Sustaining “Meaningful Use” of Health Information Technology in Low-Resource Practices

PURPOSEThe implementation of electronic health records (EHRs) has been extensively studied, but their maintenance once implemented has not. The Regional Extension Center (REC) program provides implementation assistance to priority practices—those with limited financial, technical, and organizational resources—but the assistance is time limited. Our objective was to identify potential barriers to maintenance of meaningful use of EHRs in priority primary care practices using a qualitative observational study for federally qualified health centers (FQHCs) and priority practices in Michigan.METHODSWe conducted cognitive task analysis (CTA) interviews and direct observations of health information technology implementation in FQHCs. In addition, we conducted semistructured interviews with implementation specialists serving priority practices to detect emergent themes relevant to maintenance.RESULTSMaintaining EHR technology will require ongoing expert technical support indefinitely beyond implementation to address upgrades and security needs. Maintaining meaningful use for quality improvement will require ongoing support for leadership and change management. Priority practices not associated with larger systems lack access to the necessary technical expertise, financial resources, and leverage with vendors to continue alone. Rural priority practices are particularly challenged, because expertise is often not available locally.CONCLUSIONSPriority practices, especially in rural areas, are at high risk for falling on the wrong side of a “digital divide” as payers and regulators enact increasing expectations for EHR use and information management. For those without affiliation to maintain the necessary expert staff, ongoing support will be needed for those practices to remain viable.     

Adoption of a health education intervention for family members of breast cancer patients

BACKGROUND: Relatives of breast cancer patients often face substantial uncertainty and psychological stress regarding their own health risks and optimal strategies for prevention and early detection. Efficacious educational and counseling interventions are rarely evaluated for their potential adoption and use in medical practice settings. This study evaluates a health education program for first-degree relatives of breast cancer patients based on the program's potential for being adopted and used by medical practices affiliated with cancer centers. METHODS: A randomized, controlled trial was implemented in four community hospital-based medical practices. After 9 months, clinical and administrative staff at each practice were given self-administered surveys. Of 90 staff members recruited to respond, useable responses were received from 60 (67%), including 13 physicians (31%), 43 nurses (98%), and four program managers (100%). Participants made self-reports of program awareness, program support, perceived program performance, likelihood of program adoption and use, and barriers to adoption. RESULTS: A strong majority of respondents (80%) reported that all or most staff agreed with the need for the program. Perceived program performance in meeting goals was generally favorable but varied across sites and across staff types. Overall, 56% of respondents indicated that their practices were likely or highly likely to adopt the program in full. The likelihood of adoption varied substantially across sites and across program components. CONCLUSIONS: Evaluating the potential for program adoption offers insight for tailoring preventive health interventions and their implementation strategies to improve diffusion in the field of practice.     

Investing in CenteringPregnancy™ Group Prenatal Care Reduces Newborn Hospitalization Costs

ObjectivesCenteringPregnancy™ group prenatal care is an innovative model with promising evidence of reducing preterm birth. The outpatient costs of offering CenteringPregnancy pose barriers to model adoption. Enhanced provider reimbursement for group prenatal care may improve birth outcomes and generate newborn hospitalization cost savings for insurers. To investigate potential cost savings for investment in CenteringPregnancy, we evaluated the impact on newborn hospital admission costs of a pilot incentive project, where BlueChoice Health Plan South Carolina Medicaid managed care organization paid an obstetric practice offering CenteringPregnancy $175 for each patient who participated in at least five group prenatal care sessions.MethodsUsing a one to many case-control matching without replacement, each CenteringPregnancy participant was matched retrospectively on propensity score, age, race, and clinical risk factors with five individual care participants. We estimated the odds of newborn hospital admission type (neonatal intensive care unit [NICU] or well-baby admission) for matched CenteringPregnancy and individual care cohorts with four or more visits using multivariate logistic regression. Cost savings were calculated using mean costs per admission type at the delivery hospital.ResultsOf the CenteringPregnancy newborns, 3.5% had a NICU admission compared with 12.0% of individual care newborns (p < .001). Investing in CenteringPregnancy for 85 patients ($14,875) led to an estimated net savings for the managed care organization of $67,293 in NICU costs.ConclusionsCenteringPregnancy may reduce costs through fewer NICU admissions. Enhanced reimbursement from payers to obstetric practices supporting CenteringPregnancy sustainability may improve birth outcomes and reduce associated NICU costs.     

