Publications by authors named "Robert G Brooks"

69 Publications

Healthcare costs associated with antiretroviral adherence among medicaid patients.

Appl Health Econ Health Policy 2015 Feb;13(1):69-80

College of Public Health, Health Policy and Management, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612-3805, USA,

Background: The relationship of antiretroviral therapy (ART) adherence to total healthcare expenditures for Medicaid-insured people living with HIV or AIDS (PLWHA) is not well understood, especially among asymptomatic HIV-positive patients.

Objective: This study examined Medicaid-insured HIV-positive and AIDS-diagnosed patient groups to determine the association of ART adherence to mean monthly total healthcare expenditures in the 24-month measurement period, controlling for demographic, geographic, insurance, and clinical factors. The present study extends the existing literature by analyzing the relationship of ART adherence to total healthcare costs for asymptomatic HIV-positive patients separately from those patients with AIDS-defining conditions.

Methods: This retrospective study utilized claims data from Florida Medicaid claims from July 2006 through June 2011. All patients (n = 502) were HIV-positive, aged 18-64 years, non-pregnant, and ART naïve for at least 12 months prior to the measurement period. Each patient was categorized, based on medication possession ratios, as adherent (≥90 %) or non-adherent (<90 %), and were divided into two groups: HIV positive (n = 232) and AIDS diagnosed (n = 270). Generalized linear models predicted the mean monthly total expenditures for the non-adherence group versus the adherence group.

Results: For the HIV-positive group, the adjusted mean monthly expenditures for the non-adherent group were US$1,291; the adherent group adjusted mean monthly expenditures were US$1,926. The HIV-positive non-adherent group adjusted mean monthly expenditures were significantly less than the adherent group (-40 %, p < 0.001). However, for the AIDS-diagnosed group, there was not a statistically significant association of ART adherence to total healthcare expenditures (p = 0.29).

Conclusion: The results show that the relationship of ART adherence to healthcare costs is more complex than previously reported.
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http://dx.doi.org/10.1007/s40258-014-0138-1DOI Listing
February 2015

Characteristics of all, occasional, and frequent emergency department visits due to ambulatory care-sensitive conditions in Florida.

J Ambul Care Manage 2012 Apr-Jun;35(2):149-58

Department of Healthcare Policy and Research, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA.

We studied characteristics of all, occasional, and frequent emergency department (ED) visits due to ambulatory care-sensitive conditions (ACSCs). We used a cross-sectional, split-sample design with multivariate logistic regressions using encounter-level, all-payer ED data from all Florida hospitals for the year of 2005. We evaluated associations of key patient characteristics, characteristics of ED utilization, and availability of primary care physicians in the area, with ED visits for ACSCs. We concluded that factors associated with ED use for ACSCs were similar for occasional and frequent ED users. Therefore, universal strategies for reduction of ED overutilization by increasing access to, timeliness, and quality of primary care for all patients likely to experience ACSCs should be used.
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http://dx.doi.org/10.1097/JAC.0b013e318244d222DOI Listing
July 2012

Physician and practice characteristics associated with longitudinal increases in electronic health records adoption.

J Healthc Manag 2011 May-Jun;56(3):183-97; discussion 197-8

University of Alabama at Birmingham, USA.

This article identifies practice- and physician-related characteristics associated with the increased use of EHRs by physicians in outpatient practices. Two Florida surveys conducted in 2005 and 2008 on physician use of EHRs were examined to determine the practice and physician characteristics associated with increased EHR use over time. Based on multivariate analysis, several variables were found to influence increased EHR adoption. Practice variables included participation in a single-specialty practice and percentage of Medicare patients in the practice, but not percentage of Medicaid patients in the practice. Physician characteristics included younger physician age, but not specialty nor years practicing in the community. Factors associated with EHR adoption at any given point in time did not necessarily predict longitudinal increases in EHR adoption. These results are important for physicians to consider in their potential adoption of EHRs and should also be considered by policymakers interested in promoting increased use of EHRs by physicians.
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July 2011

The use of physician-patient email: a follow-up examination of adoption and best-practice adherence 2005-2008.

J Med Internet Res 2011 Feb 25;13(1):e23. Epub 2011 Feb 25.

School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35294, USA.

Background: Improved communication from physician- patient emailing is an important element of patient centeredness. Physician-patient email use has been low; and previous data from Florida suggest that physicians who email with patients rarely implement best-practice guidelines designed to protect physicians and patients.

Objective: Our objective was to examine whether email use with patients has changed over time (2005-2008) by using two surveys of Florida physicians, and to determine whether physicians have more readily embraced the best-practice guidelines in 2008 versus 2005. Lastly, we explored the 2008 factors associated with email use with patients and determined whether these factors changed relative to 2005.

Methods: Our pooled time-series design used results from a 2005 survey (targeting 14,921 physicians) and a separate 2008 survey (targeting 7003 different physicians). In both years, physicians practicing in the outpatient setting were targeted with proportionally identical sampling strategies. Combined data from questions focusing on email use were analyzed using chi-square analysis, Fisher exact test, and logistic regression.

