Strengthening laboratory systems in resource-limited settings.

Considerable resources have been invested in recent years to improve laboratory systems in resource-limited settings. We reviewed published reports, interviewed major donor organizations, and conducted case studies of laboratory systems in 3 countries to assess how countries and donors have worked together to improve laboratory services. While infrastructure and the provision of services have seen improvement, important opportunities remain for further advancement. Implementation of national laboratory plans is inconsistent, human resources are limited, and quality laboratory services rarely extend to lower tier laboratories (eg, health clinics, district hospitals). Coordination within, between, and among governments and donor organizations is also frequently problematic. Laboratory standardization and quality control are improving but remain challenging, making accreditation a difficult goal. Host country governments and their external funding partners should coordinate their efforts effectively around a host country's own national laboratory plan to advance sustainable capacity development throughout a country's laboratory system.

Are electronic health records ready for genomic medicine?

PURPOSE: The goal of this project was to assess genetic/genomic content in electronic health records. METHODS: Semistructured interviews were conducted with key informants. Questions addressed documentation, organization, display, decision support and security of family history and genetic test information, and challenges and opportunities relating to integrating genetic/genomics content in electronic health records. RESULTS: There were 56 participants: 10 electronic health record specialists, 18 primary care clinicians, 16 medical geneticists, and 12 genetic counselors. Few clinicians felt their electronic record met their current genetic/genomic medicine needs. Barriers to integration were mostly related to problems with family history data collection, documentation, and organization. Lack of demand for genetics content and privacy concerns were also mentioned as challenges. Data elements and functionality requirements that clinicians see include: pedigree drawing; clinical decision support for familial risk assessment and genetic testing indications; a patient portal for patient-entered data; and standards for data elements, terminology, structure, interoperability, and clinical decision support rules. Although most said that there is little impact of genetics/genomics on electronic records today, many stated genetics/genomics would be a driver of content in the next 5-10 years. CONCLUSIONS: Electronic health records have the potential to enable clinical integration of genetic/genomic medicine and improve delivery of personalized health care; however, structured and standardized data elements and functionality requirements are needed.

Adopting information technology to drive improvements in patient safety: lessons from the Agency for Healthcare Research and Quality health information technology grantees.

OBJECTIVES: To document and assess the experiences of 104 Agency for Healthcare Research and Quality (AHRQ)-funded health information technology (health IT) grantees in planning and implementing health IT systems. DATA SOURCE: Grant proposals and interviews with the AHRQ health IT grantees. DATA COLLECTION METHOD: Extracted descriptive data from the health IT grant proposals; conducted telephone interviews with principal investigators. PRINCIPAL FINDINGS: AHRQ funding of the health IT projects provided important support for health IT development work in various health care settings. Successful implementation required commitment from top management, dedicated staff and financial resources, an open process to encourage buy-in and enthusiasm by end users, and sheer persistence. Technologies required tailoring to the specific organization's needs. Grantees felt their projects could be replicated by others, if organizations had ample IT expertise and resources. Evaluating the value of health IT was hampered by the absence of validated instruments and measures, organizational demands that competed with data collection, and lack of evaluation expertise among health IT implementers. CONCLUSIONS: Experiences of the health IT grantees provide rich information for use by health care providers, AHRQ, and other policy makers to help strengthen future health IT development efforts, including the need to improve evaluation design and standards to assess impact.

Outpatient mental health utilization among commercially insured individuals: in- and out-of-network care.

OBJECTIVE: This study examined the rates and correlates of out-of-network outpatient mental health specialty care. RESEARCH DESIGN: Using administrative data from a large insurer, we examine the frequency of out-of-network utilization, analyze demographic and clinical characteristics of individuals receiving out-of-network care, and examine the types of service provided out-of-network. RESULTS: Out-of-network outpatient mental health care was received by 15.4% of adults who used outpatient mental health services, with 11.8% of adult outpatient mental health users receiving only out-of-network care and 3.6% receiving both in-network and out-of-network care. Out-of-network users received significantly more outpatient mental health care than individuals receiving only in-network mental health care. Rates of out-of-network psychotherapy services were substantially greater than for other commonly provided mental health services. CONCLUSION: A significant number of patients covered under this insurer received their outpatient mental health care out-of-network. This is most pronounced for individuals receiving psychotherapy. Further information is needed to improve our understanding of who seeks care from out-of-network providers and why as well as the effect of such care on clinical outcomes.

Can electronic medical record systems transform health care? Potential health benefits, savings, and costs.

To broadly examine the potential health and financial benefits of health information technology (HIT), this paper compares health care with the use of IT in other industries. It estimates potential savings and costs of widespread adoption of electronic medical record (EMR) systems, models important health and safety benefits, and concludes that effective EMR implementation and networking could eventually save more than $81 billion annually--by improving health care efficiency and safety--and that HIT-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits. However, this is unlikely to be realized without related changes to the health care system.

Functional characteristics of commercial ambulatory electronic prescribing systems: a field study.

OBJECTIVE: To compare the functional capabilities being offered by commercial ambulatory electronic prescribing systems with a set of expert panel recommendations. DESIGN: A descriptive field study of ten commercially available ambulatory electronic prescribing systems, each of which had established a significant market presence. Data were collected from vendors by telephone interview and at sites where the systems were functioning through direct observation of the systems and through personal interviews with prescribers and technical staff. MEASUREMENTS: The capabilities of electronic prescribing systems were compared with 60 expert panel recommendations for capabilities that would improve patient safety, health outcomes, or patients' costs. Each recommended capability was judged as having been implemented fully, partially, or not at all by each system to which the recommendation applied. Vendors' claims about capabilities were compared with the capabilities found in the site visits. RESULTS: On average, the systems fully implemented 50% of the recommended capabilities, with individual systems ranging from 26% to 64% implementation. Only 15% of the recommended capabilities were not implemented by any system. Prescribing systems that were part of electronic health records (EHRs) tended to implement more recommendations. Vendors' claims about their systems' capabilities had a 96% sensitivity and a 72% specificity when site visit findings were considered the gold standard. CONCLUSIONS: The commercial electronic prescribing marketplace may not be selecting for capabilities that would most benefit patients. Electronic prescribing standards should include minimal functional capabilities, and certification of adherence to standards may need to take place where systems are installed and operating.

Recommendations for comparing electronic prescribing systems: results of an expert consensus process.

Commercially available electronic prescribing systems may differ in their effects on patients' health outcomes and on patients' ability to manage costs. An expert panel convened to recommend specific features that would enable electronic prescribing systems to advance these goals. The panel authored sixty recommendations and rated each using a modified Delphi process. Ratings identified fifty-two recommendations as clearly positive for patient safety and health outcomes and forty-three recommendations as achievable in the average clinician's office within three years. Overall, these recommendations offer a synthesis of evidence and expert opinion that can help guide the development of electronic prescribing policy.