Improving Population Health Through Enhanced Targeted Regional Decision Support (Indiana)

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Summary:

Surveillance is the cornerstone of public health practice. However, health departments rely on hospital, laboratory, and clinic staff to initiate case reports. Clinical providers often underreport reportable diseases, or their reporting is incomplete, inaccurate, or delayed due to: 1) a lack of knowledge on requirements and process, 2) a lack of resources to facilitate reporting, and 3) a perceived lack of value. Under and incomplete reporting can lead to inaccurate community disease burden assessments, which can hinder interventions and preventive care. As clinical data is increasingly captured in electronic form, the potential for automated electronic reporting exists. Health information exchanges (HIEs) are an emerging source of healthcare and clinical data that can be used to improve public health surveillance practices and data quality.

This project leveraged an existing, robust HIE network in primary care clinics and implemented a decision support (CDS) intervention to facilitate awareness that a notifiable disease should be reported to a local public health agency. The research team developed a standard notifiable condition case reporting form to serve as a CDS tool. Clinic staff received reporting forms pre-populated with patient demographic data and pertinent case management information through an HIE application. A clinical messaging system delivered the forms, allowing seamless integration into healthcare providers' workflow.

The specific aims of the project were as follows:

  • Evaluate the deployment of an advanced technical framework that enhances management of notifiable condition reporting and communication between providers and population heath stakeholders. 
  • Evaluate the quality of existing healthcare data and the capacity for the technical framework to enhance data quality by measuring data quality statistics. 
  • Identify and assess facilitators and barriers associated with the implementation and utilization of a technical framework within an HIE. 

Researchers evaluated the use of the CDS tool over 1-year post implementation. Quantitative measures focused on the change in provider reporting rates, completeness of the information in submitted case reports, and timeliness with which forms were submitted to local public health authorities. Interviews with clinic staff examined the burden of case reporting, perceptions of the CDS intervention, and motivations for using the pre-populated forms as compared to the traditional paper-based forms provided by the health department.

Reporting rates in the intervention clinics significantly improved when compared to baseline rates. The completeness of information in the submitted forms also improved, but timeliness was not affected. Feedback from both clinic staff and public health workers were positive, suggesting that decision support tools can facilitate improvements in case reporting without creating additional work. Continued awareness and bidirectional communication between public health officials and their clinical partners is necessary to monitor and improve data quality over time.

Improving Population Health Through Enhanced Targeted Regional Decision Support - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS09-070: AHRQ Health Services Research (R01)
  • Grant Number: 
    R01 HS 020909
  • Project Period: 
    September 2011 – September 2016
  • AHRQ Funding Amount: 
    $2,041,559
  • PDF Version: 
    (PDF, 299.26 KB)

Summary: Clinical providers often underreport population-level disease burden or their reporting is incomplete, inaccurate, or delayed. Causes for this include: 1) a lack of knowledge on reporting requirements and process; 2) a lack of resources to facilitate the reporting process; and 3) a perceived lack of value for reporting. Underreporting and incomplete reporting can lead to inaccurate assessments of the disease burden in a community, which can hinder population health interventions and preventive care to individual patients.

As clinical data is captured increasingly in electronic form, there is potential for more comprehensive assessment of disease burden and increased automation of electronic public health reporting. Health information exchanges (HIEs) are an emerging source of health care and clinical data that can be used to facilitate information-sharing and improve data quality. An automated electronic laboratory reporting system that uses data from an integrated HIE can overcome some of the disease burden reporting limitations by enhancing population-based reporting with additional data such as recent laboratory results, enhanced patient and provider demographics, and medication history.

