Browsing by Author "Boockvar, Kenneth S."

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    Clinicians' use of Health Information Exchange technologies for medication reconciliation in the U.S. Department of Veterans Affairs: a qualitative analysis
    (Springer Nature, 2024-10-08) Snyder, Margie E.; Nguyen, Khoa A.; Patel, Himalaya; Sanchez, Steven L.; Traylor, Morgan; Robinson, Michelle J.; Damush, Teresa M.; Taber, Peter; Mixon, Amanda S.; Fan, Vincent S.; Savoy, April; Dismore, Rachel A.; Porter, Brian W.; Boockvar, Kenneth S.; Haggstrom, David A.; Locke, Emily R.; Gibson, Bryan S.; Byerly, Susan H.; Weiner, Michael; Russ-Jara, Alissa L.; Medicine, School of Medicine
    Background: Medication reconciliation is essential for optimizing medication use. In part to promote effective medication reconciliation, the Department of Veterans Affairs (VA) invested substantial resources in health information exchange (HIE) technologies. The objectives of this qualitative study were to characterize VA clinicians' use of HIE tools for medication reconciliation in their clinical practice and to identify facilitators and barriers. Methods: We recruited inpatient and outpatient prescribers (physicians, nurse practitioners, physician assistants) and pharmacists at four geographically distinct VA medical centers for observations and interviews. Participants were observed as they interacted with HIE or medication reconciliation tools during routine work. Participants were interviewed about clinical decision-making pertaining to medication reconciliation and use of HIE tools, and about barriers and facilitators to use of the tools. Qualitative data were analyzed via inductive and deductive approaches using a priori codes. Results: A total of 63 clinicians participated. Over half (58%) were female, and the mean duration of VA clinical experience was 7 (range 0-32) years. Underlying motivators for clinicians seeking data external to their VA medical center were having new patients, current patients receiving care from an external institution, and clinicians' concerns about possible medication discrepancies among institutions. Facilitators for using HIE software were clinicians' familiarity with the HIE software, clinicians' belief that medication information would be available within HIE, and their confidence in the ability to find HIE medication-related data of interest quickly. Six overarching barriers to HIE software use for medication coordination included visual clutter and information overload within the HIE display; challenges with HIE interface navigation; lack of integration between HIE and other electronic health record interfaces, necessitating multiple logins and application switching; concerns with the dependability of HIE medication information; unfamiliarity with HIE tools; and a lack of HIE data from non-VA facilities. Conclusions: This study is believed to be the first to qualitatively characterize clinicians' HIE use with respect to medication reconciliation. Results inform recommendations to optimize HIE use for medication management activities. We expect that healthcare organizations and software vendors will be able to apply the findings to develop more effective and usable HIE information displays.
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    Effect of Health Information Exchange Plus a Care Transitions Intervention on Post-Hospital Outcomes Among VA Primary Care Patients: a Randomized Clinical Trial
    (Springer, 2022-02-23) Boockvar, Kenneth S.; Koufacos, Nicholas S.; May, Justine; Schwartzkopf, Ashley L.; Guerrero, Vivian M.; Judon, Kimberly M.; Schubert , Cathy C.; Franzosa, Emily; Dixon, Brian E.; Epidemiology, Richard M. Fairbanks School of Public Health
    Background Health information exchange (HIE) notifications when patients experience cross-system acute care encounters offer an opportunity to provide timely transitions interventions to improve care across systems. Objective To compare HIE notification followed by a post-hospital care transitions intervention (CTI) with HIE notification alone. Design Cluster-randomized controlled trial with group assignment by primary care team. Patients Veterans 65 or older who received primary care at 2 VA facilities who consented to HIE and had a non-VA hospital admission or emergency department visit between 2016 and 2019. Interventions For all subjects, real-time HIE notification of the non-VA acute care encounter was sent to the VA primary care provider. Subjects assigned to HIE plus CTI received home visits and telephone calls from a VA social worker for 30 days after arrival home, focused on patient activation, medication and condition knowledge, patient-centered record-keeping, and follow-up. Measures Primary outcome: 90-day hospital admission or readmission. Secondary outcomes: emergency department visits, timely VA primary care team telephone and in-person follow-up, patients’ understanding of their condition(s) and medication(s) using the Care Transitions Measure, and high-risk medication discrepancies. Key Results A total of 347 non-VA acute care encounters were included and assigned: 159 to HIE plus CTI and 188 to HIE alone. Veterans were 76.9 years old on average, 98.5% male, 67.8% White, 17.1% Black, and 15.1% other (including Hispanic). There was no difference in 90-day hospital admission or readmission between the HIE-plus-CTI and HIE-alone groups (25.8% vs. 20.2%, respectively; risk diff 5.6%; 95% CI − 3.3 to 14.5%, p = .25). There was also no difference in secondary outcomes. Conclusions A care transitions intervention did not improve outcomes for veterans after a non-VA acute care encounter, as compared with HIE notification alone. Additional research is warranted to identify transitions services across systems that are implementable and could improve outcomes.
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    Event Notification in Support of Population Health: The Promise and Challenges from a Randomized Controlled Trial
    (IOS Press, 2017) Dixon, Brian E.; Boockvar, Kenneth S.; Epidemiology, School of Public Health
    Event notifications are real-time, electronic alerts that have the promise of improving population health by exchanging critical information to a patient's extended care team. In a trial of event noficiations in U.S. Veterans Affairs facilities, we seek to understand the impact of notifications on health care utilization within 30 and 90-days. Lessons from the trial have implications beyond the evidence by informing strategies to develop and implement event notifications in other health systems.