Results: A combined 6260 responses were available for analyses, representing a participation rate of 28.2% (4203/14,921) in 2005 and 29.4% (2057/7003) in 2008. Relative to 2005, respondents in 2008 were more likely to indicate that they personally used email with patients (690/4148, 16.6% vs 408/2001, 20.4%, c(2) (1) = 13.0, P < .001). However, physicians who reported frequently using email with patients did not change from 2005 to 2008 (2.9% vs 59/2001, 2.9%). Interest among physicians in future email use with patients was lower in 2008 (58.4% vs 52.8%, c(2) (2) = 16.6, P < .001). Adherence to email best practices remained low in 2008. When comparing 2005 and 2008 adherences with each of the individual guidelines, rates decreased over time in each category and were significantly lower for 4 of the 13 guidelines. Physician characteristics in 2008 that predicted email use with patients were different from 2005. Specifically, in multivariate analysis female physicians (OR 1.48, 95% CI 1.12-1.95), specialist physicians (OR 1.43, 95% CI 1.12-1.84), and those in a multispecialty practice (OR 1.76, 95% CI 1.30-2.37) were more likely than their counterparts to email with patients. Additionally, self-reported computer competency levels (on a 5-point Likert scale) among physicians predicted email use at every level of response.

Conclusions: Email use between physicians and patients has changed little between 2005 and 2008. However, future physician interest in using email with patients has decreased. More troubling is the decrease in adherence to best practices designed to protect physicians and patients when using email. Policy makers wanting to harness the potential benefits of physician-patient email should devise plans to encourage adherence to best practices. These plans should also educate physicians on the existence of best practices and methods to incorporate these guidelines into routine workflows.
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http://dx.doi.org/10.2196/jmir.1578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221345PMC
February 2011

EHR adoption among doctors who treat the elderly.

J Eval Clin Pract 2010 Dec;16(6):1103-7

Department of Health Care Organization and Policy, University of Alabama at Birmingham, School of Public Health, Birmingham, AL, USA.

Objectives: The purpose of this study is to examine Electronic Health Record (EHR) adoption among Florida doctors who treat the elderly. This analysis contributes to the EHR adoption literature by determining if doctors who disproportionately treat the elderly differ from their counterparts with respect to the utilization of an important quality-enhancing health information technology application.

Methods: This study is based on a primary survey of a large, statewide sample of doctors practising in outpatient settings in Florida. Logistic regression analysis was used to determine whether doctors who treat a high volume of elderly (HVE) patients were different with respect to EHR adoption.

Results: Our analyses included responses from 1724 doctors. In multivariate analyses controlling for doctor age, training, computer sophistication, practice size and practice setting, HVE doctors were significantly less likely to adopt EHR. Specifically, compared with their counterparts, HVE doctors were observed to be 26.7% less likely to be utilizing an EHR system (OR=0.733, 95% CI 0.547-0.982). We also found that doctor age is negatively related to EHR adoption, and practice size and doctor computer savvy-ness is positively associated.

Conclusions: Despite the fact that EHR adoption has improved in recent years, doctors in Florida who serve the elderly are less likely to adopt EHRs. As long as HVE doctors are adopting EHR systems at slower rates, the elderly patients treated by these doctors will be at a disadvantage with respect to potential benefits offered by this technology.
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http://dx.doi.org/10.1111/j.1365-2753.2009.01277.xDOI Listing
December 2010

The influence of payer mix on electronic prescribing by physicians.

Health Care Manage Rev 2011 Jan-Mar;36(1):95-101

Health Services Administration, University of Alabama at Birmingham, USA.

Background: Limited studies have examined electronic prescribing (e-prescribing) adoption in physician office practices. Specifically, none have explored the influence of payer mix on e-prescribing adoption among physicians.

Purpose: This study examines the impact of practice composition of Medicare, Medicaid, and private insurance on e-prescribing adoption among physicians.

Methodology/approach: Logistic regression was used to analyze data collected from a large-scale information technology-related survey of Florida physicians.

Findings: After controlling for practice and physician characteristics, physicians with the highest (odds ratio = 1.67, 95% confidence interval = 1.01-2.78) and above-average (odds ratio [OR] = 1.83, 95% confidence interval = 1.04-3.22) volume of Medicare patients were significantly more likely to e-prescribe as compared with those in the low-volume category. No differences in adoption were found across all Medicaid and private insurance practice composition categories.

Practice Implications: Our findings support the notion that direct incentives, such as those in the Medicare Modernization Act of 2003, may influence physician adoption of e-prescribing.
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http://dx.doi.org/10.1097/HMR.0b013e3181dc8246DOI Listing
August 2012

Strategy, structure, and patient quality outcomes in ambulatory surgery centers (1997-2004).

Med Care Res Rev 2011 Apr 9;68(2):202-25. Epub 2010 Sep 9.

