Research Roundups: Underinsured children; Hospital progress on electronic records; Federal officlals' work on comparative effectiveness

Aug 27 2010

New England Journal of Medicine: Underinsurance Among Children In The United States - This study examines the scope of underinsurance, or health insurance that fails to sufficiently meet the needs, of children living in the U.S. Based on information obtained from the 2007 National Survey of Children's Health, the authors of the study report, "19.3% — or 14.1 million — of all U.S. children (and 22.7% of children with continuous insurance coverage) were underinsured in 2007, exceeding the number of children without any insurance at all during the year (3.4 million) and the number who had insurance during only part of the year (7.6 million)."

Additionally, as "compared with fully insured children, those who were underinsured had substantially greater odds of being without a medical home, having difficulty obtaining referrals and care coordination, lacking family-centered care, and having difficulty obtaining needed specialty care. In fact, on the measures of access to referrals, care coordination, and specialty care, the problems affecting underinsured children were similar to those affecting children who had never been insured or who had discontinuous coverage," the authors write (Kogan et al., 8/26).

Health Affairs: A Progress Report On Electronic Health Records In U.S. Hospitals - This study examines hospitals' adoption of health information technology since the 2009 passage of the American Recovery and Reinvestment Act (ARRA), which "authorized incentive payments through Medicare and Medicaid to providers that implement certified electronic health records and demonstrate their 'meaningful use.'" Drawing on a supplemental American Hospital Association survey of acute care hospitals between March-September 2009 that asked about health IT activities as of March 2009, the authors report, "In 2009, during challenging economic times, U.S. hospitals continued to adopt electronic health records, but at a slow rate. Between 2008 and 2009, basic and comprehensive record adoption increased modestly, although both started from a low baseline level."

The authors continue, "The percentage of hospitals that meet the definition of either a basic or a comprehensive record, although increasing, remains low—less than 12 percent. From 2008 to 2009, critical-access, small, public, or rural hospitals in effect fell even further behind in the adoption of electronic health records and their key underlying functions. The same survey of U.S. hospitals conducted in the summer of 2008 found that hospitals that were critical access, small, public, nonteaching, or rural had 2-10 percent lower levels of adoption of the records. Our data … suggest that these gaps have widened." They conclude, "By 2009, very few hospitals could meet the final stage 1 rules for meaningful use. … Federal policy makers need to take concrete actions now to address this emerging digital divide and to ensure that all Americans, regardless of where they receive care, derive the benefits that health IT has to offer" (Jha et al., 8/26).

Commonwealth Fund: Electronic Medical Record Adoption In New Zealand Primary Care Physician Offices - This issue brief examines the lessons the U.S. can draw from the experience of implementing electronic medical records in New Zealand - a country in which all "1,100 general practices use an electronic medical record system with comprehensive functionality to manage patient's problem lists, enter clinical progress notes, perform electronic prescribing, and order laboratory tests and x-rays, among other tasks."

"Early on, New Zealand nurtured and supported a highly visible central unifying body or health system integrator, which operated as a national health information exchange and provided key technical services, including a support desk, implementation services, a software team designing and developing new electronic capabilities, and vender accreditation," the author writes in a summary of several lessons to be derived from New Zealand's experience.  Additionally, "Adoption of EMRs was aided by providing [general practitioners] GPs with technical support. This was made available via EMR vendors, HealthLink, primary health organizations, and independent practitioner associations," the article notes (Protti and Bowden, 8/24).

Robert Wood Johnson Foundation: Reaching Uninsured Children: Iowa's Income Tax Return and CHIP Project - "Despite rigorous outreach efforts by states, five million children who are eligible for Medicaid or the Children's Health Insurance Program (CHIP) remain uninsured," writes the author of this report that examines an effort being tested in Iowa to increase outreach and maximize enrollment for eligible, uninsured children in the state through the collection of tax information. The report describes how the state Department of Human Services (DHS) worked together with the Iowa Department of Revenue (IDR), and how tax forms were revised to include a question about the health care coverage of children in the household. "By using a question that asked for the number of dependents with AND without coverage, IDR could identify the exact number of children to whom the answer applied and also which respondents chose not to answer. The goal of this specificity was to facilitate more accurate outreach to children who were hawk-i [Iowa's CHIP] eligible but not enrolled," according to the paper.

"In all, 471 previously uninsured children obtained health coverage as a result of Iowa's 2008 tax outreach: 239 of these were approved for the hawk-i program and 232 were approved for Medicaid coverage. Material costs for the project came to $0.68 for each household that received a brochure in 2008 (including envelope, brochure, postage and handling), which translates to $83.16 per enrollee (IDR, 2009)," the author writes (Freshour-Johnston, 8/23).

Annals of Internal Medicine: Comparative Effectiveness Research: A Progress Report - "Sixteen months ago, comparative effectiveness research (CER) began its rapid rise, when The American Recovery and Reinvestment Act of 2009 … allocated $1.1 billion for CER," writes the author of this article, which summarizes how the National Institutes of Health (NIH), Agency for Health Research and Quality (AHRQ) and Office of the Secretary of Department of Health and Human Services (OS-DHHS) have used the CER funds and how that spending relates to a list of national priorities for CER that was set by the Institute of Medicine (IOM). The article also looks ahead to the creation of a national CER program.

"Although it is far too early to evaluate the outcome of the federal response to the Reinvestment Act funding, the process was impressive," the author of the article writes. Although the NIH and AHRQ were far along in their plans for disbursing Reinvestment Act funds by the time the Institutes of Medicine (IOM) priority-setting committee issued a report in June 2009, "both agencies cross-checked their choices against the IOM list of 100 priority research questions, as did the OS-DHHS. The NIH determined that their choices included 88 of the 100 IOM priorities and subsequently issued requests for applications to cover the remaining topics (10). The AHRQ has issued several requests for applications that either asked applicants to address a specific IOM high-priority research question or required the applicant to propose a topic that addressed one of the IOM priorities," according to the article (Sox, 8/2).

Medical Care Research And Review: The Commonwealth Fund Survey Of Long-Term Care Specialists - This article describes a long-term care specialist online survey conducted between September 2007 through March 2008. Of the 2,577 potential respondents, 1,147 completed the survey, according to the article. The data were analyzed in a special supplement of Medical Care Research and Review "to explore several issue areas, namely, reforming long-term care financing, improving government oversight, adopting nursing home culture change, and rebalancing long-term care away from institutions toward home- and community-based services. Analyses documenting the opinion networks of long-term care specialists and the relationship between network characteristics and attitudes toward reform are also reported," according to the article (Miller and Weissert, August 2010).

Robert Wood Johnson Foundation: Unlocking The Potential Of School Nursing: Keeping Children Healthy, In School, And Ready To Learn - This publication (.pdf) examines the role school nurses play in managing the health care needs of a medically diverse population of children and the challenges they face due to underfunding. "School nurses are well positioned to play a pivotal role in improving students' health by ensuring continuity of care, but greater coordination between the education and health care sectors will be needed to fully realize this potential," according to the article.

The piece outlines several opportunities for federal policies to improve the conditions facing school nurses, such as legislation to increase the ratio of nurses to students in schools, a national data collection of school nurses, and the creation of an office within the Departments of Education (ED) "that would provide school nurses, school social workers, school psychologists, and others with a point of contact within ED dedicated to identifying best practices, providing technical assistance, and offering professional development opportunities to its diverse constituencies" (8/18).