In an effort to improve clinician reporting of notifiable conditions to public health and the quality of the data collected, Dr. Dixon and his research team are implementing novel clinical decision support (CDS) and clinical messaging tools. The team has developed a standard notifiable condition case reporting form to serve as a CDS tool pre-populated with patient demographic data and pertinent case management information. The form will remind clinicians to report notifiable cases to the appropriate public health stakeholders and will provide guidance on the reporting information needed. A clinical messaging system will deliver the forms, allowing them to be integrated more seamlessly into health care providers’ workflow. The clinical messaging system will build on an existing HIE known as the Indiana Network for Patient Care (INPC). When forms are flagged as reportable, they will be sent to appropriate clinical providers and public health agencies and submitted to the INPC. An interrupted time-series design will evaluate the effects of the standard pre-populated form reminder intervention on a variety of outcomes, including the rate of provider reporting, data quality, and timeliness of reporting to public health officials.

An enhanced pre-populated form that includes supplemental clinical case data will also be developed and deployed. A group of public health stakeholders are determining which supplemental data elements are needed for a selected set of reportable conditions. The research team will evaluate the quality and feasibility of the supplemental data. The enhanced pre-populated form will be compared to both pre- intervention data and the standard pre-populated form on various outcomes. Lastly, the research team is administering a series of surveys and interviews throughout the research project to collect quantitative and qualitative data from clinical settings to identify factors that influence the adoption and impact of the tools on workflow, provider awareness, data quality, and user satisfaction.

Specific Aims:

  • Evaluate the process and operational outcomes of deploying an advanced technical framework and methodology in the context of a long-standing operational HIE that enhances management of population-level notifiable condition reporting and bidirectional communication among providers and population heath stakeholders using decision support tools. (Ongoing)
  • Evaluate the quality of existing health care data and the capacity of an advanced technical framework to enhance data quality by measuring baseline, pre-implementation, and post- implementation data quality statistics including accuracy, completeness, and timeliness for provider and patient demographic information, and additional relevant clinical data. (Ongoing)
  • Identify and assess facilitators and barriers—including social, behavioral, and environmental— that are associated with the implementation and utilization of an advanced technical framework both within single organizations and across multiple organizations within an HIE. (Ongoing)

2012 Activities: The research team developed the standard pre-populated case reporting form and began recruiting clinic sites to participate in the study. Currently, six urban clinic sites have signed on to participate. The research team aims to recruit up to two additional rural clinic sites. Baseline data collection began in the second half of 2012 and forms on the project’s seven reportable conditions—chlamydia, gonorrhea, syphilis, histoplasmosis, hepatitis B, hepatitis C, and salmonella—were collected from the Marion County Public Health Department. The research team is using the data to establish retrospective baseline physician reporting rates for each condition. The rates vary by disease according to prevalence, which will impact the length of time necessary for measuring post-intervention effect. The standard pre-populated reporting forms will be implemented in 2013.

The team is in the process of determining the data elements, features, and information to include on the enhanced pre-populated forms, which will vary by reported disease. The team will receive input and feedback from local health department stakeholders through a series of focus groups to be conducted in 2013. Baseline surveys were distributed to health care providers and interviews were conducted with clinic nursing staff and managers at the six study sites to assess the facilitators and barriers associated with use and impact of the CDS and clinical messaging tools. Data analysis will be ongoing in 2013.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track, and project budget spending is roughly on target.

Preliminary Impact and Findings: Information needs of local and State health departments were assessed with respect to disease reporting and surveillance by conducting two independent surveys of health department epidemiologists and communicable disease nurses. The findings indicated that there was greater than 70 percent agreement for several case report information elements (e.g., patient name, county of residence), but there was wide variation in reported importance and desired completeness for a number of information elements. Variation must be reconciled to effectively develop policies, procedures, technologies, and systems that use integrated population data to support public health use cases.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

Improving Population Health Through Enhanced Targeted Regional Decision Support - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PA: HS09-070: AHRQ Health Services Research (R01)
  • Grant Number: 
    R01 HS 020909
  • Project Period: 
    September 2011 - September 2016
  • AHRQ Funding Amount: 
    $2,041,559
  • PDF Version: 
    (PDF, 172.88 KB)

Summary: Clinical providers often underreport population-level disease burden or their reporting is incomplete, inaccurate, or delayed. A variety of reasons cause this, including: 1) a lack of knowledge on reporting requirements and process; 2) a lack of resources to facilitate the reporting process; and 3) a perceived lack of value for reporting. Underreporting and incomplete reporting can lead to inaccurate assessments of the disease burden in a community, which hinders population health interventions and preventive care delivered to individual patients.

