Redefining Residential: Strategic Interventions to Advance Youth Permanency

ABSTRACT

This is the 13th in a series of papers by the Association of Children’s Residential Centers (ACRC) addressing critical issues facing the field of residential treatment. ACRC is the longest standing association focused exclusively on the needs of children and youth who need residential intervention and their families. The purpose of the papers is to stimulate dialogue and self-examination among organizations, stakeholders, and the field.

This paper focuses on the overarching goal for all children in out-of-home care to achieve safety, permanence, and well-being, and the role of those providing quality residential interventions in accomplishing this mission. While it particularly focuses on children and youth in the child welfare system, it is applicable to all young people and families. With residential interventions a necessary therapeutic option in community systems of care (Blau, Caldwell, & Lieberman, 2014), it is important that residential providers embrace their critical role in helping children and families move toward permanency and achieve successful outcomes.     

Electronic health records: use, barriers and satisfaction among physicians who care for black and Hispanic patients

Objectives  Electronic health records (EHRs) are a promising tool to improve the quality of health care, although it remains unclear who will benefit from this new technology. Given that a small group of providers care for most racial/ethnic minorities, we sought to determine whether minority-serving providers adopt EHR systems at comparable rates to other providers.
Methods  We used survey data from stratified random sample of all medical practices in Massachusetts in 2005. We determined rates of EHR adoption, perceived barriers to adoption, and satisfaction with EHR systems.
Results  Physicians who reported patient panels of more than 40% black or Hispanic had comparable levels of EHR adoption than other physicians (27.9% and 21.8%, respectively, P  = 0.46). Physicians from minority-serving practices identified financial and other barriers to implementing EHR systems at similar rates, although these physicians were less likely to be concerned with privacy and security concerns of EHRs (47.1% vs. 64.4%, P  = 0.01). Finally, physicians from high-minority practices had similar perceptions about the positive impact of EHRs on quality (73.7% vs. 76.6%, P  = 0.43) and costs (46.9% vs. 51.5%, P  = 0.17) of care.
Conclusions  In a state with a diverse minority population, we found no evidence that minority-serving providers had lower EHR adoption rates, faced different barriers to adoption or were less satisfied with EHRs. Given the importance of ensuring that minority-serving providers have equal access to EHR systems, we failed to find evidence of a new digital divide.     

Feasibility of Long-Term Outcomes Measurement by Residential Providers

ABSTRACT

Policy makers and funders working to address best practices for residential care and treatment require evidence for the effectiveness of residential interventions, particularly related to maintenance of effects post-discharge. With support from the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services, the Building Bridges Initiative and providers of residential interventions partnered with Chapin Hall to study the feasibility of a method for collecting follow-up data on the functioning of young people who were recently discharged from residential treatment. This paper describes the implementation and findings regarding the feasibility of (1) identifying the location of youth 6 months post-discharge, (2) contacting the caregivers of these youth for the purpose of administering a follow-up survey, and (3) administering a brief (10-min) survey inquiring about youth functioning in key domains. The results of this research provide guidance for measuring youth progress and outcomes after residential interventions. This study also lays the groundwork for a larger post-discharge outcomes study that includes linkage to administrative data, baseline data on youth functioning, and assessment of the services received in the context of residential interventions. Data and information obtained from the feasibility study provide evidence for the viability of a brief, telephone-administered post-discharge survey with caregivers.     

Satisfaction after the transition between electronic health record systems at six ambulatory practices