Department of Healthcare Policy and Research, Virginia Commonwealth University, School of Medicine, P.O. Box 980430, Richmond, VA 23298, USA.

The purpose of this study was to examine potential associations among ambulatory surgery centers' (ASCs) organizational strategy, structure, and quality performance. The authors obtained several large-scale, all-payer claims data sets for the 1997 to 2004 period. The authors operationalized quality performance as unplanned hospitalizations at 30 days after outpatient arthroscopy and colonoscopy procedures. The authors draw on related organizational theory, behavior, and health services research literatures to develop their conceptual framework and hypotheses and fitted fixed and random effects Poisson regression models with the count of unplanned hospitalizations. Consistent with the key hypotheses formulated, the findings suggest that higher levels of specialization and the volume of procedures may be associated with a decrease in unplanned hospitalizations at ASCs.
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http://dx.doi.org/10.1177/1077558710378523DOI Listing
April 2011

Predictors of physician satisfaction among electronic health record system users.

J Healthc Qual 2010 Jan-Feb;32(1):35-41

Department of Heath Care Organization and Policy, University of Alabama, Birmingham School of Public Health, AL, USA.

Electronic health records (EHRs) have experienced slow adoption rates but play an important role in improving ambulatory quality of care. Sustained use of EHRs is closely related to physician satisfaction, however little research exists on this issue. We focused on physician EHR users to determine factors that are related to satisfaction with the level of computerization in their office practice. After controlling for various factors, physicians with more robust EHRs, and those who adopted their system two or more years ago, were more likely to be satisfied. Lastly, several individual EHR functionalities were independently related to improved satisfaction.
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http://dx.doi.org/10.1111/j.1945-1474.2009.00062.xDOI Listing
March 2010

How well does diagnosis-based risk-adjustment work for comparing ambulatory clinical outcomes?

Health Care Manag Sci 2009 Dec;12(4):420-33

Department of Family Medicine and Rural Health, Florida State University College of Medicine, 1115 West Call Street, Suite 3200-C, Tallahassee, FL 32306-4300, USA.

This paper examines the empirical consistency of the Diagnosis Cost Groups/Hierarchical Condition Categories (DCG/HCC) risk-adjustment method for comparing 7-day mortality between hospital-based outpatient departments (HOPDs) and freestanding ambulatory surgery centers (ASCs). We used patient level data for the three most common outpatient procedures provided during the 1997-2004 period in Florida. We estimated base-line logistic regression models without any diagnosis-based risk adjustment and compared them to logistic regression models with the DCG/HCC risk-adjustment, and to conditional logit models with a matched cohort risk-adjustment approach. We also evaluated models that adjusted for primary diagnoses only, and then for all available diagnoses, to assess how the frequently absent secondary diagnoses fields in ambulatory surgical data affect risk-adjustment. We found that risk-adjustment using both diagnosis-based methods resulted in similar 7-day mortality estimates for HOPD patients in comparison with ASC patients in two out of three procedures. We conclude that the DCG/HCC risk-adjustment method is relatively consistent and stable, and recommend this risk-adjustment method for health policy research and practice with ambulatory surgery data. We also recommend using risk-adjustment with all available diagnoses.
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http://dx.doi.org/10.1007/s10729-009-9101-3DOI Listing
December 2009

Postdischarge adverse events in children: a cause for concern.

Jt Comm J Qual Patient Saf 2009 Dec;35(12):620-1

Center on Patient Safety, Florida State University College of Medicine, Tallahassee, USA.

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http://dx.doi.org/10.1016/s1553-7250(09)35087-4DOI Listing
December 2009

Quality improvement in local health departments: results of the NACCHO 2008 survey.

J Public Health Manag Pract 2010 Jan-Feb;16(1):49-54

Florida State University College of Medicine, Tallahassee, Florida 32306, USA.

Objectives: To assess the current status of quality improvement (QI) within local health departments (LHDs) and examine the characteristics associated with such QI efforts.

Methods: A QI module was administered to a representative sample of 545 LHDs along with the core instrument in the 2008 NACCHO Profile survey of all LHDs nationally. Using the Profile survey data set, a quantitative approach was employed to determine the current status of QI within LHDs. Statistical analysis was performed to identify characteristics of LHDs associated with QI. The response rate to the QI module was 82 percent.

Results: Of the 448 LHDs that responded to the QI Module, 55 percent reported conducting formal QI efforts during the previous 2 years. Forty-four percent of these LHDs used a specific framework for QI, 56 percent used at least one of four commonly employed QI tools or techniques, and customer focus and satisfaction was the most frequently reported area (76%) of QI efforts. LHDs with large size of jurisdiction population and those with centralized governance were more likely to have engaged in quality or performance improvement, have managers who received formal QI training, and have provided QI training to staff.