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    Event Notification in Support of Population Health: The Promise and Challenges from a Randomized Controlled Trial
    (IOS Press, 2017) Dixon, Brian E.; Boockvar, Kenneth S.; Epidemiology, School of Public Health
    Event notifications are real-time, electronic alerts that have the promise of improving population health by exchanging critical information to a patient's extended care team. In a trial of event noficiations in U.S. Veterans Affairs facilities, we seek to understand the impact of notifications on health care utilization within 30 and 90-days. Lessons from the trial have implications beyond the evidence by informing strategies to develop and implement event notifications in other health systems.
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    Impact of event notification services on timely follow-up and rehospitalization among primary care patients at two Veterans Affairs Medical Centers
    (Oxford University Press, 2021-11-25) Dixon, Brian E.; Judon, Kimberly M.; Schwartzkopf, Ashley L.; Guerrero, Vivian M.; Koufacos, Nicholas S.; May, Justine; Schubert, Cathy C.; Boockvar, Kenneth S.; Medicine, School of Medicine
    Objective: To examine the effectiveness of event notification service (ENS) alerts on health care delivery processes and outcomes for older adults. Materials and methods: We deployed ENS alerts in 2 Veterans Affairs (VA) medical centers using regional health information exchange (HIE) networks from March 2016 to December 2019. Alerts targeted VA-based primary care teams when older patients (aged 65+ years) were hospitalized or attended emergency departments (ED) outside the VA system. We employed a concurrent cohort study to compare postdischarge outcomes between patients whose providers received ENS alerts and those that did not (usual care). Outcome measures included: timely follow-up postdischarge (actual phone call within 7 days or an in-person primary care visit within 30 days) and all-cause inpatient or ED readmission within 30 days. Generalized linear mixed models, accounting for clustering by primary care team, were used to compare outcomes between groups. Results: Compared to usual care, veterans whose primary care team received notification of non-VA acute care encounters were 4 times more likely to have phone contact within 7 days (AOR = 4.10, P < .001) and 2 times more likely to have an in-person visit within 30 days (AOR = 1.98, P = .007). There were no significant differences between groups in hospital or ED utilization within 30 days of index discharge (P = .057). Discussion: ENS was associated with increased timely follow-up following non-VA acute care events, but there was no associated change in 30-day readmission rates. Optimization of ENS processes may be required to scale use and impact across health systems. Conclusion: Given the importance of ENS to the VA and other health systems, this study provides guidance for future research on ENS for improving care coordination and population outcomes.
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    Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention
    (Taylor & Francis, 2022) Koufacos, Nicholas S.; May, Justine; Judon, Kimberly; Franzosa, Emily; Dixon, Brian E.; Schubert, Cathy C.; Schwartzkopf, Ashley L.; Guerrero, Vivian M.; Traylor, Morgan; Boockvar, Kenneth S.; Medicine, School of Medicine
    Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.
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    Perceptions of event notification following discharge to improve geriatric care: qualitative interviews of care team members from a 2-site cluster randomized trial
    (Oxford University Press, 2021) Franzosa, Emily; Traylor, Morgan; Judon, Kimberly M.; Guerrero Aquino, Vivian; Schwartzkopf, Ashley L.; Boockvar, Kenneth S.; Dixon, Brian E.; Epidemiology, Richard M. Fairbanks School of Public Health
    Objective: To assess primary care teams' perceptions of a health information exchange (HIE) event notification intervention for geriatric patients in 2 Veterans Health Administration (VHA) medical centers. Materials and methods: We conducted a qualitative evaluation of an event notification alerting primary care teams to non-VHA hospital admissions and emergency department visits. Data were collected through semistructured interviews (n = 23) of primary care team physicians, nurses and medical assistants. Study design and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Results: Team members found the alerts necessary, helpful for filling information gaps, and effective in supporting timely follow-up care, although some expressed concern over scheduling capacity and distinguishing alerts from other VHA notices. Participants also suggested improvements including additional data on patients' diagnosis and discharge instructions, timing alerts to patients' discharge (including clear next steps), including additional team members to ensure alerts were acted upon, and implementing a single sign-on. Discussion: Primary care team members perceived timely event notification of non-VHA emergency department visits and hospital admissions as potentially improving post-discharge follow-up and patient outcomes. However, they were sometimes unsure of next steps and suggested the alerts and platform could be streamlined for easier use. Conclusions: Event notifications may be a valuable tool in coordinating care for high-risk older patients. Future intervention research should explore the optimal amount and types of information and delivery method across sites and test the integration of alerts into broader care coordination efforts.
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    Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial
    (Biomed Central, 2019-07-04) Dixon, Brian E.; Schwartzkopf, Ashley L.; Guerrero, Vivian M.; May, Justine; Koufacos, Nicholas S.; Bean, Andrew M.; Penrod, Joan D.; Schubert, Cathy C.; Boockvar, Kenneth S.; Epidemiology, Richard M. Fairbanks School of Public Health
    BACKGROUND: Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. METHODS: In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. DISCUSSION: While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered 23 February 2016.