Rationale, aims and objectives Early adopters of electronic health records (EHRs) are transitioning from older to newer EHRs to satisfy meaningful use requirements. Facilitators and barriers to satisfaction after transitioning are important to understand as provider satisfaction is linked with improvement in health care. Method We conducted a cross‐sectional survey of providers who transitioned from an older to a newer EHR at six academic, urban ambulatory medical practices. A novel survey was developed to assess: (1) satisfaction with the EHR implementation; (2) patterns of information technology use; (3) work perceptions; (4) methods for completing clinical tasks; and (5) demographic characteristics. We analysed the results using bivariate and multivariate analyses. Results The response rate was 64% (n = 197). A small majority were satisfied with the new EHR (64%, n = 120). Providers who reported satisfaction with overall quality of work life, their workload and the transition were more likely to be satisfied with the new EHR (P < 0.01). Providers who reported using the Internet at least daily were also more likely to be satisfied with the new EHR (P < 0.05). In a multivariate model, satisfaction with the transition was a strong predictor of satisfaction with the new EHR (P < 0.01). Barriers to satisfaction include dissatisfaction with: maintaining problem and medication lists, tracking health maintenance information, referring to clinical practice guidelines and ordering laboratory and radiology tests (P < 0.01). Conclusion This study provides groundwork for understanding the facilitators and barriers to provider satisfaction after the transition between EHRs and provides insight into areas requiring attention by entities undergoing similar transitions.     

Motivations and barriers to implementing electronic health records and ED information systems in Japan

Background

Although electronic health record systems (EHRs) and emergency department information systems (EDISs) enable safe, efficient, and high-quality care, these systems have not yet been studied well. Here, we assessed (1) the prevalence of EHRs and EDISs, (2) changes in efficiency in emergency medical practices after introducing EHR and EDIS, and (3) barriers to and expectations from the EHR-EDIS transition in EDs of medical facilities with EHRs in Japan.

Materials and methods

A survey regarding EHR (basic or comprehensive) and EDIS implementation was mailed to 466 hospitals. We examined the efficiency after EHR implementation and perceived barriers and expectations regarding the use of EDIS with existing EHRs. The survey was completed anonymously.

Results

Totally, 215 hospitals completed the survey (response rate, 46.1%), of which, 76.3% had basic EHRs, 4.2% had comprehensive EHRs, and 1.9% had EDISs. After introducing EHRs and EDISs, a reduction in the time required to access previous patient information and share patient information was noted, but no change was observed in the time required to produce medical records and the overall time for each medical care. For hospitals with EHRs, the most commonly cited barriers to EDIS implementation were inadequate funding for adoption and maintenance and potential adverse effects on workflow. The most desired function in the EHR-EDIS transition was establishing appropriate clinical guidelines for residents within their system.

Conclusion

To attract EDs to EDIS from EHR, systems focusing on decreasing the time required to produce medical records and establishing appropriate clinical guidelines for residents are required.     

Searching the PDF Haystack: Automated Knowledge Discovery in Scanned EHR Documents

Background  Clinicians express concern that they may be unaware of important information contained in voluminous scanned and other outside documents contained in electronic health records (EHRs). An example is “unrecognized EHR risk factor information,” defined as risk factors for heritable cancer that exist within a patient''s EHR but are not known by current treating providers. In a related study using manual EHR chart review, we found that half of the women whose EHR contained risk factor information meet criteria for further genetic risk evaluation for heritable forms of breast and ovarian cancer. They were not referred for genetic counseling. Objectives  The purpose of this study was to compare the use of automated methods (optical character recognition with natural language processing) versus human review in their ability to identify risk factors for heritable breast and ovarian cancer within EHR scanned documents. Methods  We evaluated the accuracy of the chart review by comparing our criterion standard (physician chart review) versus an automated method involving Amazon''s Textract service (Amazon.com, Seattle, Washington, United States), a clinical language annotation modeling and processing toolkit (CLAMP) (Center for Computational Biomedicine at The University of Texas Health Science, Houston, Texas, United States), and a custom-written Java application. Results  We found that automated methods identified most cancer risk factor information that would otherwise require clinician manual review and therefore is at risk of being missed. Conclusion  The use of automated methods for identification of heritable risk factors within EHRs may provide an accurate yet rapid review of patients'' past medical histories. These methods could be further strengthened via improved analysis of handwritten notes, tables, and colloquial phrases.     