Conclusion: The 2008 NACCHO Profile QI module furnishes an excellent baseline for measuring progress of health department QI activities as accreditation and other related activities intensify. A clear definition of QI in public health that is understood by practitioners will greatly increase our ability to measure the adoption of QI by LHDs. Further research is necessary to identify and explore some of the predictors and possible barriers to increasing the application of QI by LHDs.
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http://dx.doi.org/10.1097/PHH.0b013e3181bedd0cDOI Listing
May 2012

The role of information technology usage in physician practice satisfaction.

Health Care Manage Rev 2009 Oct-Dec;34(4):364-71

Department of Health Care Organization and Policy, University of Alabama at Birmingham, USA.

Background: Despite the growing use of information technology (IT) in medical practices, little is known about the relationship between IT and physician satisfaction.

Purpose: The objective of this study was to examine the relationship between physician IT adoption (of various applications) and overall practice satisfaction, as well as satisfaction with the level of computerization at the practice.

Methods: Data from a Florida survey examining physicians' use of IT and satisfaction were analyzed. Odds ratios (ORs), adjusted for physician demographics and practice characteristics, were computed utilizing logistic regressions to study the independent relationship of electronic health record (EHR) usage, PDA usage, use of e-mail with patients, and the use of disease management software with satisfaction. In addition, we examined the relationship between satisfaction with IT and overall satisfaction with the current medical practice.

Results: In multivariate analysis, EHR users were 5 times more likely to be satisfied with the level of computerization in their practice (OR = 4.93, 95% CI = 3.68-6.61) and 1.8 times more likely to be satisfied with their overall medical practice (OR = 1.77, 95% CI = 1.35-2.32). PDA use was also associated with an increase in satisfaction with the level of computerization (OR = 1.23, 95% CI = 1.02-1.47) and with the overall medical practice (OR = 1.30, 95% CI = 1.07-1.57). E-mail use with patients was negatively related to satisfaction with the level of computerization in the practice (OR = 0.69, 95% CI = 0.54-0.90). Last, physicians who were satisfied with IT were 4 times more likely to be satisfied with the current state of their medical practice (OR = 3.97, 95% CI = 3.29-4.81).

Implications: Physician users of IT applications, especially EHRs, are generally satisfied with these technologies. Potential adopters and/or policy makers interested in influencing IT adoption should consider the positive impact that computer automation can have on medical practice.
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http://dx.doi.org/10.1097/HMR.0b013e3181a90d53DOI Listing
January 2010

The relationship between local hospital IT capabilities and physician EMR adoption.

J Med Syst 2009 Oct;33(5):329-35

Department of Health Care Organization and Policy, UAB School of Public Health, Ryals #330, 1530 3rd Ave. South, Birmingham, AL 35294-0022, USA.

In light of new federal policies allowing hospitals to subsidize the cost of information systems for physicians, we examine the relationship between local hospital investments in information technology (IT) and physician EMR adoption. Data from two Florida surveys were combined with secondary data from the State of Florida and the Area Resource File (ARF). Hierarchal logistic regression was used to examine the effect of hospital adoption of clinical information systems on physician adoption of EMR systems after controlling for confounders. In multivariate analysis, each additional clinical IT application adopted by a local hospital was associated with an 8% increase in the odds of EMR adoption by physicians practicing in that county. Given this existing relationship between hospital IT capabilities and physician adoption patterns, federal policies designed to encourage this more directly will positively promote the proliferation of EMR systems.
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http://dx.doi.org/10.1007/s10916-008-9194-0DOI Listing
October 2009

Quality improvement in local health departments: progress, pitfalls, and potential.

J Public Health Manag Pract 2009 Nov-Dec;15(6):494-502

National Association of County and City Health Officials, Washington, DC, USA.

Objectives: To assess the current deployment of quality improvement (QI) approaches within local health departments (LHDs) and gain a better understanding of the depth and intensity of QI activities.

Methods: A mixed quantitative and qualitative approach was employed to determine the current status of QI utilization within LHDs. All respondents from the 2005 NACCHO Profile QI module questionnaire who indicated that their LHD was involved in some kind of QI activity received a follow-up Web-based survey in 2007. A smaller convenience sample of 30 LHDs representing all groups of respondents was selected for the follow-up interview to validate and expound upon survey data.

Results: Survey response rate was 62 percent (181/292). Eighty-one percent of LHDs reported QI programmatic activities, with 39 percent occurring agency-wide. Seventy-four percent of health departments had staff trained in QI methods. External funding sources for QI were infrequent (28%). LHDs that were serving large jurisdictions and LHDs that were subunits of state health agencies (centralized states) were more likely to engage in most QI activities. However, interview responses did not consistently corroborate survey results and noted a need for shared definitions.

Conclusion: Multiple factors, including funders and accreditation, may be driving the increase of QI for public health. Additional research to confirm and validate these findings is necessary. A common QI vocabulary is also recommended.
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http://dx.doi.org/10.1097/PHH.0b013e3181aab5caDOI Listing
January 2010

Bypassing the local rural hospital for outpatient procedures.

