© Mary Ann Liebert, Inc. DOI: 10.1089/dis.2007.104706
Implementing Health Information Technology to
Improve the Process of Health Care Delivery:
A Case Study
MARILYN FOLLEN, R.N., M.S.N.,1 RACHEL CASTANEDA, Ph.D.,2,3
MELISSA MIKELSON, R.N., B.S.N.,1 DEBRAH JOHNSON, R.N., B.S.N.,1
ALISA WILSON, Ph.D.,2 KEIKO HIGUCHI, M.P.H.2
ABSTRACT
Integration of health information is critical to the provision of effective, quality care in to-day’s fragmented health care system. The increasing prevalence of chronic conditions and the demand for a comprehensive understanding of patient health on the part of providers are dri-ving the need for the integration of health information through electronic health information systems. Two distinct health information systems currently utilized in the health care field include electronic medical records (EMR) and chronic disease management systems (CDMS). The integration of these systems is likely to enable the efficient management of health formation and improve the quality of health care as it would provide real-time patient in-formation in a coordinated manner. The lack of real-time inin-formation may result in delayed treatment, uninformed decisions, inefficient resource use, and medical errors. Despite their importance and widespread support, these systems have slow provider adoption rates. Our understanding of how health information technology may be used to improve health care is limited by the relative paucity of research on the adoption, integration, and implementation of these 2 types of systems. This paper documents the use of an EMR at Marshfield Clinic, a multidisciplinary group practice in the United States. We review the concomitant use of an EMR for clinical data capture and the implementation of a proprietary CDMS, InformaCare®, for care management of chronic diseases. These 2 systems allow providers to deliver health care using evidence-based guidelines that meet the Institute of Medicine’s aim of providing safe, efficient, patient-centered, and timely care. (Disease Management2007;10:208–215)
INTRODUCTION
T
HE DELIVERY OF HEALTH CARE in the UnitedStates is under intense scrutiny due to the fragmented way in which care is delivered and reimbursed. Policy makers have suggested that the integration of patient information from
dis-parate sources using health information sys-tems may improve both the delivery and qual-ity of patient care. Results of a survey of key opinion leaders indicates that increased use of in-formation technology to improve the quality and safety of careis one of their 3 highest priorities.1
The Institute of Medicine also has cited the use
1Marshfield Clinic, Marshfield, Wisconsin.
2Pfizer Health Solutions Inc, Santa Monica, California.
3Department of Medicine, University of California Los Angeles, California. 208
of health information technology systems as an important quality improvement tool.2,3
The way in which most patient records are stored contributes to the fragmented delivery of health care. The majority of medical infor-mation is still recorded on paper, making it challenging to efficiently coordinate care, ef-fectively measure quality, or reduce medical er-rors in a manner that is not labor intensive.4
The costs associated with system inefficiencies and associated medical errors are estimated to be as much as $29 billion annually.5The broad
adoption of health information technology sys-tems within the US health care system has been proposed as a strategy to simultaneously re-duce medical errors, increase quality of care, and save the health care system billions of dol-lars annually.3,4
Given the potential advantages of using an electronic infrastructure for patient care, the time for the adoption and use of health infor-mation systems for quality care improvement has come.6 Despite the various benefits of
health information technology systems, there has been relatively little systematic study of their adoption or utilization. This paper exam-ines the implementation and use of an elec-tronic medical record (EMR) and chronic disease management system (CDMS) at Marsh-field Clinic and how these systems are used to facilitate and enhance patient care and provider satisfaction. A patient scenario is pre-sented as an example of how health care providers actually use and work with these 2 health information systems at the Marshfield Clinic. Policy implications for implementing health information technology systems are dis-cussed relative to how their adoption and in-tegration can affect the delivery of coordinated health care and improve patient outcomes.
HEALTH INFORMATION TECHNOLOGY SYSTEMS
The health information technology system currently generating the most interest is the EMR.7,8,9Operating as a clinical data repository
or warehouse,10 the EMR provides access to
real-time patient-level medical information, of-ten through a Web-based interface.
