Improving the Delivery of Health Services at the Health Systems Level - Emerging Research
Clinicians have used telehealth and telemedicine in rural settings and for hard-to-access specialties for years, but its use became ubiquitous during the COVID-19 pandemic. AHRQ-funded research is evaluating how telehealth can be more seamlessly integrated into clinical care, including the following:
Dr. Sunday Clark of the Society for Academic Emergency Medicine is convening a conference on telehealth in emergency medicine to develop a national research agenda supporting telehealth in emergency medicine. The conference will aim to strengthen the collaborative exchange of ideas among stakeholders for prioritizing research agendas and best practices that may lead to improvements in patient outcomes and reduce disparities for patients seeking emergency care.
Dr. Daniella Meeker from the University of Southern California is studying the impacts of the COVID-19 pandemic on telehealth utilization, outcomes, and disparities to improve the healthcare system’s readiness for future public health emergencies. The research team will use a nationwide information system of telehealth services and insurance claims to explore variations between diagnostic and treatment patterns for telehealth versus in-person outpatient care, as well as the ability of telehealth to fill the gaps in ambulatory care. The research aims to elucidate whether telehealth data may be used as a public health surveillance tool to improve an ambulatory care pandemic response.
AHRQ has long been at the forefront of advancing and disseminating effective tools and strategies to spread knowledge and associated evidence-based interventions on a wider scale, including across healthcare settings and software vendors. The following studies demonstrate AHRQ’s commitment to disseminate and scale successful tools and strategies across different healthcare systems and technologies (e.g., different EHRs) and disseminate lessons learned about how to achieve scalability and interoperability.
Dr. Deborah Jill Cohen of Oregon Health and Science University is developing an evidence-based practical guide to integrating patient-generated digital health data into EHRs of ambulatory care practices. This work aims to advance the integration and meaningful use of patient-generated digital health data, including collecting these data collaboratively with patients and identifying patterns and red flags for clinical workflows and care planning.
Dr. Saira Haque and a team of researchers at RTI International are pilot testing two open-source electronic care (e-care) plan applications for managing patients with chronic kidney disease and at least one additional chronic condition. Both e-care applications—one provider-facing and the other patient-facing—retrieve patient data and related resources from EHRs and other health IT systems for aggregation, analysis, and sharing with other healthcare team members. Both e-care plan applications will be open-source, SMART on FHIR applications in order to advance the use of e-care plans for patients with multiple chronic conditions across different healthcare settings.
A team of researchers at the MITRE Corporation, led by Kathy Mikk, JD, is developing a prototype infrastructure that enables the automated discovery and retrieval of patient-centered outcomes research (PCOR) findings within repositories maintained by AHRQ’s Center for Evidence and Practice Improvement (CEPI). The goal of the CEPI Evidence Discovery and Retrieval (CEDAR) project is to make these evidence repositories more findable, accessible, interoperable, and reusable (FAIR) using technologies such as application programming interfaces (APIs). These technologies allow health information technology developers to design new and exciting ways to make information available where, when, and how stakeholders need it most.
Dr. Kit N. Simpson and Dr. Kathryn L. King are investigating the quality and efficacy of the Medical University of South Carolina’s four innovative telehealth programs launched during the COVID-19 pandemic: 1) virtual urgent care screening, 2) remote patient monitoring for COVID-19 positive patients, 3) continuous virtual monitoring to reduce workforce risk and utilization of personal protective equipment, and 4) the transition of outpatient care to telehealth. The research team will evaluate overall patient volumes, service uptake, delivery learning curves, safety and quality indicators over time, and population health outcomes. The goal of this research is to provide evidence needed to evolve patient care post-COVID-19 that will ensure the highest quality of care, support changes in payment regulations, reduce the health disparities currently present with the delivery of telehealth services, and promote equal access for all.
A team led by Drs. Alex Spyropoulos and Thomas G. McGinn of the Feinstein Institute for Medical Research is investigating the integration of a service-oriented architecture (SOA) platform-based CDS system into inpatient and emergency department clinical workflows. The research team will embed two validated clinical prediction rules (CPRs) in two commercial EHRs using a CDS system built on a SOA. The research team hypothesizes that by using CDS implemented with standards and service-oriented architecture, guidelines could be implemented throughout the healthcare system, allowing for faster dissemination and updates when guidelines change. Such an approach could markedly reduce the cost of developing and maintaining CDS, and potentially increase the uptake of evidence-based research findings into clinical practice.
Nurses are directly involved in almost all aspects of patient care in acute care settings, including bedside and medication management, monitoring and assessing, and performing immediate interventions to reduce risk or prevent medical complications. AHRQ investigates how digital healthcare solutions and other health IT can support the work of nurses to improve quality of care and medication safety.