As clinical data is captured increasingly in electronic form, there is potential for more comprehensive assessment of disease burden and increased automation of electronic public health reporting. Health information exchanges (HIEs) are an emerging source of health care and clinical data that can be used to facilitate information-sharing and data quality. An automated electronic laboratory reporting system that leverages data from an integrated HIE can overcome some of the disease burden reporting limitations by enhancing population-based reporting with additional data such as recent laboratory results, enhanced patient and provider demographics, and medication history.

In an effort to improve clinician reporting of notifiable conditions to public health, and to improve the quality of the data collected, this project is implementing novel clinical decision support and clinical messaging tools. The research team will develop a standard pre-populated case reporting form to serve as a clinical decision support tool containing patient demographic data and pertinent case management information. The form will remind clinicians to report notifiable cases to the appropriate public health stakeholders and will provide guidance on the reporting information needed. A clinical messaging system will deliver the forms, allowing them to be integrated more seamlessly into health care providers' workflow. The clinical messaging system will build on an existing HIE known as the Indiana Network for Patient Care (INPC). When forms are flagged as reportable, they will be sent to appropriate clinical providers and public health agencies and submitted to the INPC. An interrupted time series design will be used to evaluate the effects of the standard pre-populated form reminder intervention on a variety of outcomes, including the rate of provider reporting, data quality, and timeliness of reporting to public health officials.

An enhanced pre-populated form that includes supplemental clinical case data will also be developed and deployed. A group of public health stakeholders will determine which supplemental data elements are needed for a select set of reportable conditions. The research team will evaluate the quality and feasibility of the supplemental data. The enhanced pre-populated form will be compared to both pre-intervention data and the standard pre-populated form on various outcomes.

Lastly, the research team will administer a series of interviews throughout the research project to collect qualitative data from clinicians and public health stakeholders to identify factors that influence the impact of the tools on workflow, provider awareness, and user satisfaction.

The implementation of automated data capture and information enhancements will streamline the reporting workflow for notifiable conditions, lower barriers to reporting and case followup, increase data completeness, and capture a greater portion of communicable disease burden.

Specific Aims:

  • Evaluate the process and operational outcomes of deploying an advanced technical framework and methodology in the context of a long-standing operational HIE that enhances management of population-level notifiable condition reporting and bidirectional communication among providers and population heath stakeholders using decision support tools. (Ongoing)
  • Evaluate the quality of existing health care data and the capacity of an advanced technical framework to enhance data quality by measuring baseline, pre-implementation and post-implementation data quality statistics including accuracy, completeness, and timeliness for provider and patient demographic information, and additional relevant clinical data. (Upcoming)
  • Identify and assess facilitators and barriers - including social, behavioral, and environmental - that are associated with the implementation and utilization of an advanced technical framework both within single organizations and across multiple organizations within an HIE. (Ongoing)

2011 Activities: This project was initiated in the fourth quarter of 2011 and activities primarily involved project start-up. Institutional review board applications were submitted and are pending approval. Development of data collection and analysis plans is in process, along with clinic recruitment strategies, including outreach to clinic directors and coordinating clinic site visits. Planning for the project kickoff meeting occurred and the meeting for all co-investigators and research staff will be held in early 2012. Lastly, a technical project plan to activate the prototype electronic forms generation process was developed and will be validated in early 2012.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track and the project budget funds are somewhat underspent. Once subcontracts are executed, project budget spending will be on track.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Improving Population Health Through Enhanced Targeted Regional Decision Support - Final Report

Citation:
Dixon B. Improving Population Health Through Enhanced Targeted Regional Decision Support - Final Report. (Prepared by Indiana University under Grant No. R01 HS020909). Rockville, MD: Agency for Healthcare Research and Quality, 2017. (PDF, 1.05 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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Research Method: 
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