EMR systems have wide-ranging potential for enhancing patient care and decreasing med-ical errors. Empirmed-ical evidence suggests that implementation of an EMR can offer multiple benefits. Their use can facilitate the provis-ion of evidence-based decisprovis-ion support for providers to manage patients in a timely and systematic way.11,12,13EMRs may also facilitate
complete electronic documentation and effi-cient sharing of patient information across mul-tiple providers, document medications pre-scribed, and laboratory tests ordered and performed. In addition, some systems allow pharmacists the ability to dispense medications as well as check for drug-drug interactions, al-lowing providers and pharmacists to work more collaboratively to ensure that patients re-ceive adequate information about their med-ications. EMRs also may be used to order lab-oratory tests, which should obviate duplicate or unnecessary testing. Each of these EMR functions contributes to the efficiency with which patient information is managed14as well
as the quality of care provided. Not only do EMRs lead to cost and time resource benefits for health care providers, but their use has also led to an estimated cost savings of $23 billion for Medicare and $31 billion for private payers annually.13These cost savings are attributable
to the accumulation of electronic data, the re-duction in staff time used to locate, pull, and file patient medical records, and a decrease in the duplication of tests and services.15
The CDMS is another useful health informa-tion technology tool available to health care providers. Unlike EMRs that provide real-time, point-of-care patient information, CDMSs were developed as electronic tools to enhance how health care providers manage patients with 1 or more chronic conditions.16These
computer-guided programs have been shown to improve the quality of health care by providing clinical support grounded in evidence-based medi-cine.17Several CDMSs include tools for disease
risk stratification accompanied by disease-spe-cific guidelines and protocols for effective care management.16
Providing technology-based feedback to providers about patients with multiple chronic diseases is an effective means of improving ad-herence to guideline recommendations and
en-hancing total care management.18 Studies
fo-cused on improving care for hypertension19
and diabetes20,21for example, documented that
CDMSs are effective disease management (DM) tools that facilitate reductions in disease-specific symptoms and increase improved health behaviors. Given that care for patients with chronic diseases absorbs more than 75% of the nation’s health care dollars,22 CDMSs
should be considered important for improving care for patients with chronic conditions.
UTILIZATION AND INTEGRATION OF HEALTH INFORMATION TECHNOLOGY
AT THE MARSHFIELD CLINIC The Marshfield Clinic in Wisconsin is one of the largest private, multispecialty health deliv-ery systems in the United States. The clinic em-ploys over 730 physicians in 80 medical spe-cialties and subspespe-cialties.23The clinic has been
using an internally developed EMR system for more than 20 years. Since December 2004 it also has been using a commercially available CDMS product (InformaCare®) to collect and manage patient information as part of its DM and Com-munity Health Access programs. Marshfield Clinic employs 11 full-time nurse care man-agers (at a state average of $54,527, plus bene-fits for each nurse) and 2 nurse supervisors for their DM program and Community Health Ac-cess programs.24These programs are also
sup-ported by 1 data manager, 1 data analyst, and 2 health service coordinators.25 To date, over
1000 patients have been managed by nurse care managers who use these 2 systems.26
Marshfield’s EMR system
The EMR system used at the Marshfield Clinic was developed in the late 1960s in re-sponse to the growing volume of patients served. The clinic implemented the EMR to provide access to large volumes of clinical and administrative data for a single patient with a fast response time, to reduce administrative and patient costs, and to improve patient care by minimizing duplication of services while pro-moting integration of care across specialties. Currently, the EMR system is accessed by
Marsh-field physicians, nonphysician providers, phar-macists, nurses, care managers, and social workers, as well as cooperating hospitals. It contains indexes to all “events” that patients have encountered while enrolled at Marshfield, as well as text documentation including office notes, operative reports, discharge summaries, and patient problem lists and alerts.
