk” visits. Additional questions assessed patients’ trust in their providers and their general feelings about the visit. The primary outcome was a self-reported diagnostic concern. Multivariate logistic regression tested whether the primary outcome was predicted by instrument variables.ResultsOf 293 566 visits, the algorithm identified 1282 eligible patients, of whom 486 responded. After applying exclusion criteria, 418 patients were included in the analysis. Fifty-one patients (12.2%) identified a diagnostic concern. Patients were more likely to report a concern if they disagreed with statements “the care plan the provider developed for me addressed all my medical concerns” [odds ratio (OR), 2.65; 95% confidence interval [CI], 1.45–4.87) and “I trust the provider that I saw during my visit” (OR, 2.10; 95% CI, 1.19–3.71) and agreed with the statement “I did not have a good feeling about my visit” (OR, 1.48; 95% CI, 1.09–2.01).ConclusionPatients can identify diagnostic concerns based on a proactive online structured evaluation of visit notes. This surveillance strategy could potentially improve transparency in the diagnostic process.     

Evaluating the Accuracy of Existing EMR Data as Predictors of Follow-up Providers

In order to evaluate the accuracy of existing EMR data in predicting follow-up providers, a retrospective analysis was performed on six months of data for inpatient and ED encounters occurring at two hospitals, and on related outpatient data. Sensitivity and Positive Predictive Value (PPV) were calculated for each of eight predictors, to determine their effectiveness in predicting follow-up providers. Our findings indicate that access to longitudinal patient care records can improve prediction of which providers a patient is likely to see post-discharge compared to simply using Primary Care Provider data from admissions records. Of the predictors evaluated, a patient''s past appointment history was the best predictor of which providers they would see in the future (PPV = 48% following inpatient visits, 35% following emergency department visits). However, even the best performing predictors failed to predict more than half of the follow-up providers and might generate many “false” alerts.     

CMA brief offers suggestions as federal commission studies country's blood-gathering system

The CMA hopes the Commission of Inquity on the Blood System, chaired by Mr. Justice Horace Krever, “will restore faith in a system that is essential for the health and safety of all Canadians.” However, the cost implications any recommendations may have for the health care system must also be taken into consideration. The CMA made several recommendations in response to the commission's interim report.     

Shared clinical decision-making on vaccines: out of sight,out of mind

Clinical decision support systems, which provide automated reminders in electronic health systems, are designed to provide physicians and other health professionals support in clinical decision-making. New clinical guidance from the Advisory Committee on Immunization Practices on a new category of recommendations referred to as “shared clinical decision-making” have left providers struggling to interpret how to best implement recommendations for adult vaccines. The issue at hand is how to ensure that a conversation between the patient and provider occurs. While traditional clinical decision support systems have driven immunization for years, these systems support a binary default opt-in process. The goal for shared decision-making is the discussion rather than the vaccination. The recommended provider–patient conversations need to be supported with both provider guidance as well as tools to ensure vaccines are not omitted from the conversations, particularly as future vaccine candidates progress through the vaccine development pipeline.     

Three Decades of Research on Computer Applications in Health Care: Medical Informatics Support at the Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality and its predecessor organizations—collectively referred to here as AHRQ—have a productive history of funding research and development in the field of medical informatics, with grant investments since 1968 totaling $107 million. Many computerized interventions that are commonplace today, such as drug interaction alerts, had their genesis in early AHRQ initiatives.This review provides a historical perspective on AHRQ investment in medical informatics research. It shows that grants provided by AHRQ resulted in achievements that include advancing automation in the clinical laboratory and radiology, assisting in technology development (computer languages, software, and hardware), evaluating the effectiveness of computer-based medical information systems, facilitating the evolution of computer-aided decision making, promoting computer-initiated quality assurance programs, backing the formation and application of comprehensive data banks, enhancing the management of specific conditions such as HIV infection, and supporting health data coding and standards initiatives.Other federal agencies and private organizations have also supported research in medical informatics, some earlier and to a greater degree than AHRQ. The results and relative roles of these related efforts are beyond the scope of this review.Three decades ago, when the federal government''s National Center for Health Services Research and Development began to support research on computer applications in health care, few imagined the impact that information systems and sciences would have on medical care today. For most, the idea of a national clearinghouse of guidelines, available through a computer that sits on a home office desktop, seemed like science fiction. For a few researchers and those supporting their work, however, visions of what could become possible in the management of health care information called for development of computerized systems and the evaluation of their effects on quality, cost, and access to care.The Agency for Healthcare Research and Quality (AHRQ, from 1999) and its predecessor agencies—the National Center for Health Services Research and Development (beginning in 1968) and the Agency for Health Care Policy and Research (from 1989 to 1999)—have a rich history of funding research, development, and evaluation in medical informatics. Although the grant investments since 1968 total only $107 million ($246 million in 2000 dollars), they supported initiatives that have established a research framework for many of the computer applications now being used today.The focus of AHRQ''s early research funding in medical informatics was on acquiring patient care data and communicating patient care management information. The goal was not only to improve the quality of care, but also to achieve reductions in costs and medical personnel resource use by processing data more efficiently. Research aimed at improving communication of information was targeted at what we would call today “getting the right information to the right place at the right time.” The promise of this research was its ability to provide findings that would guide reorganization of care delivery, take advantage of the more rapid communication of necessary information, and reduce manpower needs.¹ Over time, AHRQ''s funding has emphasized the application of health services research methods to evaluations of information technology used in community health settings. This article highlights key accomplishments emerging from AHRQ''s funding that have improved the quality of patient care in studied sites and have the potential to improve health care in all settings.Other federal agencies (such as the National Library of Medicine, the Veterans Health Administration, and the Department of Defense) and private organizations (such as The John A. Hartford Foundation, The Robert Wood Johnson Foundation, and the American Hospital Association) have supported developments in medical informatics, with some having greater research expenditures and earlier histories than AHRQ. Nevertheless, it is the Agency''s contributions to medical informatics that are the focus of this study. The purpose of this article is to provide a historical perspective for understanding the benefits of past research funded by AHRQ that supports health care applications of information technology today and that foreshadows AHRQ''s medical informatics initiatives for the future.     