J Rural Health 2009 ;25(2):174-81

Department of Family Medicine and Rural Health, Florida State University College of Medicine, Tallahassee, FL 32306-4300, USA.

Purpose: To assess the amount of local rural hospital outpatient department (HOPD) bypass for outpatient procedures.

Methods: We analyzed data on colonoscopies and upper gastrointestinal endoscopies performed in the state of Florida over the period 1997-2004.

Findings: Approximately, 53% of colonoscopy and 45% of upper gastrointestinal endoscopy patients bypassed their local rural hospital for treatment at either a free-standing ambulatory surgical center (ASC) or a nonlocal hospital outpatient department. Independent predictors of bypass included risk-adjusted severity of the patient's medical condition, insurance status, and race. Patients treated in ASCs were predominately healthier, white and commercially insured. Nonlocal HOPDs tend to treat a sicker cohort of patients who were publicly insured or under managed care.

Conclusions: The results indicate that patients who bypass their local HOPD to an ASC differ from those bypassing to a nonlocal HOPD, and that patient factors influencing bypass for outpatient procedures differ from those influencing inpatient bypass. From a policy perspective, as procedures continue to migrate from the inpatient to the outpatient setting, bypassing the local rural hospital for treatment elsewhere could create conditions that negatively impact rural hospital operations.
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http://dx.doi.org/10.1111/j.1748-0361.2009.00214.xDOI Listing
January 2010

Aligning public health financing with essential public health service functions and National Public Health Performance Standards.

J Public Health Manag Pract 2009 Jul-Aug;15(4):299-306

Florida State University College of Medicine, Tallahassee, FL 32306, USA.

The purpose of this study was to assess the alignment of state and local health department financing with the 10 essential public health service (10EPHS) categories and National Public Health Performance Standards (NPHPS). To determine this, we collected primary data from the Florida Department of Health (FDOH) for fiscal year 2005-2006 and compared it with secondary data collected in the same year through NPHPS survey instruments. A structured interview technique was used to collect primary budget data from each program office at the FDOH and assign each program budget to 10EPHS categories. Local county health department (CHD) expenditures were assessed through an interview with the director and budget chief of one small, medium, and large CHD, and results were then extrapolated for other local CHDs. It was possible for almost 98 percent of the FDOH budget to be allocated into the 10EPHS categories. A majority of resources (68.7%) were used for individual healthcare services, category 7b (assuring provision of services) and category 7a (linking people to needed services). No direct correlation was found between the level of funding by 10EPHS category and the performance standards scores at state or local levels. Public health continues to utilize a majority of its available resources for individual healthcare services, despite increasing requests for improved population-based programs.
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http://dx.doi.org/10.1097/PHH.0b013e3181a02074DOI Listing
September 2009

Reducing the impact of the health care access crisis through volunteerism: a means, not an end.

Am J Public Health 2009 Jul 14;99(7):1166-9. Epub 2009 May 14.

Division of Health Affairs, Florida State University College of Medicine, 1115 W Call St, Tallahassee, FL 32306-4300, USA.

In the absence of meaningful health reform, Florida implemented a volunteer health care program to strengthen the existing safety net. Since program implementation in 1992, over $1 billion of services have been provided to uninsured and underserved populations. Currently, over 20,000 volunteers participate statewide. Key incentives for provider participation have been an organized framework for volunteering and liability protection through state-sponsored sovereign immunity. Volunteerism, although not a solution to the health care crisis, serves as a valuable adjunct pending full-scale health care reform.
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http://dx.doi.org/10.2105/AJPH.2008.145623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696674PMC
July 2009

Influence of pay-for-performance programs on information technology use among child health providers: the devil is in the details.

Pediatrics 2009 Jan;123 Suppl 2:S92-6

Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35294, USA.

Objective: Pay-for-performance programs are used to promote improved health care quality, often through increased use of health information technology. However, little is known about whether pay-for-performance programs influence the adoption of health information technology, especially among child health providers. This study explored how various pay-for-performance compensation methods are related to health information technology use.

Methods: Survey data from 1014 child health providers practicing in Florida were analyzed by using univariate and multivariate techniques. Questions asked about the adoption of electronic health records and personal digital assistants, as well as types of activities that affected child health provider compensation or income.

Results: The most common reported method to affect respondents' compensation was traditional productivity or billing (78%). Of the pay-for-performance-related methods of compensation, child health providers indicated that measures of clinical care (41%), patient surveys and experience (34%), the use of health information technology (29%), and quality bonuses or incentives (27%) were a major or minor factor in their compensation. In multivariate logistic regression analyses, only pay-for-performance programs that compensated directly for health information technology use were associated with an increased likelihood of electronic health record system adoption. Pay-for-performance programs linking measures of clinical quality to compensation were positively associated with personal digital assistant use among child health providers.