There are several specific elements of this particular EMR, such as a Medication Manager and a Dashboard, that are useful provider tools for tracking and monitoring patient health in-formation. For instance, the Medication Man-ager and the Dashboard issue reminders or prompts to providers at the point of care (eg, patient is due for a laboratory test, mammo-gram, or other scheduled service). The EMR fa-cilitates the coordination of information across multiple health care applications, including appointment and medical record tracking, lab-oratory, radiology, and pharmacy data, and clinical documentation of health status (eg, transcription services, immunization tracking, data interfaces with hospitals and laboratories).
The CDMS
The Marshfield Clinic uses InformaCare,®a
proprietary DM system developed by Pfizer Health Solutions Inc (Santa Monica, CA). In-formaCare was specifically designed to aid care managers with clinical decision making tools for patients with chronic disease. At the Marsh-field Clinic, InformaCare is exclusively used by the nurse care managers responsible for man-aging patients enrolled in telephonic DM pro-grams. It serves as a patient data registry that stores clinical and behavioral disease-related information such as telephonic call schedules, tasks, and a patient problem list. It also offers a medication database and decision-making support for care managers via system alerts, feedback, and a variety of online documents, including a care manager guide with recom-mendations and strategies for achieving patient care goals.
InformaCare facilitates care manager inter-action with the provider as the care manager communicates the information received from InformaCare to Marshfield Clinic providers. Similarly, care managers have access to patient
information via the Marshfield EMR to meet the individualized needs of the patient popu-lation they care for with clinical support from InformaCare.
Both the EMR and the CDMS have benefits for Marshfield Clinic patients. The adoption and integration of these systems has signifi-cantly revolutionized the delivery of health care by providing real-time access to patient data that is readily accessible to the care man-agers via Marshfield Clinic desktop applica-tions. Because they are supported by sophisti-cated technology, care managers are able to move between system applications without re-dundant entry of patient information. Infor-maCare has facilitated care planning for pa-tients with multiple chronic conditions and has assisted with the coordination and communi-cation of patient health between providers. Marshfield Clinic values the 2 systems for their potential to increase patient safety, offer flexi-bility, and provide comprehensive patient data that support patient care.
Provider satisfaction surveys were used to evaluate the impact of care management using the health information technology systems in
the Marshfield Clinic. Satisfaction outcomes about the utilization of health information tech-nology systems and care management provide useful information about the barriers and suc-cesses of adoption. Such data can also be used to improve quality of care. With a response rate of 32%, there was high provider satisfaction with care management as supported by the health information technology systems as 67% of providers “strongly agreed or agreed” it was very helpful. According to the providers, such services improved the quality of care (50%) and patient satisfaction (33%), as well as operational efficiencies by saving provider time (22%) and staff time (26%). Table 1 presents other provider responses demonstrating high satisfaction.27
INTEGRATING PATIENT HEALTH INFORMATION: A PATIENT SCENARIO
To illustrate how the EMR and the CDMS are currently used at Marshfield Clinic, consider the following patient care scenario.
Mr. P, a 67-year-old male diagnosed with congestive heart failure, was discharged from
TABLE1. PROVIDERSATISFACTIONSURVEYRESULTS(N46)
Strongly Strongly
agree Agree Disagree disagree No response
Item % N % N % N % N % N
The service has 28.3% 13 41.3% 19 6.5% 3 0.0% 0 23.9% 11 improved the self-care
behaviors of my patients and their families.
The team communicates 26.1% 12 45.7% 21 4.3% 2 0.0% 0 23.9% 11 with me/my team at
clinically appropriate times and in an appropriate situation-specific format (ie, telephone, EMR, email).
The service improves 21.7% 10 39.1% 18 8.7% 4 6.5% 3 23.9% 11 both my practice
efficiency and my patients’ clinical outcomes.
The service is helpful to 28.3% 13 39.1% 18 8.7% 4 6.5% 3 13.0% 6 me/my staff in
an affiliated Marshfield Clinic hospital. Mr. P’s inpatient admission and discharge documents were entered directly into Marshfield’s EMR system upon hospital discharge. These docu-ments contain important medical and care planning information such as the discharge dis-position, scheduled follow-up appointments, provider consults, pharmacy prescriptions, and rehabilitation care that has been ordered and/or completed. Upon learning about Mr. P’s hospitalization, his care manager, Ms. C, ac-cessed InformaCare from her desktop to create a task to remind her to contact Mr. P about his post-hospitalization follow-up. Prior to con-tacting Mr. P, she also used her desktop to ac-cess his records in the EMR Dashboard, a user-friendly “executive summary” of important patient information, such as diagnoses, clinical problems, medications, laboratory data, as well as future and past medical appointments.
