An unprecedented federal effort is under way to boost the adoption of electronic health records and spur innovation in health care delivery. We reviewed the recent literature on health information technology to determine its effect on outcomes, including quality, efficiency, and provider satisfaction. We found that 92 percent of the recent articles on health information technology reached conclusions that were positive overall. We also found that the benefits of the technology are beginning to emerge in smaller practices and organizations, as well as in large organizations that were early adopters. However, dissatisfaction with electronic health records among some providers remains a problem and a barrier to achieving the potential of health information technology. These realities highlight the need for studies that document the challenging aspects of implementing health information technology more specifically and how these challenges might be addressed.

Objective The capability to share data, and harness its potential to generate knowledge rapidly and inform decisions, can have transformative effects that improve health. The infrastructure to achieve this goal at scale—marrying technology, process, and policy—is commonly referred to as the Learning Health System (LHS). Achieving an LHS raises numerous scientific challenges.Materials and methods The National Science Foundation convened an invitational workshop to identify the fundamental scientific and engineering research challenges to achieving a national-scale LHS. The workshop was planned by a 12-member committee and ultimately engaged 45 prominent researchers spanning multiple disciplines over 2 days in Washington, DC on 11–12 April 2013.Results The workshop participants collectively identified 106 research questions organized around four system-level requirements that a high-functioning LHS must satisfy. The workshop participants also identified a new cross-disciplinary integrative science of cyber-social ecosystems that will be required to address these challenges.Conclusions The intellectual merit and potential broad impacts of the innovations that will be driven by investments in an LHS are of great potential significance. The specific research questions that emerged from the workshop, alongside the potential for diverse communities to assemble to address them through a ‘new science of learning systems’, create an important agenda for informatics and related disciplines.

Over the past two decades the number of opioid pain relievers sold in the United States rose dramatically. This rise in sales was accompanied by an increase in opioid-related overdose deaths. In response, forty-nine states (all but Missouri) created prescription drug monitoring programs to detect high-risk prescribing and patient behaviors. Our objectives were to determine whether the implementation or particular characteristics of the programs were effective in reducing opioid-related overdose deaths. In adjusted analyses we found that a state’s implementation of a program was associated with an average reduction of 1.12 opioid-related overdose deaths per 100,000 population in the year after implementation. Additionally, states whose programs had robust characteristics—including monitoring greater numbers of drugs with abuse potential and updating their data at least weekly—had greater reductions in deaths, compared to states whose programs did not have these characteristics. We estimate that if Missouri adopted a prescription drug monitoring program and other states enhanced their programs with robust features, there would be more than 600 fewer overdose deaths nationwide in 2016, preventing approximately two deaths each day.

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Background Elderly patients who leave an acute care hospital after a stroke or a hip fracture may be discharged home or undergo post-acute rehabilitative care in an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Since 15% of Medicare expenditures are for these types of post-acute care, it is important to understand their relative costs and the health outcomes they produce. Objective To assess Medicare payments for and outcomes of patients discharged from acute care to an IRF, a SNF, or home after an inpatient diagnosis of stroke or hip fracture between January 2002 and June 2003. Research Design This is an observational study based on Medicare administrative data. We adjust for observable differences in patient severity across post-acute care sites and we use instrumental variables estimation to account for unobserved patient selection. Study Outcomes Mortality, return to community residence, and total Medicare post-acute payments by 120 days after acute care discharge. Results Relative to discharge home, IRFs improve health outcomes for hip fracture patients. SNFs reduce mortality for hip fracture patients, but increase rates of institutionalization for stroke patients. Both sites of care are far more expensive than discharge to home. Conclusions When there is a choice between IRF and SNF care for stroke and hip fracture patients, the marginal patient is better off going to an IRF for post-acute care. However, given the marginal cost of an IRF stay compared to returning home, the gains to these patients should be considered in light of the additional costs.

The enactment of the Patient Protection and Affordable Care Act is a signal achievement on the road to reform, which arguably began with the passage of the American Recovery and Reinvestment Act of 2009. That statute's Health Information Technology for Economic and Clinical Health (HITECH) provisions created an essential foundation for restructuring health care delivery and for achieving the key goals of improving health care quality; reducing costs; and increasing access through better methods of storing, analyzing, and sharing health information. This article discusses the range of initiatives under HITECH to support health reform, including proposed regulations on "meaningful use" and standards; funding of regional extension centers and Beacon communities; and support for the development and use of clinical registries and linked health outcomes research networks, all of which are critical to carrying out the comparative clinical effectiveness research that will be expanded under health reform.

IMPORTANCE Medications for opioid use disorder, including buprenorphine hydrochloride and methadone hydrochloride, are highly effective at improving outcomes for individuals with the disorder. For pregnant women, use of these medications also improves pregnancy outcomes, including the risk of preterm birth. Despite the known benefits of medications for opioid use disorder, many pregnant and nonpregnant women with the disorder are not receiving them. OBJECTIVE To determine whether pregnancy and insurance status are associated with a woman's ability to obtain an appointment with an opioid use disorder treatment clinician. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study with random assignment of clinicians and simulated-patient callers (performed in "secret shopper" format), outpatient clinics that provide buprenorphine and methadone were randomly selected from publicly available treatment lists in 10 US states (selected for variability in opioid-related outcomes and policies) from March 7 to September 5, 2019. Pregnant vs nonpregnant woman and private vs public insurance assigned randomly to callers to create unique patient profiles. Simulated patients called the clinics posing as pregnant or nonpregnant women to obtain an initial appointment with a clinician. MAIN OUTCOMES AND MEASURES Appointment scheduling, wait time, and out-of-pocket costs. RESULTS A total of 10 871 unique patient profiles were assigned to 6324 clinicians. Among all women, 2312 of 3420 (67.6%) received an appointment with a clinician who prescribed buprenorphine, with lower rates among pregnant vs nonpregnant callers (1055 of 1718 [61.4%] vs 1257 of 1702 [73.9%]; relative risk, 0.83; 95% CI, 0.79-0.87). For clinicians who prescribed methadone, there was no difference in appointment access for pregnant vs nonpregnant callers (240 of 271 [88.6%] vs 237 of 265 [89.4%]; relative risk, 0.99; 95% CI, 0.93-1.05). Insurance was frequently not accepted, with 894 of 3420 buprenorphine-waivered prescribers (26.1%) and 174 of 536 opioid treatment programs (32.5%) granting appointments only when patients agreed to pay cash. Median wait times did not differ between pregnant and nonpregnant callers among buprenorphine prescribers (3 days [interquartile range, 1-7 days] vs 3 days [interquartile range, 1-7 days]; P = .43) but did differ among methadone prescribers (1 day [interquartile range, 1-4 days] vs 2 days [interquartile range, 1-6 days]; P = .049).

Objective. To assess the relative impact of clinical factors versus nonclinical factors--such as postacute care (PAC) supply--in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care. Data Sources and Study Setting. Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data. Study Design. We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements. Data Collection/Extraction Methods. A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999. Principal Findings. PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there. Conclusions. We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes--or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.Key Words. postacute care, provider supply, Medicare, rehabilatation, nursing homes Postacute care (PAC) was the fastest growing sector of the Medicare program throughout the early to mid-1990s. A number of factors including payment incentives, advances in drug treatments and surgical techniques, and improvements in outpatient care contributed to shorter lengths of stay in acute care hospitals and corresponding increases in PAC use. As more hospitalized patients transfer to PAC, the need to better understand the factors driving such transfers is growing. 413