Impact of an electronic medical record system on community-based primary care practices

BACKGROUND: Although primary care physicians are increasingly interested in adopting electronic medical record (EMR) systems, few use such systems in practice. This study explores the organizational impact of an EMR system on community-based practices that have overcome the initial barriers and are experienced EMR users. METHODS: Five primary care practices that are members of a national research network participated in this study. Using qualitative methods, including semistructured interviews and observations, we assessed the impact of an EMR system on the work lives of various user groups. RESULTS: Physicians and staff indicated that the EMR system has changed not only how they manage patient records but also how they communicate with each other, provide patient care services, and perform job responsibilities. The EMR is also perceived by its users to have an impact on practice costs. Although in most practices physicians and staff were unaware of actual expenses and cost savings associated with the EMR, those in practices that have eliminated duplicate paper-based systems believe they have realized cost savings. CONCLUSIONS: Several important themes emerged. The organizational context in which the system is implemented is important. Effective leadership, the presence of a system champion, availability of technical training and support, and adequate resources are essential elements to the success of the EMR.     

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance

Objectives: To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care.

Design: Qualitative case studies using semi-structured interviews and documentation review.

Setting: Twelve purposively sampled PCG/Ts in England.

Participants: Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members.

Main outcome measures: Participants' perceptions of the role of clinical governance in PCG/Ts.

Results: PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment).

Conclusion: PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

     

Accessibility of primary care physician practice sites in South Carolina for people with disabilities

BackgroundQuality and level of health care provided for people with disabilities at primary care physician's offices can be drastically impacted by the level of accessibility of the practice. The study goal was to assess the accessibility of primary care physician practices sites in South Carolina for people with mobility or sensory disabilities.MethodsPrimary care offices were contacted through two different networks, and 68 agreed to a modified accessibility assessment. Prior to each visit, practice characteristics were gathered. The rehabilitation engineer assessed the sites for 93 specific accessibility items using a tape measure, inclinometer, and weight scale. The survey items were taken from the American with Disabilities Act Accessibility Guidelines (ADAAG).ResultsThe level of accessibility varied substantially; the average practice was deemed adequate on 70% of the items assessed. The strongest predictor of overall accessibility was the year of construction or most recent renovation. Hospital-owned buildings were significantly more accessible (P = 0.04) when controlling for year built. Key aspects of accessibility that were often lacking included car- and van-accessible parking, lever door handles, clear floor space and grab bars in the restroom, TTY telephone or a hearing aid–compatible telephone, wheelchair accessible scale, and an adjustable-height examination table.ConclusionThe accessibility of primary care practice sites in South Carolina is suboptimal. Research is needed to identify effective approaches for encouraging primary care practices to make their practices fully accessible.     

Dentists' Perceptions of Barriers to Providing Dental Care to Pregnant Women

PurposeThe purpose of the study was to understand US dentists' attitudes, knowledge, and practices regarding dental care for pregnant women and to determine the impact of recent papers on oral health and pregnancy and guidelines disseminated widely.MethodsIn 2006 and 2007, the investigators conducted a mailed survey of all 1,604 general dentists in Oregon; 55.2% responded). Structural equation modeling was used to estimate associations between dentists' attitudes toward providing care to pregnant women, dentists' knowledge about the safety of dental procedures, and dentists' current practice patterns.ResultsDentist's perceived barriers have the strongest direct effect on current practice and might be the most important factor deterring dentists from providing care to pregnant patients. Five attitudes (perceived barriers) were associated with providing less dental services: time, economic, skills, dental staff resistance, and peer pressure. The final model shows a good fit with a chi-square of 38.286 (p = .12; n = 772; df = 52) and a Bentler-Bonett normed fit index of .98 and a comparative fit index of .993. The root mean square error of approximation is .02.ConclusionFindings suggest that attitudes are significant determinants of accurate knowledge and current practice. Multidimensional approaches are needed to increase access to dental care and protect the oral health of women during pregnancy. Despite current clinical recommendations to deliver all necessary care to pregnant patients during the first, second, and third trimesters, dentists' knowledge of the appropriateness of procedures continues to lag the state of the art in dental science.     