Ms. C reviewed the Dashboard, which in-cludes diagnosis, medications prescribed, pre-ventive measures met, medical history, dias-tolic dysfunction, and any past problems. She learned that Mr. P experienced fluid imbalance and required frequent adjustments to his med-ication regimen. She also reviewed the Infor-maCare “Contacts” section to find out when a care manager last spoke with him and learned that a care manager last spoke with Mr. P ap-proximately 1 month before his recent hospi-talization.
Ms. C accessed InformaCare to review DM program notes and accessed the EMR for any office notes regarding Mr. P’s current medical status. The office notes are crucial as they con-tain the physician’s assessment, care plan, and medication regime. From her review of what the pharmacist and social worker entered in the EMR, she learned that Mr. P, for financial rea-sons, was often non-adherent to his medication regimen. She also learned that he had a recent appointment with his cardiologist and that an-other follow-up appointment was scheduled for the next month. Ms. C identified an oppor-tunity for reinforcing with Mr. P the impor-tance of keeping his appointment. From the of-fice notes in the EMR, she also reviewed his laboratory test results and chest X-ray. She learned from the EMR that he recently received a cardiac pacemaker that is monitored tele-phonically. If necessary, she can access
pace-maker monitoring reports and directly connect to the cardiology department to report any problems he may be experiencing. Ms. C also used the EMR to review Mr. P’s medication dis-charge list with the information contained in the EMR’s Medications Manager.
Upon completion of her review of Mr. P’s clinical information stored in the EMR and In-formaCare, she called him. While on the phone, she assessed his functional status and whether or not he understood the medication regimen prescribed to him at discharge. After learning that Mr. P did not fill his prescriptions due to financial concerns, she made an online referral to a social worker in Marshfield Clinic’s Com-munity Health Resources, a program that as-sists Marshfield patients with finding resources to cover medication costs or transportation is-sues. Using InformaCare, Ms. C administered a heart failure questionnaire and updated Mr. P’s Care Plan to reflect that he has difficulty breathing in the afternoon at times. She also created a follow-up task for this problem in In-formaCare and added a note in the EMR for his physician, pharmacist, and social worker to re-view relative to his medication noncompliance due to financial concerns.
Ms. C noticed that Mr. P did not complete any advance directive documents and asked him about planning this part of his future care; she updated InformaCare with this new infor-mation. She then reviewed the EMR’s PreServ module. The PreServ module provides an “at-a-glance” summary of the patient’s current sta-tus in obtaining preventive care. Ms. C learned that Mr. P was overdue for a colonoscopy re-ferral and offered to contact his provider; she flagged this as a task to complete in Informa-Care.
At the conclusion of the call, Ms. C asked Mr. P if he had any questions or concerns. He told her that he did not remember his physician’s earlier instructions regarding his ability to drive, whether he could safely drive alone or required someone to drive for him. She ac-cessed the physician notes in the EMR and read it aloud to him; the note stated “the patient can drive by himself now.” Mr. P conveyed that he was very pleased with the fact that Ms. C was able to access his medical information in “real time” and indicated that he would call Ms. C if he had any questions about his physician
in-structions after his upcoming scheduled office visit.
As illustrated in this patient scenario, the 2 health information technology systems are in-tegrated as they assist care managers trained in telephonic DM programs to facilitate informa-tion sharing about a patient’s health status and treatment with the entire health care team. This integration provides a richer understanding of the complex functional status of a patient from all perspectives—health, clinical, behavioral, and psychosocial—than would otherwise be possible without expending considerable time and effort in a paper-based system.