Dr. Carolyn J. Sun of Hunter College is investigating the use of an innovative nursing surveillance tool to monitor bedside shift reporting and hourly rounding. The surveillance tool includes wall-mounted hardware in the patient room with computer vision to provide constant surveillance, a Wi-Fi operated call bell, color-coded call lights, and a companion software supplied via a mobile phone app that integrates all these technologies. The research team will analyze the comprehensive data on BSR, HR, and other nurse interactions at the bedside and their effect on nurse-sensitive patient outcomes such as patient falls, pressure ulcer injuries, and hospital-acquired infections.
Led by Dr. Raj M. Ratwani, a team of researchers at the MedStar Health Research Institute is investigating the usability and safety hazards associated with electronic medication administration records (eMARs) in acute inpatient settings. The research team will develop a human factors-informed medication administration workflow risk assessment tool that allows healthcare facility leaders and EHR vendors to assess information flow, design, and safety of eMARs systems. The overall study goal is to improve medication administration workflow and reduce medication errors. This has been particularly important during the COVID-19 pandemic, as nurses are managing higher-acuity patients and complex medication treatments, while also limiting exposure to infected patients.
Care coordination involves deliberately organizing patient care activities and sharing information among all providers involved with a patient to achieve safer and more effective care. Such coordination includes knowing a patient's needs and preferences in advance of needing care and ensuring that this information leads to safe, appropriate, and effective care for a patient. AHRQ funds research on promising interventions aimed at improving communication and coordination, especially during care transitions. During the transition of care, critical information about a patient’s condition and health outcomes needs to be communicated accurately and coordinated between the care teams, the patient, and family to ensure that safe, high-quality care is provided, and care continuity is maintained.
Dr. Giana Davidson and team at the University of Washington are evaluating the Pharmacy Integrated Transitions (PIT) program and its effect on medication-related problems and patient and caregiver satisfaction among those transitioning from a hospital to a skilled nursing facility. The research team is comparing the traditional, paper-based Joint Commission discharge process to the PIT program, which involves a structured handoff between clinical teams using teleconferencing and a pharmacist to monitor patient medication in the process. The PIT program aims to deter medication-related issues, improve communication between providers and patients, reduce hospital readmissions, and alleviate patient emotional distress by appropriately addressing medication safety during care transitions.
Led by Dr. Arti D. Desai and team at Seattle Children’s Hospital are investigating the use of a novel cloud-based, multidisciplinary care plan, Cloud Care, for children with medical complexity. Cloud Care stores data about a patient’s care plan based on priorities highlighted by parents and providers. Members of the care team can collaboratively review and edit the care plan in real time. The research team is studying the feasibility and acceptability of Cloud Care with the goals of increasing the utility of care plans to inform care coordination for this vulnerable population of children and to improve patient- and family-centered outcomes.
Health information systems are rapidly being implemented and optimized in a variety of healthcare environments, including emergency departments. These systems offer promising solutions to challenges related to cost, efficiency, patient safety, and medical errors, but technologies must be implemented in ways that support provider workflow and reduce cognitive burden. The following research highlights AHRQ-funded work on the use of digital healthcare solutions to support improvements in emergency medicine.
The COVID-19 pandemic has exposed vulnerabilities across the U.S. healthcare system. These include challenges related to prevention, such as containment strategies to prevent spread; preparation, such as ensuring sufficient supplies for testing and personal protective equipment; and response, such as anticipating surge events and ensuring sufficient staffing, space, and supplies. Drs. David R. Kaufman and Yalini Senathirajah of SUNY Downstate Medical Center are investigating the data needs, decision-making processes, and clinical workflows of hospitals that have been highly impacted by the COVID-19 pandemic. The research team will employ cognitive engineering frameworks to model information workflow and to inform the development of a set of prototypes, including dashboards, visualizations, and data integration tools. The overall goal is to improve emergency responsiveness to more common emergency preparedness events.
Led by Dr. Titus Schleyer of Indiana University–Purdue University at Indianapolis is studying the use of an HIE and EHR integration application, Health Dart, on data access and use in ED settings. Health Dart, using FHIR standards, grants providers access to relevant HIE data based on an initial set of conditions, including chest pain, abdominal pain, dizziness, back pain, pregnancy, arrhythmia, and dyspnea. The research team is studying clinician acceptance of the Health Dart application, data utilization, and overall impact on clinical outcomes. The study aims to further the use of interoperable technologies nationwide as a strategy to reduce unnecessary diagnostic tests, medical expenses, and provider burden in emergency care.