Impact of the HITECH financial incentives on EHR adoption in small,physician-owned practices

BackgroundPhysicians in small physician-owned practices in the United States have been slower to adopt EHRs than physicians in large practices or practices owned by large organizations. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 included provisions intended to address many of the potential barriers to EHR adoption cited in the literature, including a financial incentives program that has paid physicians and other professionals $13 billion through December 2015.ObjectiveGiven the range of factors that may be influencing physicians’ decisions on whether to adopt an EHR, and given the level of HITECH expenditures to date, there is significant policy value in assessing whether the HITECH incentives have actually had an impact on EHR adoption decisions among U.S. physicians in small, physician-owned practices. This study addresses this question by analyzing physicians’ own views on the influence of the HITECH incentives as well as other potential considerations in their decision-making on whether to adopt an EHR.MethodsUsing data from a national survey of physicians, five composite scales were created from groups of survey items to reflect physician views on different potential facilitators and barriers for EHR adoption as of 2011, after the launch of the HITECH incentives program. Multinomial and binary logistic regression models were specified to test which of these physician-reported considerations have a significant relationship with EHR adoption status among 1043 physicians working in physician-owned practices with no more than 10 physicians.ResultsPhysicians’ views on the importance of the HITECH financial incentives are strongly associated with EHR adoption during the first three years of the HITECH period (2010–2012). In the study’s primary model, a one-point increase on a three-point scale for physician-reported influence of the HITECH financial incentives increases the relative risk of being in the process of adoption in 2011, compared to the risk of remaining a non-adopter, by a factor of 4.02 (p < 0.001, 95% CI of 2.06–7.85). In a second model which excludes pre-HITECH adopters from the data, a one-point increase on the incentives scale increases the relative risk of having become a new EHR user in 2010 or 2011, compared to the risk of remaining a non-adopter, by a factor of 3.98 (p < 0.01, 95% CI of 1.48–10.68) and also increases the relative risk of being in the process of adoption in 2011 by a factor of 5.73 (p < 0.001, 95% CI of 2.57–12.76), compared to the risk of remaining a non-adopter in 2011. In contrast, a composite scale that reflects whether physicians viewed choosing a specific EHR vendor as challenging is not associated with adoption status.ConclusionsThis study’s principal finding is that the HITECH financial incentives were influential in accelerating EHR adoption among small, physician-owned practices in the United States. A second finding is that physician decision-making on EHR adoption in the United States has not matched what would be predicted by the literature on network effects. The market’s failure to converge on a dominant design in the absence of interoperability means it will be difficult to achieve widespread exchange of patients’ clinical information among different health care provider organizations.     

Security of Patient and Study Data Associated with DICOM Images when Transferred Using Compact Disc Media

The transmission of patient and imaging data between imaging centers and other interested individuals is increasingly achieved by means of compact disc digital media (CD). These CDs typically contain, in addition to the patient images, a DICOM reader and information about the origin of the data. While equipment manufacturers attach disclaimers to these discs and specify the intended use of such media, they are often the only practical means of transmitting data for small medical, dental, or veterinary medical centers. Images transmitted by these means are used for clinical diagnosis. This has lead to a heavy reliance on the integrity of the data. This report describes attempts to alter significant patient and study data on CD media and their outcome. The results show that data files are extremely vulnerable to alteration, and alterations are not detectable without detailed analysis of file structure. No alterations to the DICOM readers were required to achieve this; changes were applied only to the data files. CDs with altered data can be readily prepared, and from the point of view of individuals viewing the images, function identically to the original manufacturer’s CD. Such media should be considered unsafe where there is a potential for financial or other gain to be had from altering the data, and the copy cannot be cross-checked with the original data.     

User-designed information tools to support communication and care coordination in a trauma hospital

BackgroundIn response to inherent inadequacies in health information technologies, clinicians create their own tools for managing their information needs. Little is known about these clinician-designed information tools. With greater appreciation for why clinicians resort to these tools, health information technology designers can develop systems that better meet clinicians’ needs and that can also support clinicians in design and use of their own information tools.ObjectiveTo describe the design characteristics and use of a clinician-designed information tool in supporting information transfer and care coordinationDesignObservations, semi-structured interviews, and photographing were used to collect data. Participants were six nurse coordinators in a high-volume trauma hospital. Content analysis was carried out and interactions with information tools were analyzed.ResultsNurse coordinators used a paper-based information tool (a nurse coordinator’s clipboard) that consisted of the compilation of essential data from disparate information sources. The tool was assembled twice daily through (1) selecting and formatting key data from multiple information systems (such as the unit census and the EHR), (2) data reduction (e.g., by cutting and whitening out non-essential items from the print-outs of computerized information systems), (3) bundling (e.g., organizing pieces of information and taping them to each other), and (4) annotating (e.g., through the use of colored highlighters and shorthand symbols). It took nurse coordinators an average of 41 min to assemble the clipboard. The design goals articulated by nurse coordinators to fit the tool into their tasks included (1) making information compatible with the mobile nature of their work, (2) enabling rapid information access and note-taking under time pressure, and (3) supporting rapid information processing and attention management through the effective use of layout design, shorthand symbols, and color-coding.ConclusionsClinicians design their own information tools based on the existing health information technologies to meet their information needs. The characteristics of these clinician-designed tools provide insights into the “realities” of how clinicians work with health information technologies. The findings suggest an often overlooked role for health information technologies: facilitating user creation of information tools that will best meet their needs.     