Satisfaction of health‐care providers with electronic health records and perceived barriers to its implementation in the United Arab Emirates

The integration of electronic health records (EHRs) has shown promise in improving health‐care quality. In the United Arab Emirates, EHRs have been recently adopted to improve the quality and safety of patient care. A cross‐sectional survey of 680 health‐care providers (HCPs) was conducted to assess the satisfaction of HCPs in the United Arab Emirates with EHRs' impact on access/viewing, documentation and medication administration and to explore the barriers encountered in their use. Data were collected over 6 months from April to September 2014. High overall satisfaction with EHRs was reported by HCPs, suggesting their acceptance. Physicians reported the greatest overall satisfaction with EHRs, although nurses showed significantly higher satisfaction with the impact on medication administration compared with other HCPs. The most significant barriers reported by nurses were lack of belief in the value of EHRs for patients and lack of adequate computer skills. Given the large investment in technology, additional research is necessary to promote the full utilization of EHRs. Nurses need to be aware of the value of EHRs for patient care and be involved in all stages of EHR implementations to maximize its meaningful use for better clinical outcomes.     

Luddite or luminary?

The Electronic Health Record (EHR) charge is on across the country, with increasing investments in systems infrastructure, the adoption of standards and the integration of health information systems within regions and across sectors of care. In the near term, whether they are institution- or community-based, all nurses will need to use the various functional components of EHRs. Infoway has set a direction for Canada to reach the goal of having an EHR for 50% of Canadians by 2010 (Canada Health Infoway 2007). As an investment partner, Infoway is working within all provincial and territorial jurisdictions to deploy the foundations of the Canadian EHR. Client and provider registries, laboratory, diagnostic imaging and drug information systems, public health surveillance and telehealth applications are among the key functional components. Additionally, funding is being directed to innovative technological approaches, including investments to facilitate clients' access to care, and information and support for cancer care, mental health and primary care.     

Possibilities and Implications of Using the ICF and Other Vocabulary Standards in Electronic Health Records

There is now widespread recognition of the powerful potential of electronic health record (EHR) systems to improve the health‐care delivery system. The benefits of EHRs grow even larger when the health data within their purview are seamlessly shared, aggregated and processed across different providers, settings and institutions. Yet, the plethora of idiosyncratic conventions for identifying the same clinical content in different information systems is a fundamental barrier to fully leveraging the potential of EHRs. Only by adopting vocabulary standards that provide the lingua franca across these local dialects can computers efficiently move, aggregate and use health data for decision support, outcomes management, quality reporting, research and many other purposes. In this regard, the International Classification of Functioning, Disability, and Health (ICF) is an important standard for physiotherapists because it provides a framework and standard language for describing health and health‐related states. However, physiotherapists and other health‐care professionals capture a wide range of data such as patient histories, clinical findings, tests and measurements, procedures, and so on, for which other vocabulary standards such as Logical Observation Identifiers Names and Codes and Systematized Nomenclature Of Medicine Clinical Terms are crucial for interoperable communication between different electronic systems. In this paper, we describe how the ICF and other internationally accepted vocabulary standards could advance physiotherapy practise and research by enabling data sharing and reuse by EHRs. We highlight how these different vocabulary standards fit together within a comprehensive record system, and how EHRs can make use of them, with a particular focus on enhancing decision‐making. By incorporating the ICF and other internationally accepted vocabulary standards into our clinical information systems, physiotherapists will be able to leverage the potent capabilities of EHRs and contribute our unique clinical perspective to other health‐care providers within the emerging electronic health information infrastructure. Copyright © 2013 John Wiley & Sons, Ltd.     

Redefining Residential: Toward Rational Use of Psychotropic Medication

This is the eleventh in a series of papers issued by the Association of Children’s Residential Centers (ACRC) regarding key issues faced by the field in response to emerging research, policy, and best practice. This paper builds on the previous papers in the Redefining Residential Series to address psychotropic medication use in residential treatment. Evidence for use of psychotropic medication with children and youth and the complications presented by youth typically served in residential centers are reviewed. Several critical practices residential programs should consider implementing are identified. Barriers to successful implementation are examined. A call is made for increased emphasis on what is described as rational use of psychotropic medications, prescribed in conjunction with other treatment modalities and careful monitoring of progress and outcomes.     