Conclusions: Pay-for-performance programs that do not directly emphasize health information technology use do not influence the adoption of electronic health records among Florida physicians treating children. Understanding how different pay-for-performance compensation methods incentivize health information technology adoption is important for improving quality.
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http://dx.doi.org/10.1542/peds.2008-1755HDOI Listing
January 2009

Use of health information technology by children's hospitals in the United States.

Pediatrics 2009 Jan;123 Suppl 2:S80-4

aDepartment of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35294, USA.

Objective: The purpose of this study was to examine the adoption of health information technology by children's hospitals and to document barriers and priorities as they relate to health information technology adoption.

Methods: Primary data of interest were obtained through the use of a survey instrument distributed to the chief information officers of 199 children's hospitals in the United States. Data were collected on current and future use of a variety of clinical health information technology and telemedicine applications, organizational priorities, barriers to use of health information technology, and hospital and chief information officer characteristics.

Results: Among the 109 responding hospitals (55%), common clinical applications included clinical scheduling (86.2%), transcription (85.3%), and pharmacy (81.9%) and laboratory (80.7%) information. Electronic health records (48.6%), computerized order entry (40.4%), and clinical decision support systems (35.8%) were less common. The most common barriers to health information technology adoption were vendors' inability to deliver products or services to satisfaction (85.4%), lack of staffing resources (82.3%), and difficulty in achieving end-user acceptance (80.2%). The most frequent priority for hospitals was to implement technology to reduce medical errors or to promote safety (72.5%).

Conclusion: This first national look at health information technology use by children's hospitals demonstrates the progress in health information technology adoption, current barriers, and priorities for these institutions. In addition, the findings can serve as important benchmarks for future study in this area.
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http://dx.doi.org/10.1542/peds.2008-1755FDOI Listing
January 2009

A comparative study of quality outcomes in freestanding ambulatory surgery centers and hospital-based outpatient departments: 1997-2004.

Health Serv Res 2008 Oct 26;43(5 Pt 1):1485-504. Epub 2007 Nov 26.

Division of Health Affairs, Department of Family Medicine and Rural Health, Florida State University College of Medicine, 1115 West Call Street, Suite 3200, Tallahassee, FL 32306-4300, USA.

Research Objective: To compare quality outcomes from surgical procedures performed at freestanding ambulatory surgery centers (ASCs) and hospital-based outpatient departments (HOPDs).

Data Sources: Patient-level ambulatory surgery (1997-2004), hospital discharge (1997-2004), and vital statistics data (1997-2004) for the state of Florida were assembled and analyzed.

Study Design: We used a pooled, cross-sectional design. Logistic regressions with time fixed-effects were estimated separately for the 12 most common ambulatory surgical procedures. Our quality outcomes were risk-adjusted 7-day and 30-day mortality and 7-day and 30-day unexpected hospitalizations. Risk-adjustment for patient demographic characteristics and severity of illness were calculated using the DCG/HCC methodology adjusting for primary diagnosis only and separately for all available diagnoses.

Principal Findings: Although neither ASCs nor HOPDs performed better overall, we found some difference by procedure that varied based on the risk-adjustment approach used.

Conclusions: There appear to be important variations in quality outcomes for certain procedures, which may be related to differences in organizational structure, processes, and strategies between ASCs and HOPDs. The study also confirms the importance of risk-adjustment for comorbidities when using administrative data, particularly for procedures that are sensitive to differences in severity.
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http://dx.doi.org/10.1111/j.1475-6773.2007.00809.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653888PMC
October 2008

Quality of care in accredited and nonaccredited ambulatory surgical centers.

Jt Comm J Qual Patient Saf 2008 Sep;34(9):546-51

Center on Patient Safety, Division of Health Affairs, Florida State University College of Medicine, Tallahassee, USA.

Background: Little is known about quality outcomes in accredited and nonaccredited ambulatory surgical centers (ASCs). Quality outcomes in ASCs accredited by either the Accreditation Association for Ambulatory Health Care (AAAHC) or The Joint Commission were compared with those of nonaccredited ASCs in Florida.

Methods: Patient-level ambulatory surgery and hospital discharge data from Florida for 2004 were merged and analyzed. Multivariate logistic regressions were estimated separately for the five most common ambulatory surgical procedures: colonoscopy, cataract removal, upper gastroendoscopy, arthroscopy, and prostate biopsy. Statistical models examined differences in risk-adjusted 7-day and 30-day unexpected hospitalizations between nationally accredited and nonaccredited ASCs. In addition to risk adjustment, each model controlled for facility volume of procedure and patient demographic characteristics including gender, race, age, and insurance type.

Results: In multivariate analyses that controlled for facility volume and patient characteristics, patients at Joint Commission-accredited facilities were still significantly less likely to be hospitalized after colonoscopy. Specifically, compared with patients treated in nonaccredited ASCs regulated by the state agency, patients treated at those facilities were 10.9% less likely to be hospitalized within 7 days (adjusted odds ratio [OR] = 0.891; 95% confidence interval [C.I.], 0.799-0.993) and 9.4% less likely to be hospitalized within 30 days (adjusted OR = 0.906; 95% C.I., 0.850-0.966). No other differences in unexpected hospitalization rates were detected in the other procedures examined.

