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Including social determinants of health (SDoH) data in health outcomes research is essential for studying the sources of healthcare disparities and developing strategies to mitigate stressors. In this report, we describe a pragmatic design and approach to explore the encoding needs for transmitting SDoH screening tool responses from a large safety-net hospital into the National Covid Cohort Collaborative (N3C) OMOP dataset. We provide a stepwise account of designing data mapping and ingestion for patient-level SDoH and summarize the results of screening. Our approach demonstrates that sharing of these important data - typically stored as non-standard, EHR vendor specific codes - is feasible. As SDoH screening gains broader use nationally, the approach described in this paper could be used for other screening instruments and improve the interoperability of these important data.

Examine how the Electronic Health Record (EHR) and its related systems support or inhibit provider collaboration.Health care systems in the US are simultaneously implementing EHRs and transitioning to more collaborative delivery systems; this study examines the interaction between these two changes.This qualitative study of five US EHR implementations included 49 interviews and over 60 hours of provider observation. We examined the role of the EHR in building relationships, communicating, coordinating, and collaborative decision-making.The EHR plays four roles in collaboration: a repository, a messenger, an orchestrator, and a monitor. While EHR performance varied, common themes were decreased trust due to poor quality documentation, incomplete communication, potential for increased effectiveness through better coordination, and the emerging role of the EHR in identifying performance gaps.Both organizational and technical innovations are needed if the EHR is to truly support collaborative behaviors.

BACKGROUND: Care management has demonstrated improvements in quality of care for patients with complex care needs. The extent to which these interventions benefit race/ethnic minority populations is unclear. OBJECTIVES: To characterize race/ethnic differences in the longitudinal control of clinical outcomes for patients with complex care needs enrolled in Care Management Plus, a health information technology-enabled care coordination intervention. RESEARCH DESIGN: Multilevel models of repeated observations from clinical encounters before and after program enrollment for six Oregon and California primary care clinics. SUBJECTS: A total of 18,675 clinic patients were examined. We estimated multilevel models for 1,481 and 5,320 care-managed individuals with repeated hemoglobin A1c and blood pressure measurements, respectively. MEASURES: Primary outcomes were changes over time for two clinical markers of health status for complex care patients: (1) hemoglobin A1c for patients with diabetes, and (2) mid-BP (average systolic and diastolic blood pressure). RESULTS: We found significant reductions in A1c for patients with previously uncontrolled A1c (pre-period slope, b=1.03 [0.83, 1.24]; post-period slope, b=−0.63 [−0.91, −0.35]). For mid-BP we found increasing unconditional pre-period trajectories (b=3.52 [2.39, 4.64]) and decreasing post-period trajectories (b=−5.21 [−5.70, −4.72]). We also found the trajectories of A1c and mid-BP were not statistically different for Black, Latino, and White patients. CONCLUSIONS: These analyses demonstrate some promising results for intermediate clinical outcomes for underrepresented patients with complex chronic care needs. It remains to be seen whether these health care system delivery redesigns yield long-term benefits for patients, such as improvements in function and quality of life.

Care coordination is at the forefront of current health reform efforts, yet most electronic health records (EHRs) lack the functionality needed to facilitate and document care coordination activities. The Integrated Care Coordination Information System (ICCIS) was iteratively developed with user input to meet these needs. Following 16 months of system use, ICCIS users and developers were interviewed about their experiences. These interviews, along with quantitative information about system use, were analyzed using a combination of Linstone's Multiple Perspective approach and the ABC framework to determine lessons learned about novel system creation. Overall, clinicians saw value in specialized health information technology (HIT) tools for care coordination as long as development focuses on providing user-requested functionality that integrates closely with existing HIT systems and workflows. Close integration between novel HIT and EHRs may increase use by relieving the cited fatigues of duplicative data entry, multiple system logins, and potential data inconsistencies.

Quality measurement has been slow to make a major impact in health care. Initial measures were too simple to affect outcomes of importance. Incentive programs such as Meaningful Use encourage better measures, but in process may become more complex. We evaluated the measures selected for Meaningful Use in two ways: we counted unique concept identifiers, taxonomies, and aggregated concepts as measures of complexity; and we surveyed informatics professionals to assess difficulty. There were 20,316 unique concept identifiers, 35 taxonomies, and 317 aggregated concepts across the 45 measures. Half the respondents reported measures at least moderately difficult. The number of identifiers was associated with fewer implementations (r=-.37); rating-of-difficulty was associated with more taxonomies (r=.24). The impact on accuracy may be substantial when moving to measures intended to be more relevant to clinical outcomes but requiring the use of more taxonomies, unused structured concept identifiers, or concepts only in free text fields.

We describe architectural strategies and issues regarding health information exchange (HIE). This description is organized as a continuum of options, between separated systems and a monolithic approach. We discuss characteristics, examples and potential impacts of each approach, based on generalized observations of practical implementations. We also describe how strategies can migrate along the continuum, which allows for approaches that mature from an initial implementation to a long-term strategy.

Unmet information needs of physicians and patients are common, but those of nurse care managers - defined as collaborative care planners for with chronic conditions - are less well understood. We taped and transcribed daily activities and conducted semi-structured interviews of 7 care managers, and analyzed questions elicited through this work through a variety of frameworks.

To determine how the addition of generalist care managers and collaborative information technology to an ambulatory team affects the care of patients with diabetes.Multiple ambulatory clinics within Intermountain Health Care (IHC), a large integrated delivery network.A retrospective cohort study comparing diabetic patients treated by generalist care managers with matched controls was completed. Exposure patients had one or more contacts with a care manager; controls were matched on utilization, demographics, testing, and baseline glucose control. Using role-specific information technology to support their efforts, care managers assessed patients' readiness for change, followed guidelines, and educated and motivated patients.Patient data collected as part of an electronic patient record were combined with care manager-created databases to assess timely testing of glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels and changes in LDL and HbA1c levels.In a multivariable model, the odds of being overdue for testing for HbA1c decreased by 21 percent in the exposure group (n=1,185) versus the control group (n=4,740). The odds of being tested when overdue for HbA1c or LDL increased by 49 and 26 percent, respectively, and the odds of HbA1c7.0 percent also increased by 19 percent in the exposure group. The average HbA1c levels decreased more in the exposure group than in the controls. The effect on LDL was not significant.Generalist care managers using computer-supported diabetes management helped increase adherence to guidelines for testing and control of HbA1c levels, leading to improved health status of patients with diabetes.

Advanced clinical information systems have been proposed to improve patient care in terms of safety, effectiveness, and efficiency. In order to be effective, such systems require detailed patient-specific clinical information in a form easily reviewed by clinicians. We have developed a patient summary worksheet for use in outpatient clinics, which presents a structured overview of patient health information. The worksheet provides patient demographic information, specific problems and conditions, the patient's current medication profile, laboratory test results pertinent to patient problems, and disease-specific or preventive care actionable advisories. Usage has grown from a few hundred to over 25,000 unique patients per month during a two-year period. Diabetic patients for whom the worksheet is accessed are significantly more likely to be in compliance with accepted testing regimens for glycosolated hemoglobin (OR 1.47, 95% CI 1.28, 1.61).