CONCLUSION
The impetus for this paper was to develop a better understanding of how the use of 2 dis-tinct health information technology systems can be adapted by a large, multispecialty health care system to potentially improve the overall efficiency and quality of care. It illustrates that the EMR and CDMS are 2 useful tools for mon-itoring clinical and behavioral data as well as chronic disease symptoms. Together, the EMR and CDMS allow care managers to more seam-lessly work together with other members of the health care team to customize care manage-ment programs for patients. Understanding how Marshfield Clinic implemented its EMR and CDMS systems and the benefits it has achieved by using these 2 applications may help facilitate adoption of similar health infor-mation technology in other health care settings. There were some important operational is-sues that arose among the providers and care managers during the beginning phases of the implementation of these 2 health information technology systems. A few providers wanted to maintain their previous clinical management styles. Persistent communication and educa-tion regarding the importance of the integra-tion of the EMR and CDMS systems was used to address this barrier to adoption. Communi-cations specifically addressed how the 2 tools worked together to incorporate clinical and be-havioral information that would ultimately in-crease the quality of patient care and improve patient safety. As a result, in less than 1 year after implementation, most providers
em-braced the new care management system sup-ported by EMR and CDMS, as evidenced by the results from the provider satisfaction sur-vey. Lack of awareness among care managers about how to use the 2 new systems was an-other barrier to the effective implementation of the EMR and CDMS. As a result, systematic care manager training was employed to ensure that there was a common understanding of the data most appropriate for each system to pre-vent duplicative data collection. With ample training on a standardized process flow and data collection, care managers were able to uti-lize the best features in the 2 systems effec-tively.
Despite the successful implementation and integration of the EMR and CDMS at Marsh-field Clinic, one limitation is that the EMR and the CDMS are not electronically linked. Cur-rently there is evaluation of data to test the ef-fect of these systems on patient health out-comes. Based on the patient scenario, we can only infer that implementing these 2 health in-formation technology systems within care management programs may improve the pro-cess of care, ensure patient safety, and reduce health care costs. Because chronic illnesses within the US population are burdening an al-ready overtaxed health care system, we believe that these 2 systems can be instrumental in al-leviating current system inefficiencies. Not only can EMR systems help ensure consistent documentation and timely monitoring of dis-ease-specific clinical measures, but CDMS sys-tems can also help coordinate workflows and communication among providers as well as provide clinical support and education to pa-tients, thereby leading to better health out-comes. Clearly, data are urgently needed to evaluate the real-world application of these systems in terms of accurately gauging their relative effectiveness in promoting positive outcomes. An evaluation by Marshfield Clinic is currently under way to collect patient clini-cal and behavioral data to test the effect of these systems on patient health outcomes. The met-rics that will be used to measure the impact of the integration of the 2 electronic health infor-mation technology systems will be based on empirical clinical guidelines in preventive care and disease-specific care. For example, using electronic data from the 2 systems, the
Marsh-field Clinic will assess rates of completed an-nual influenza vaccinations, anan-nual physical examinations, and all-important quality of care measures. Disease-specific metrics also will be examined, such as changes in medication ad-herence among heart failure patients using ACE-inhibitors or angiotensin receptor block-ers and hemoglobin A1c values among patients with diabetes. In addition, comorbid conditions among the patient population will be assessed (eg, the number of patients screened for de-pression).
From a health care policy perspective, given the tremendous benefit of health information technology systems in applied health care set-tings, more widespread efforts aimed at in-creasing utilization and adoption rates are war-ranted. The government in particular plays an important role in overseeing this process, as the adoption of these systems may depend on powerful financial incentives, such as pay for performance, that will reward organizations for using such systems and motivate policies that provide these systems to small provider groups at an affordable price.28Political
atten-tion to EMRs and health care informaatten-tion tech-nology is evidenced by the bipartisan support and unanimous passage of the Wired for Healthcare Quality Act (S.1418) in the US Sen-ate that includes federal funding in the form of grants for health information technology adop-tion.29Financing alone, however, will not fully
address the other barriers that challenge the transition from paper-based methods to the adoption of health information technology sys-tems.