Home-based record prevalence among children aged 12–23 months from 180 demographic and health surveys

BackgroundThere is currently a re-focus at the global level on the importance of the home-based record within vaccination service delivery as an important information resource but there are few reports of ever and current home-based record prevalence across countries.MethodsWe considered all Demographic and Health Surveys (starting with DHS round 3) conducted between 1993 and 2013 for which a final dataset was available in the public domain at the time of the analysis. Ever and current prevalence of home-based records for recording vaccination was estimated for children aged 12–23 months at the time of the survey through a secondary analysis of data from 180 Demographic and Health Surveys conducted in 67 countries derived from questions asked of women aged 15–49 years for their children on home-based record availability and retention. Ever home-based record prevalence is the proportion of children aged 12–23 months who have ever received a home-based record. Current home-based record prevalence is the proportion of children aged 12–23 months for whom a home-based record was available for viewing by the surveyor at the time of the survey.ResultsEstimated ever home-based record prevalence was ≥90% in 116 surveys from 52 countries and was <70% in 15 surveys from 7 countries. Estimated current home-based record prevalence was ≥80% in 31 surveys from 23 countries and was <50% in 51 surveys from 24 countries. Current home-based record prevalence was <80% as of the most recent survey during 2010–2013 for five (Bangladesh, Ethiopia, Nigeria, Indonesia and Pakistan) of the ten countries with the largest birth cohorts globally. Among 34 countries that conducted three or more DHS, we observed improvements in both ever and current home-based record prevalence of >10% points in six countries. Current home-based record prevalence increased >10% points in six countries where the ever prevalence was maintained at ≥90% across the period of observation. And, no meaningful change was observed in estimated ever and current home-based record prevalence in 11 countries, five of which maintained ever prevalence ≥90% across the period of observation. High home-based record loss rates were observed in many countries.ConclusionsThe results here show that despite improvements in the availability, utilization and retention of home-based records for recording vaccination history in some countries, opportunities remain to change the mind-set in many national immunization programmes around the importance of the home-based record, particularly in countries with large birth cohorts. Immunization programmes are encouraged to monitor ever and current home-based record prevalence. Nationally representative household surveys collecting information on immunization coverage should include ever and current home-based record prevalence in the standard survey reports and tables to better enable programme managers to identify problems and target corrective action.     

Comparison of a Web-Based Dietary Assessment Tool with Software for the Evaluation of Dietary Records

Background

Dietary assessment in clinical practice is performed by means of computer support, either in the form of a web-based tool or software. The aim of the paper is to present the results of the comparison of a Slovenian web-based tool with German software for the evaluation of four-day weighted paper-and-pencil-based dietary records (paper-DRs) in pregnant women.

Methods

A volunteer group of pregnant women (n=63) completed paper-DRs. These records were entered by an experienced research dietitian into a web-based application (Open Platform for Clinical Nutrition, OPEN, http://opkp.si/en, Ljubljana, Slovenia) and software application (Prodi 5.7 Expert plus, Nutri-Science, Stuttgart, Germany, 2011). The results for calculated energy intake, as well as 45 macro- and micronutrient intakes, were statistically compared by using the non-parametric Spearman’s rank correlation coefficient. The cut-off for Spearman’s rho was set at >0.600.

Results

12 nutritional parameters (energy, carbohydrates, fat, protein, water, potassium, calcium, phosphorus, dietary fiber, vitamin C, folic acid, and stearic acid) were in high correlation (>0.800), 18 in moderate (0.600–0.799), 11 in weak correlation (0.400–0.599), while 5 (arachidonic acid, niacin, alpha-linolenic acid, fluoride, total sugars) did not show any statistical correlation.

Conclusion

Comparison of the results of the evaluation of dietary records using a web-based dietary assessment tool with those using software shows that there is a high correlation for energy and macronutrient content.     

Editor's Choice: Birth month affects lifetime disease risk: a phenome-wide method

Objective An individual’s birth month has a significant impact on the diseases they develop during their lifetime. Previous studies reveal relationships between birth month and several diseases including atherothrombosis, asthma, attention deficit hyperactivity disorder, and myopia, leaving most diseases completely unexplored. This retrospective population study systematically explores the relationship between seasonal affects at birth and lifetime disease risk for 1688 conditions.Methods We developed a hypothesis-free method that minimizes publication and disease selection biases by systematically investigating disease-birth month patterns across all conditions. Our dataset includes 1 749 400 individuals with records at New York-Presbyterian/Columbia University Medical Center born between 1900 and 2000 inclusive. We modeled associations between birth month and 1688 diseases using logistic regression. Significance was tested using a chi-squared test with multiplicity correction.Results We found 55 diseases that were significantly dependent on birth month. Of these 19 were previously reported in the literature (P < .001), 20 were for conditions with close relationships to those reported, and 16 were previously unreported. We found distinct incidence patterns across disease categories.Conclusions Lifetime disease risk is affected by birth month. Seasonally dependent early developmental mechanisms may play a role in increasing lifetime risk of disease.