Discussion: With the exception of one procedure, systematic differences in quality of care do not exist between ASCs that are accredited by AAAHC, those accredited by the Joint Commission, or those not accredited in Florida.
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http://dx.doi.org/10.1016/s1553-7250(08)34069-0DOI Listing
September 2008

Market effects on electronic health record adoption by physicians.

Health Care Manage Rev 2008 Jul-Sep;33(3):243-52

Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, USA.

Background: Despite the advantages of electronic health record (EHR) systems, the adoption of these systems has been slow among community-based physicians. Current studies have examined organizational and personal barriers to adoption; however, the influence of market characteristics has not been studied.

Purpose: The purpose of this study was to measure the effects of market characteristics on EHR adoption by physicians.

Methodology: Generalized hierarchal linear modeling was used to analyze EHR survey data from Florida which were combined with data from the Area Resource File and the Florida Office of Insurance Regulation. The main outcome variable was self-reported use of EHR by physicians.

Findings: A total of 2,926 physicians from practice sizes of 20 or less were included in the sample. Twenty-one percent (n = 613) indicated that they personally and routinely use an EHR system in their practice. Physicians located in counties with higher physician concentration were found to be more likely to adopt EHRs. For every one-unit increase in nonfederal physicians per 10,000 in the county, there was a 2.0% increase in likelihood of EHR adoption by physicians (odds ratio = 1.02, confidence interval = 1.00-1.03). Health maintenance organization penetration rate and poverty level were not found to be significantly related to EHR adoption. However, practice size, years in practice, Medicare payer mix, and measures of technology readiness were found to independently influence physician adoption.

Practice Implications: Market factors play an important role in the diffusion of EHRs in small medical practices. Policy makers interested in furthering the adoption of EHRs must consider strategies that would enhance the confidence of users as well as provide financial support in areas with the highest concentration of small medical practices and Medicare beneficiaries. Health care leaders should be cognizant of the market forces that enable or constrain the adoption of EHR among their practices and those of their competitors.
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http://dx.doi.org/10.1097/01.HMR.0000324904.19272.c2DOI Listing
August 2008

Hospital financial performance: does IT governance make a difference?

Health Care Manag (Frederick) 2008 Jan-Mar;27(1):71-8

Medical Informatics, College of Information, Florida State University, Tallahassee, FL 32106-2100, USA.

This study examined whether information technology (IT) governance, a term describing the decision authority and reporting structures of the chief information officer (CIO), is related to the financial performance of hospitals. The study was conducted using a combination of primary survey data regarding health care IT adoption and reporting structures of Florida acute care hospitals, with secondary data on hospital financial performance. Multiple regression models were used to evaluate the relationship of the 3 most commonly identified reporting structures. Outcome variables included measures of operating revenue and operating expense. All models controlled for overall IT adoption, ownership, membership in a hospital system, case mix, and hospital bed size. The results suggest that IT governance matters when it comes to hospital financial performance. Reporting to the chief financial officer brings positive outcomes; reporting to the chief executive officer has a mixed financial result; and reporting to the chief operating officer was not associated with discernible financial impact.
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http://dx.doi.org/10.1097/01.hcm.0000285033.58677.32DOI Listing
June 2008

The role of organizational factors in the adoption of healthcare information technology in Florida hospitals.

Health Care Manag Sci 2008 Mar;11(1):1-9

Center for Research in Healthcare Systems and Policies, College of Business Administration, University of South Florida, 8350 N. Tamiami Trail, SMC-C222, Sarasota, FL 34243, USA.

This study examines whether specific organizational characteristics, such as hospital size, geographic location (urban versus rural), system membership (stand-alone versus system-affiliated), and tax status (for-profit versus non-profit), influence adoption of healthcare information technologies (HIT) in hospitals. We hypothesize the above organizational characteristics to be related to hospitals' adoption of clinical, administrative, and strategic HIT, as well as all HIT in general. Using survey data collected from 98 Florida hospitals, we demonstrate that hospital size, system membership, and tax status, but not geographic location, are systematically related to HIT adoption, and that such factors explain about 28-41% of the adoption variance. A mixed pattern of effects emerge for clinical, administrative, and strategic HIT. For instance, hospital size appears to be less relevant for administrative HIT, where its effect is compensated by those of system membership and tax status. Implications for future HIT research and practice are discussed.
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http://dx.doi.org/10.1007/s10729-007-9036-5DOI Listing
March 2008

Are we ready for terrorism? Emergency medical technicians' and paramedics' training and self-perceived competence since September 11.

Am J Disaster Med 2007 Jan-Feb;2(1):26-32

Florida State University College of Medicine, Tallahassee, USA.