Increasing Access to WIC through Discount Variety Stores: Findings from Qualitative Research

BackgroundMany low-income neighborhoods do not include a full-service grocery store. In these communities, discount variety stores (DVS) can be convenient points of food access. However, no identified DVS are authorized to accept Special Supplemental Nutrition Program for Women, Infants, and Children Program (WIC) benefits.ObjectiveOne national DVS retailer implemented WIC in 10 stores located in low-income communities in North Carolina over a 10-month pilot period to assess WIC feasibility.MethodsTo better understand the facilitators and barriers to WIC implementation from the perspective of DVS staff, we analyzed 36 in-depth interviews with employees of this DVS chain at corporate, manager, and store clerk levels.ResultsMost participants provided positive feedback about implementing and offering WIC. Many store employees had personal experience participating in WIC, which increased their understanding of the WIC shopping experience. Store staff’s prior WIC participation and customers’ proximity to DVS locations were facilitators to implementation. Primary barriers included limited choice of store products for customers, complicated or unclear labeling of WIC products, and difficulty training employees to process WIC vouchers.ConclusionsThese findings suggest that whereas most employees viewed WIC positively, barriers related to product selection and training must be addressed. Notably, North Carolina’s recent change to an electronic system to process WIC transactions requires minimal manual employee training and should address several barriers to implementation. However, the computer system upgrades necessary to accept electronic WIC transactions may be a barrier for DVS to continued WIC acceptance. Future research is needed to evaluate implementation of electronic WIC transactions in DVS.     

Food Program Participation Influences Nutrition Practices in Early Care and Education Settings

ObjectiveTo determine differences by Child and Adult Care Food Program (CACFP) participation on nutrition requirements and best practices and barriers to implementing both in early care and education programs (ECEs) stratified by context (centers vs home-based ECEs).DesignCross-sectional survey.SettingThree-thousand and fourteen licensed Nebraska ECEs in 2017.ParticipantsOne-thousand three hundred forty-five ECEs.Main Outcome Measure(s)Director-reported nutrition practices in classrooms serving children aged 2-5 years (8 requirements for foods served, 5 best practices for foods served, and 14 best practices for mealtime behaviors).AnalysisChi-square analysis adjusted for multiple comparisons.ResultsOf the sample, 86.8% participated in CACFP, 21.7% were center-based, and 78.3% were home-based. Overall, CACFP participation was related to the higher implementation of CACFP requirements for foods served (P < 0.004 for all) and receiving professional development on nutrition (P < 0.012). In home-based ECEs only, CACFP participation was related to a higher prevalence of serving meals family-style (P = 0.002); however, these practices had low implementation overall.Conclusion and ImplicationsFindings suggest strengthening of requirements to include staff mealtime behaviors beyond service of healthful foods. Improving CACFP enrollment and including CACFP standards in state licensing requirements may be key strategies for improving nutrition practices in ECEs.     

Fall prevention and monitoring of assisted living patients: an exploratory study of physician perspectives

