NURS 503 Week 4 Discussion Board Forum 2 on Data and Technology in Population Health Example

Discussion Board Forum 2: Using Data and Health Information Technology to Manage a Population

NURS 503 Managing Population Health, Discussion Board Forum 2

Thread by [Student Name]

The hospital example and the classmates replied to are composites written for a model discussion.

At a hospital where I worked, an emergency department began offering HIV tests to more patients, and the number of tests rose quickly. Six months later a review found that several positive results had sat in the record for days before anyone contacted the patient, and two patients were never reached. The tests were done; the population was not managed. That story is a good illustration of why population health depends on data that follow people across every step of care, not only on the step a program is built around.

Nash et al. (2016) describe population health management as requiring the ability to identify a defined population, stratify it by need and track it over time, which in practice means registries, analytics and information that moves between settings. For HIV the steps are already defined as the care continuum: diagnosis, linkage to care, retention, treatment and viral suppression. When CDC researchers apportioned the 2016 transmissions across the continuum, the group responsible for the most, roughly 43%, was people already diagnosed but out of care, ahead of the roughly 38% from those not yet diagnosed (Li et al., 2019). Diagnosis without follow-up moves a person from the largest source of new infections to the second largest, not out of the risk altogether.

Three tools would have closed the gap in my example. A registry of every patient with a reactive HIV test would have shown, on one screen, who had not yet been contacted. An alert routed to a named person, such as the program's nurse navigator, rather than to whichever physician ordered the test, would have made someone responsible. Data shared with the local health department, which is permitted for public health purposes, would have allowed the department's disease intervention specialists to locate patients the hospital could not reach. None of these is expensive, but each requires deciding in advance who acts on the data.

Proverbs gives a farmer's version of population health: "Know well the condition of your flocks, and give attention to your herds" (English Standard Version Bible, 2001/2016, Proverbs 27:23). A registry is a modern way of knowing the condition of the flock. The moral point is that care for people includes the unglamorous work of keeping track, and someone must be assigned to act on what the tracking shows.

For my future practice as an advanced practice nurse, the lesson is that every screening program needs a follow-up program built at the same time. I will not support adding a test to a protocol without a plan for who sees the result, who calls the patient and how we know the call happened.

Reply to Olivia

Olivia, your concern that adding alerts will worsen alert fatigue is well founded. Clinicians in many systems already override most medication alerts, and a new alert for every test result would likely meet the same fate. Two design choices reduce that risk. First, send the alert only for results that require action, such as a reactive HIV test, rather than for every test. Second, route it to one role with protected time to act, as Patel et al. (2018) recommend when they describe health system nudge units that change the defaults and pathways inside the record rather than adding warnings. The population health text makes a similar point about designing care processes so that the right person does the right task at the right time (Nash et al., 2016). In my example, a single alert to a nurse navigator would have been more effective than several alerts to busy physicians. Has your organization ever removed alerts as part of a quality project? Retiring low-value alerts can make the important ones visible again, and staff often notice the difference within weeks.

Reply to Ethan

Ethan, you raised an important question about patient privacy when hospitals share data with health departments, and HIV is an area where confidentiality fears keep people from testing. I think the answer is that sharing must be both lawful and visible to patients. Branson et al. (2006), in the CDC recommendations that made opt-out screening routine, emphasized that patients should be told testing will be done and that results are confidential, which builds the trust that makes routine testing acceptable. Federal privacy rules permit disclosures to public health authorities for disease control, but patients are more likely to accept that sharing when it is explained. The CDC modeling also suggests why sharing is worth the effort: reconnecting people who know their status but are not in care addresses the largest share of transmissions (Li et al., 2019). Your idea of adding a sentence to the test offer explaining how results are protected is a good one. Have you seen patients decline testing because of privacy concerns in your clinic? Their reasons would help shape the wording of that sentence.

References

Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., & Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recommendations and Reports, 55(RR-14), 1-17.

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Li, Z., Purcell, D. W., Sansom, S. L., Hayes, D., & Hall, H. I. (2019). Vital signs: HIV transmission along the continuum of care, United States, 2016. Morbidity and Mortality Weekly Report, 68(11), 267-272. https://doi.org/10.15585/mmwr.mm6811e1

Nash, D. B., Fabius, R. J., Skoufalos, A., Clarke, J. L., & Horowitz, M. R. (2016). Population health: Creating a culture of wellness (2nd ed.). Jones & Bartlett Learning.

Patel, M. S., Volpp, K. G., & Asch, D. A. (2018). Nudge units to improve the delivery of health care. The New England Journal of Medicine, 378(3), 214-216. https://doi.org/10.1056/NEJMp1712984