The US continues to be a target for terrorist activities that threaten the lives of the populace. Training on preparedness and response for emergency medical technicians (EMTs) and paramedics is critical to the success of an early response to any such attack. Previous surveys have suggested that terrorism-specific training has been modest at best since September 11. In order to gain further insight into emergency personnel's level of training and competence, we sent surveys to 4,000 EMTs and paramedics in the state of Florida in late 2005 and early 2006. Results show a much higher level of training than previously reported from other states and suggest a direct correlation between the amount and type of training and self-reported competence. Our results suggest that most emergency personnel are receiving terrorism-specific training, but gaps in competencies exist and require the attention of educators and policymakers.
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March 2008

Hospital quality of care: does information technology matter? The relationship between information technology adoption and quality of care.

Health Care Manage Rev 2008 Jan-Mar;33(1):51-9

Center on Patient Safety, Florida State University College of Medicine, Tallahassee, FL, USA.

Background: Hospitals have been slow to adopt information technology (IT) largely because of a lack of generalizable evidence of the value associated with such adoption.

Purpose: To explore the relationship between IT adoption and quality of care in acute-care hospitals.

Methods: Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between various measures of IT adoption and several quality indicators after controlling for confounders. Adoption of IT was measured using a previously validated method that considers clinical, administrative, and strategic IT capabilities of acute-care hospitals. Quality measures included the Inpatient Quality Indicators developed by the Agency for Healthcare Research and Quality.

Results: Data from 98 hospitals were available for analyses. Hospitals adopted an average of 11.3 (45.2%) clinical IT applications, 15.7 (74.8%) administrative IT applications, and 5 (50%) strategic IT applications. In multivariate regression analyses, hospitals that adopted a greater number of IT applications were significantly more likely to have desirable quality outcomes on seven Inpatient Quality Indicator measures, including risk-adjusted mortality from percutaneous transluminal coronary angioplasty, gastrointestinal hemorrhage, and acute myocardial infarction. An increase in clinical IT applications was also inversely correlated with utilization of incidental appendectomy, and an increase in the adoption of strategic IT applications was inversely correlated with risk-adjusted mortality from craniotomy and laparoscopic cholecystectomy.

Practice Implications: Hospital adoption of IT is associated with desirable quality outcomes across hospitals in Florida. These findings will assist hospital leaders interested in understanding better the effect of costly IT adoption on quality of care in their institutions.
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http://dx.doi.org/10.1097/01.HMR.0000304497.89684.36DOI Listing
February 2008

Hospital adoption of information technologies and improved patient safety: a study of 98 hospitals in Florida.

J Healthc Manag 2007 Nov-Dec;52(6):398-409; discussion 410

Florida State University College of Medicine, Tallahassee, Florida, USA.

Most of the studies linking the use of information technology (IT) to improved patient safety have been conducted in academic medical centers or have focused on a single institution or IT application. Our study explored the relationship between overall IT adoption and patient safety performance across hospitals in Florida. Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between measures of IT adoption and the Patient Safety Indicators (PSIs) of the Agency for Healthcare Research and Quality. We found that eight PSIs were related to at least one measure of IT adoption. Compared with administrative IT adoption, clinical IT adoption was related to more patient safety outcome measures. Hospitals with the most sophisticated and mature IT infrastructures performed significantly better on the largest number of PSIs. Adoption of IT is associated with desirable performance on many important measures of hospital patient safety. Hospital leaders and other decision makers who are examining IT systems should consider the impact of IT on patient safety.
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January 2008

The use of information technologies among rural and urban physicians in Florida.

J Med Syst 2007 Dec;31(6):483-8

College of Medicine, Florida State University, 1115 West Call Street, Tallahassee, FL 32306-4300, USA.

This study examines rural urban differences in the use of various information technologies (IT) applications by physicians in the ambulatory setting. Findings suggest that no differences exist between rural and urban physicians with respect to the use of a computer (77.4 vs 81.4; p=.144) or with the availability of an Internet connection (95.0 vs 96.5; p=.249) in the office. However, rural physicians were significantly less likely than urban doctors to indicate using e-mail with patients (7.9 vs 17.2%; p<.001) and slightly less likely to use a personal digital assistant (PDA) (32.3 vs 37.9; p=.091). Rural doctors were significantly less likely to indicate routinely using an electronic health records (EHR) system (17.6 vs 24.1; p=.020). EHR differences between rural and urban physicians were not significant (p=.124) in multivariate analyses and were explained away by practice size (p<.001) and practice type (p=.015). Most barriers to EHR did not differ between rural and urban physicians. However, rural physicians more commonly cited barriers associated with temporary disruptions to productivity or disruptions in access to records when computers systems fail. In sum, EHR use and patient e-mailing is less common in rural areas. While much of this variability can be explained by rural practice characteristics, these findings illustrate the need for further efforts to identify and alleviate barriers and encourage health IT adoption in rural areas.
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http://dx.doi.org/10.1007/s10916-007-9088-6DOI Listing
December 2007
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