ObjectiveExplore physician perspectives on their involvement in fall prevention and monitoring for residential care/assisted living (RC/AL) residents.DesignExploratory cross-sectional study; mailed questionnaire.SettingFour RC/AL communities, North Carolina.ParticipantsPrimary physicians for RC/AL residents.MeasurementsPast Behavior and future Intentions of physicians with regard to (1) fall risk assessment and (2) collaboration with RC/AL staff to reduce falls and fall risks among RC/AL residents were explored using Theory of Planned Behavior (TPB) constructs. Predictor variables examined (1) physicians’ views on their own responsibilities (Attitude), (2) their views of expectations from important referent groups (Subjective Norms), and (3) perceived constraints on engaging in fall prevention and monitoring (Perceived Behavioral Control).ResultsPhysicians reported conducting fall risk assessments of 47% of RC/AL patients and collaborating with RC/AL staff to reduce fall risks for 36% of RC/AL patients (Behavior). These proportions increased to 75% and 62%, respectively, for future Intentions. TPB-based models explained approximately 60% of the variance in self-reported Behavior and Intentions. Physician’s involvement in fall prevention and monitoring was significantly associated (P < .05) with their perceptions of barriers and facilitators—ease, time, reimbursement, and expertise.ConclusionThis study provides first data on physician beliefs regarding their involvement in fall risk assessment of RC/AL patients and collaboration with RC/AL staff to reduce fall risks of individual patients. Challenges to physician involvement identified in our study are not unique or specific to the RC/AL setting, and instead relate to clinical practice and reimbursement constraints in general.     

The adoption level of electronic medical records in hebron hospitals based on the electronic medical record adoption model (EMRAM)

BackgroundElectronic Medical Records (EMRs) have become a priority for hospitals, and assessing the level of deployment of EMRs nationwide is essential to better utilization. The Electronic Medical Record Adoption Model (EMRAM) is one of the widely used EMR assessment systems worldwide.ObjectivesStudy aims at assessing the adoption level of EMRs in Palestine using the EMRAM model, specifically Hebron city hospitals, as a case study.MethodsUsing a semi-structured interview as a research instrument, a total of 5 interviews were conducted with IT directors responsible for EMR systems used by all of the 5 hospitals in Hebron.ResultsOur study showed that EMRs in Hebron have a low level of EMR capabilities. Besides, we found Hebron public hospital is better than the private ones in adopting EMRs.RecommendationsPalestinian hospitals are advised to invest more in their EMR systems to gain more capabilities. Besides, the Palestinian Ministry of Health and the Palestinian government should encourage hospitals to proceed.     

Assessing Sexual Assault Survivors' Access to Emergency Contraception: Results From a Mixed Methods Study in South Carolina

BackgroundProvision of emergency contraceptive pills (ECPs) is widely recognized as the standard of care to prevent pregnancy after a sexual assault. However, previous research has shown that hospitals do not routinely counsel sexual assault patients about or provide sexual assault survivors with ECPs or accurate referrals.MethodsWe undertook a mixed methods study to assess policies and practices regarding the provision of ECPs for sexual assault survivors in South Carolina. The study includes four components: An analysis of the South Carolina Victims' Rights Amendment, in-depth interviews with rape crisis agency and state agency representatives, a survey of hospital emergency department staff, and a survey of hospital emergency department administrators.FindingsOur findings indicate that hospital policies and practices regarding ECP-related services for sexual assault patients are generally consistent with the standard of care. According to hospital staff and administrators, requiring a police report and/or undergoing a rape kit examination before providing ECPs do not seem to be significant access barriers. However, hospitals that do not conduct rape kit examinations transfer patients to other facilities, and these initial hospitals do not routinely provide patients with ECPs before transfer.ConclusionOur findings suggest that further research to document whether transfer practices and reporting requirements impede access to ECPs is warranted. Furthermore, our results support the recommendation that any woman reporting sexual assault should be immediately offered dedicated, progestin-only ECPs. Last, our results suggest that key stakeholders in the sexual assault community could be engaged to improve sexual assault and ECP-related services in South Carolina.     

Predictors of the Decision to Adopt Motivational Interviewing in Community Health Settings

The purpose of this study is to concurrently examine the impact of individual and organizational characteristics on the decision to adopt the evidence-based practice (EBP) motivational interviewing (MI) among directors and staff (n?=?311) in community health organizations (n?=?92). Results from hierarchical linear modeling indicated that, at the individual level, attitudes toward EBPs and race each predicted directors’ decisions to adopt, while gender predicted staff’s decisionmaking. At the organizational level, organizational climate was inversely associated with both staff’s and directors’ decisions to adopt MI. Organizational barriers to implementing EBPs and use of reading materials and treatment manuals were related to directors’ decision to adopt. Type of organization and staff attributes were associated with staff’s decision to adopt. These findings underscore the need to tailor dissemination and implementation strategies to address differences between directors and staff in the adoption of EBPs.     