Meaningful Use of Electronic Health Records

The concerns on patient safety and quality improvement in health care are increasing. There is growing use of technology in health care, particularly use of the electronic health record (EHR). As this occurs, the health care system is transforming. The federal government has become involved in EHR implementation, encouraging improved health care. The Centers for Medicare & Medicaid Services are implementing the Meaningful Use (MU) Incentive Program for Medicare- and Medicaid-eligible providers. As EHR implementation and MU Programs grow, it is important for the nurse practitioner (NP) to be aware of the MU Program. As NPs become engaged in using EHRs, MU will have an impact on changing health care systems and implications related to clinical practice and improved outcomes.     

Physician Specialty and Variations in Adoption of Electronic Health Records

Objective

Efforts to promote adoption of electronic health records (EHRs) have focused on primary care physicians, who are now expected to exchange data electronically with other providers, including specialists. However, the variation of EHR adoption among specialists is underexplored.

Methods

We conducted a retrospective cross-sectional study to determine the association between physician specialty and the prevalence of EHR adoption, and a retrospective serial cross-sectional study to determine the association of physician specialty and the rate of EHR adoption over time. We used the 2005–2009 National Ambulatory Medical Care Survey. We considered fourteen specialties, and four definitions of EHR adoption (any EHR, basic EHR, full EHR, and a novel definition of EHR sophistication). We used multivariable logistic regression, and adjusted for several covariates (geography, practice characteristics, revenue characteristics, physician degree).

Results

Physician specialty was significantly associated with EHR adoption, regardless of the EHR definition, after adjusting for covariates. Psychiatrists, dermatologists, pediatricians, ophthalmologists, and general surgeons were significantly less likely to adopt EHRs, compared to the reference group of family medicine / general practitioners. After adjustment for covariates, these specialties were 44 – 94% less likely to adopt EHRs than the reference group. EHR adoption increased in all specialties, by approximately 40% per year. The rate of EHR adoption over time did not significantly vary by specialty.

Conclusions

Although EHR adoption is increasing in all specialties, adoption varies widely by specialty. In order to insure each individual’s network of providers can electronically share data, widespread adoption of EHRs is needed across all specialties.     

Electronic health records: the new vehicle for drug labeling, safety, and efficacy

As labeling has become more complex, effective provider communication has become more difficult. Until the HITECH (Health Information Technology for Economic and Clinical Health) Act, which provided billions of federal payments to encourage the use of electronic health records (EHRs) and e-prescribing, adoption of EHRs was slow. Delivery of actionable drug information within EHRs unites providers, patients,professional liability carriers, and the US Food and Drug Administration (FDA) because it improves safety and decreases liability/costs. At PDR Network, we deliver full labeling, warnings,risk evaluation and mitigation strategies (REMS), adverse event reporting, and adherence services within the provider's workflow, across multiple EHRs.     

Electronic health records: which practices have them,and how are clinicians using them?

Background Limited data exist to estimate the use of electronic health records (EHRs) in ambulatory care practices in the United States. Methods We surveyed a stratified random sample of 1829 office practices in Massachusetts in 2005. The one‐page survey measured use of health information technology, plans for EHR adoption and perceived barriers to adoption. Results A total of 847 surveys were returned, for a response rate of 46%. Overall, 18% of office practices reported having an EHR. Primary‐care‐only and mixed practices reported similar adoption rates (23% and 25%, respectively, P = 0.70). The adoption rate in specialty practices (14%) was lower compared with both primary‐care‐only (P < 0.01) and mixed (P < 0.05) practices. The number of clinicians in the practice strongly correlated with EHR adoption (P < 0.001), with fewer small practices adopting EHRs. Among practices that have EHRs with laboratory and radiology result retrieval capabilities, at least 87% of practices report that a majority of their clinicians actively use these functionalities, while 74% of practices with electronic decision support report that the majority of clinicians actively use it. Among the practices without an EHR, 13% plan to implement one within the next 12 months, 24% within the next 1–2 years, 11% within the next 3–5 years, and 52% reported having no plans to implement an EHR in the foreseeable future. The most frequently reported barrier to implementation was lack of adequate funding (42%). Conclusions Overall, fewer than 1 in 5 medical practices in Massachusetts have an EHR. Even among adopters, though, doctor usage of EHR functions varied considerably by functionality and across practices. Many clinicians are not actively using functionalities that are necessary to improve health care quality and patient safety. Furthermore, among practices that do not have EHRs, more than half have no plan for adoption. Inadequate funding remains an important barrier to EHR adoption in ambulatory care practices in the United States.     