The Prevalence of Depression among patients and its detection by Primary Health Care Workers at Matawale Health Centre (Zomba)

Background

Little information is available on the prevalence of depression in Malawi in primary health care settings and yet there is increased number of cases of depression presenting at tertiary level in severe form.

Aim

The aim of the study was to determine the prevalence of depression among patients and its detection by health care workers at a primary health care clinic in Zomba.

Methods

A cross-sectional survey was done among patients attending outpatient department at Matawale Health Centre, in Zomba from 1st July 2009 through to 31st July 2009. A total of 350 adults were randomly selected using systematic sampling. The “Self Reporting Questionnaire”, a questionnaire measuring social demographic factors and the Structured Clinical Interview for DSM-IV Axis I disorders Non-Patient Version (SCID-NP) were administered verbally to the participants.

Findings

The prevalence of depression among the patients attending the outpatients department was found to be 30.3% while detection rate of depression by clinician was 0%.

Conclusion

The results revealed the magnitude of depression which is prevalent in the primary health care clinic that goes undiagnosed and unmanaged. It is therefore recommended that primary health care providers do thorough assessments to address common mental disorders especially depression and they should be educated to recognise and manage depression appropriately at primary care level.     

Care transitions as opportunities for clinicians to use data exchange services: how often do they occur?

Background

The electronic exchange of health information among healthcare providers has the potential to produce enormous clinical benefits and financial savings, although realizing that potential will be challenging. The American Recovery and Reinvestment Act of 2009 will reward providers for ‘meaningful use’ of electronic health records, including participation in clinical data exchange, but the best ways to do so remain uncertain.

Methods

We analyzed patient visits in one community in which a high proportion of providers were using an electronic health record and participating in data exchange. Using claims data from one large private payer for individuals under age 65 years, we computed the number of visits to a provider which involved transitions in care from other providers as a percentage of total visits. We calculated this ‘transition percentage’ for individual providers and medical groups.

Results

On average, excluding radiology and pathology, approximately 51% of visits involved care transitions between individual providers in the community and 36%–41% involved transitions between medical groups. There was substantial variation in transition percentage across medical specialties, within specialties and across medical groups. Specialists tended to have higher transition percentages and smaller ranges within specialty than primary care physicians, who ranged from 32% to 95% (including transitions involving radiology and pathology). The transition percentages of pediatric practices were similar to those of adult primary care, except that many transitions occurred among pediatric physicians within a single medical group.

Conclusions

Care transition patterns differed substantially by type of practice and should be considered in designing incentives to foster providers'' meaningful use of health data exchange services.     

Health economics and cost-effectiveness research with special reference to hemato-oncology

The cost of health care is increasing globally, especially in cancer. Health economics is an increasingly important field and medical professionals should have a working knowledge of the basis for health technology assessment such as cost-effectiveness analysis, cost utility analysis and cost benefit analysis. There are limited studies on health technology assessment regarding expensive therapies, primarily from high-income countries, but these cannot be applied to countries with different gross domestic product (GDP) and cost of health care delivery. There is a need to carry out health economics related research utilizing data from India. Whereas clinical trials establish the efficacy of new drugs in controlled environments, with strict inclusion and exclusion criteria, their transferability to the “real-world” situation is not always true. With the shifting of the global cancer burden to middle-income and lower middle-income countries, this field is going to assume greater importance in the future. Health economics research conducted in India may be of benefit to other countries with similar economies. The Armed Forces Medical Services of India, with a well-established system of assessing health outcomes, and robust system of accounting for expenses, can provide the lead for these studies.     

“Smart Forms” in an Electronic Medical Record: Documentation-based Clinical Decision Support to Improve Disease Management

Clinical decision support systems (CDSS) integrated within Electronic Medical Records (EMR) hold the promise of improving healthcare quality. To date the effectiveness of CDSS has been less than expected, especially concerning the ambulatory management of chronic diseases. This is due, in part, to the fact that clinicians do not use CDSS fully. Barriers to clinicians'' use of CDSS have included lack of integration into workflow, software usability issues, and relevance of the content to the patient at hand. At Partners HealthCare, we are developing “Smart Forms” to facilitate documentation-based clinical decision support. Rather than being interruptive in nature, the Smart Form enables writing a multi-problem visit note while capturing coded information and providing sophisticated decision support in the form of tailored recommendations for care. The current version of the Smart Form is designed around two chronic diseases: coronary artery disease and diabetes mellitus. The Smart Form has potential to improve the care of patients with both acute and chronic conditions.