Challenges with Implementing a Patient-Centered Medical Home Model for Women Veterans

BackgroundThe Veterans Health Administration (VA) Patient Aligned Care Team (PACT) initiative aims to ensure that all patients receive care consistent with medical home principles. Women veterans’ unique care needs and minority status within the VA pose challenges to delivery of equitable, comprehensive primary care for this population. Currently, little is known about whether and/or how PACT should be tailored to better meet women veterans' needs.MethodsIn 2014, we conducted semistructured interviews with 73 primary care providers and staff to examine facilitators and barriers encountered in providing PACT-principled care to women veterans. Respondents were located in eight VA medical centers in eight different states across the United States.ResultsRespondents perceived PACT as improving continuity of care for patients and as increasing ability of nursing staff to practice at the top of their license. However, the implementation of core medical home features and team huddles was inconsistent and varied both within and across medical centers. Short staffing, inclusion of part-time providers on teams, balancing performance requirements for continuity and same-day access, and space constraints were identified as ongoing barriers to PACT implementation. Challenges unique to care of women veterans included a higher prevalence of psychosocial needs, the need for specialized training of primary care personnel, and short staffing owing to additional sharing of primary care support staff with specialist providers.ConclusionProviders and staff face unique challenges in delivering comprehensive primary care to women veterans that may require special policy, practice, and management action if benefits of PACT are to be fully realized for this population.     

Nutrition Educator Adoption and Implementation of an Experiential Foods Curriculum

ObjectiveDescribe changes in Nutrition Educator (NE) and Extension Agent (EA) motivation, self-efficacy, and behavioral capability over time after experiential food tasting curriculum training. Identify promoters of curriculum adoption, implementation, and future use.DesignMixed methods design including surveys, lesson implementation reports, and interviews.SettingNew Mexico limited-resource schools.ParticipantsConvenience sample of New Mexico Extension NE (n = 42) and their EA supervisors (n = 21).InterventionThree-hour curriculum training employing Social Cognitive Theory and Diffusion of Innovations.Main Outcome MeasuresPerceived change in motivation, self-efficacy, and behavioral capability from post-training through 8-month post-training; promoters and challenges to curriculum adoption, implementation, and future use.AnalysisRepeated-measures ANOVA analyzed perceived behavior change over time. Significance was set at P ≤ .05. Qualitative responses were categorized by theme.ResultsGains in NE motivation, self-efficacy, and behavioral capability were sustained at 8 months post-training. High adoption/implementation rates (79%) were attributed to strong implementation expectations, observational learning, experiential training elements, and perceived curriculum compatibility. Environmental factors including time constraints, personnel turnover, and scheduling conflicts proved challenging.Conclusions and ImplicationsMaximizing curriculum simplicity and compatibility and incorporating behavioral capability, observational learning, and expectations into training support adoption and use. Adaptations and techniques to problem-solve challenges should be provided to new curricula implementers.     

Family Child Care Providers’ Nutrition Practices and Policies: Happy Healthy Homes

ObjectiveDetermine the impact of family child care home providers’ nutrition knowledge, confidence, and perceived barriers on program nutrition best practices and written nutrition policies.MethodsCross-sectional analysis of self-reported surveys of 49 female providers in Oklahoma City analyzed with Spearman correlation, multivariate linear and logistic regression (α < 0.05).ResultsConfidence and barriers were significantly correlated (r_s(47) = −0.4, P = 0.004). Independent variables explained 36% of practices (r² = 0.357). Nutrition knowledge (standard β = 0.442, P = 0.001) and confidence (standard β = 0.358, P = 0.008) were significantly associated with practices; barriers were not. No significant association between independent variables and written policies resulted.Conclusions and ImplicationsProvider nutrition knowledge and confidence appear to be suitable targets to improve nutrition practices. Further research can evaluate possible influences on the presence and quality of family child care home written nutrition policies and specific nutrition policy topics associated with healthier nutrition practices.