EHR adoption among doctors who treat the elderly

Objectives The purpose of this study is to examine Electronic Health Record (EHR) adoption among Florida doctors who treat the elderly. This analysis contributes to the EHR adoption literature by determining if doctors who disproportionately treat the elderly differ from their counterparts with respect to the utilization of an important quality‐enhancing health information technology application. Methods This study is based on a primary survey of a large, statewide sample of doctors practising in outpatient settings in Florida. Logistic regression analysis was used to determine whether doctors who treat a high volume of elderly (HVE) patients were different with respect to EHR adoption. Results Our analyses included responses from 1724 doctors. In multivariate analyses controlling for doctor age, training, computer sophistication, practice size and practice setting, HVE doctors were significantly less likely to adopt EHR. Specifically, compared with their counterparts, HVE doctors were observed to be 26.7% less likely to be utilizing an EHR system (OR = 0.733, 95% CI 0.547–0.982). We also found that doctor age is negatively related to EHR adoption, and practice size and doctor computer savvy‐ness is positively associated. Conclusions Despite the fact that EHR adoption has improved in recent years, doctors in Florida who serve the elderly are less likely to adopt EHRs. As long as HVE doctors are adopting EHR systems at slower rates, the elderly patients treated by these doctors will be at a disadvantage with respect to potential benefits offered by this technology.     

Clinician Perceptions of Pediatric Growth Chart Use and Electronic Health Records in Kentucky

Background

Growth chart recording is a key component of pediatric care. EHR systems could provide several growth charting functionalities compared to paper methods. To our knowledge, there has been no U.S. study exploring clinicians’ perceptions and practices related to recording of growth parameters as they adapt to electronic methods.

Objectives

To explore clinician practices regarding recording growth parameters as they adapt to electronic health records (EHR) and to investigate clinician perceptions of electronic growth charting using EHR.

Methods

An online survey of pediatricians and family practitioners in Kentucky inquiring about EHR usage, specifically use of growth charting with EHR, was conducted.

Results

Forty-six percent of respondents utilized EHRs, with pediatricians lagging family practitioners, and academic pediatricians lagging non-academicians. There was no consensus on EHR platforms being used. Almost a third of those who used EHR did not utilize electronic growth charting. Clinicians using EHR reported that electronic growth charts would improve clinician satisfaction and clinical efficiency as well as parent satisfaction and parent education. Only 12% of respondents provided copies of growth charts to parents at the end of their visit and discussed growth parameters with parents, with clinicians using EHR more likely to engage in these activities than non-EHR users.

Conclusion

Although Kentucky clinicians continue to slowly adopt EHRs, clinician perceptions and practices reflect enduring barriers to widespread use of electronic growth charting in pediatric and family practice. However, our results suggest that electronic growth charting has important benefits for both clinicians and patients, and greater adoption is expected as EHRs become standard across health care systems.     

Health information technology: transforming chronic disease management and care transitions

Adoption of health information technology (HIT) is a key effort in improving care delivery, reducing costs of health care, and improving the quality of health care. Evidence from electronic health record (EHR) use suggests that HIT will play a significant role in transforming primary care practices and chronic disease management. This article shows that EHRs and HIT can be used effectively to manage chronic diseases, that HIT can facilitate communication and reduce efforts related to transitions in care, and that HIT can improve patient safety by increasing the information available to providers and patients, improving disease management and safety.     

Strategic considerations during electronic health record implementation

Early decisions during electronic health record (EHR) implementation can determine the long-term success of the EHR within organizations. Questions that should be addressed during EHR implementation are presented with an emphasis on how these questions relate to the success and usability of EHRs.