Although more health organizations are adopting pay-for-performance approaches to provide incentives for providers to improve pa-tient care, rigorous analyses on the impact of pay for performance are few.30 A study
com-paring preventive care outcomes in a pay-for-performance program addressing diabetes care in PacifiCare Health Systems resulted in a sig-nificant difference in quality of care between participants and non-participants.31
Addition-ally, Physician Group Practice (PGP) Demon-stration projects, where select physician group practices are charged with investing in process improvements to improve patient care quality through a pay-for-performance initiative, are focusing on expanded data systems, care
man-agement programs, and coordination of care ef-forts to improve patient care.32Continuing
re-search into pay for performance is necessary to identify specific external factors, such as how pay for performance works in organizations with varying information technology capabili-ties, that can differentially affect pay-for-per-formance benefits and outcomes.
While an increasing number of large health systems are considering the adoption of health information technology systems to improve health care quality,33,34the actual adoption rate
of EMRs in the United States is slow and not widespread,35 with only about 15% to 20% of
solo-practice physician offices and 20% to 25% of hospitals adopting such systems.36Common
barriers to adoption include resistance by health care providers and health systems be-cause of high implementation costs with no re-turn on investment to the provider, suboptimal design of products and user interfaces, main-tenance of the validity and confidentiality of data, uncertainties regarding interoperability standards, and inadequate technical support.37
The key to the future, we believe, is to create a more supportive environment in which inter-ested health care parties work together to ad-dress these common and formidably challeng-ing issues.
REFERENCES
1. The Commonwealth Fund. The Commonwealth Fund Health Care Opinion Leaders Survey: Assessing Con-gress’s Policy Priorities. February 2006. Available at:
www.cmwf.org/surveys/surveys_show.htm?doc_ id358343. Accessed June 26, 2007.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
3. Taylor R, Bower A, Girosi F, Bigelow J, Fonkych K, Hillestad R. Promoting health information technol-ogy: is there a case for more-aggressive government action? Health Aff. 2005;24:1234–1245.
4. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Po-tential health benefits, savings, and costs. Health Aff. 2005;24:1103–1117.
5. Report of the Quality Interagency Coordination Task Force. Report to the President. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. February 2000. Avail-able at: http://www.premierinc.com/safety/topics/ patient_safety/downloads/03_errorsquIc6.pdf. Ac-cessed May 17, 2005.
6. Leape LL. Institute of Medicine medical error figures are not exaggerated. JAMA. 2000;284:95–97.
7. Lynam KB, Karlan VJ. Electronic medical record sys-tems: trends in large group practices. Group Pract J. 2002;51:18–24.
8. Harris Interactive. eHealth’s influence continues to grow as usage of the internet by physicians and pa-tients increases. Healthcare News. 2003;3:1–7.
9. American Academy of Family Physicians. Survey shows high member interest in EHR system. FP Report 2003. Available at: www.aafp.org/fpr/ 20030300/8.html. Accessed June 27, 2007.
10. Bria WF, II. Applied medical informatics: information you can use! Chest. 2006;129:446–451.
11. Balas EA. The clinical value of computerized infor-mation services: a review of ninety-eight randomized clinical trials. Arch Fam Med. 1996;5:271–278.
12. Hunt DL. Effects of computer-based clinical decision support systems on physician performance and pa-tient outcomes. JAMA. 1998;280:1339–1346.
13. Fonkych K, Taylor R. The State and Pattern of Health Information Technology Adoption. Santa Monica, CA: RAND; 2005.
14. Tierney WM, McDonald CJ, Hui SL, Martin DK. Com-puter predictions of abnormal test results: effects on outpatient testing. JAMA. 1988;259:1194–1198. 15. Wang SJ, Middleton B, Prosser LA, et al. A
cost-ben-efit analysis of electronic medical records in primary care. Am J Med. 2003;114:397–403.
16. Jantos LD, Holmes ML. IT tools for chronic disease management: how do they measure up? California Healthcare Foundation, July 2006. Available at:
www.chcf.org/documents/chronicdisease/ITTools ForChronicDiseaseManagement.pdf. Accessed June 25, 2007.
17. Clayton PD, Hripcsak G. Decision support in health-care. Int J Biomed Comput. 1995;39:59–66.
18. Lobach DF. Electronically distributed, computer-gen-erated, individualized feedback enhances the use of a computerized practice guideline. Proc AMIA Annu Fall Symp 1996:493–497.
19. Brownbridge G, Evans A, Fitter M, Platts M. An interactive computerized protocol for the manage-ment of hypertension: effects on the general practi-tioner’s clinical behaviour. J R Coll Gen Pract. 1986; 36:198–202.
20. Lobach DF, Hammond WE. Development and evalu-ation of a computer-assisted management protocol (CAMP): Improved compliance with care guidelines for diabetes mellitus. Proc Annu Symp Comput Appl Med Care 1994:787–791.
21. Nilasena DS, Lincoln MJ. A computer-generated re-minder system improves physician compliance with diabetes preventive care guidelines. Proc Annu Symp Comput Appl Med Care 1995:640–645.
22. Centers for Disease Control and Prevention. Chronic disease overview. Available at: www.cdc.gov/nc-cdphp/overview.htm. Accessed June 27, 2007. 23. Marshfield Clinic Overview. Available at: http://
www.marshfieldclinic.org/patients/default.aspx? pageabout_legacy. Accessed July 25, 2006.
24. University of Wisconsin. Employment and Full-Time Salary Information. Available at: www.uwgb.edu/ careers/Word_Docs_MajorReport.doc. Accessed June 27, 2007.
25. Marshfield Clinic. Outcomes Datamarts. Marshfield, WI: Marshfield Clinic; 2007.
26. Marshfield Clinic. Community Health Access Case Management Annual Report. Marshfield, WI: Marsh-field Clinic; 2006.
27. Marshfield Clinic. Physician Survey Results. Marsh-field, WI: Marshfield Clinic; 2006.
28. Iglehart JK. Pursuing health IT: The delicate dance of government and the market. Health Aff. 2005;24: 1100–1101.
29. Congressional Budget Office. Wired for Health Care Quality Act. Available at: www.cbo.gov/show-doc.cfm?index6585&sequence0. Accessed June 27, 2007.
30. Rosenthal MB. Pay-for-Performance in Healthcare: Trends, Impact and Policy Issues. Harvard School of Public Health. Available at: http://ksgfiona.harvard. edu/m-rcbg/hcdp/readings/Pay-for-Performance %20in%20Health%20Care.pdf. Accessed June 27, 2007.
31. Rosenthal MB, Frank RG, Zhonghe L, et al. Early ex-perience with pay-for-performance: from concept to practice. JAMA. 2005;294:1788–1793.
32. Trisolini M, Kautter PJ, Aggarwal J. Medicare Physi-cian Group Practices : Innovations in Quality and Ef-ficiency. New York: The Commonwealth Fund; 2006. 33. Bodenheimer T, Wagner EH, Grumbach K. Improv-ing primary care for patients with chronic illness: the chronic care model, part 2. JAMA. 2002;288:1909–1914. 34. Hynes DM, Perrin RA, Rappaport S, Stevens JM, De-makis JG. Informatics resources to support healthcare quality improvement in the Veterans Health Admin-istration. JAMA. 2004;11:344–350.
35. Wharton Health Care Management Alumni Associa-tion. Managed healthcare insights: health care quality means business. Managed Care. 2003;12(suppl):1–28. Available at: www.managedcaremag.com/supple-ments/0301_hcquality/0301.hcquality_suppl.pdf. Accessed June 28, 2007.
36. Fonkych K, Taylor R. The State and Pattern of Health Information Technology Adoption. Santa Monica, CA: RAND; 2005.
37. Miller RH, Sim I. Physicians’ use of electronic med-ical records: barriers and solutions. Health Aff. 2004;23:116–126.
Address reprint requests to:
Keiko Higuchi, MPH 1125 Royal Lane San Carlos, CA 94070 E-mail: [email protected]
