Julia Adler-Milstein

University of California, San Francisco | UCSF · Department of Medicine

Objectives To develop indices of US hospital interoperability to capture the current state and assess progress over time. Materials and Methods A Technical Expert Panel (TEP) informed selection of items from the American Hospital Association Health IT Supplement survey, which were aggregated into interoperability concepts (components) and then fur...

Background The COVID-19 pandemic revealed major gaps in public health agencies’ (PHAs’) data and reporting infrastructure, which limited the ability of public health officials to conduct disease surveillance, particularly among racial or ethnic minorities disproportionally affected by the pandemic. Leveraging existing health information exchange or...

Objectives: We analyzed trends in adoption of advanced patient engagement and clinical data analytics functionalities among critical access hospitals (CAHs) and non-CAHs to assess how historical gaps have changed. Materials and methods: We used 2014, 2018, and 2023 data from the American Hospital Association Annual Survey IT Supplement to measur...

Importance In the context of a growing volume of electronic health record (EHR)–based work and post–COVID-19 pandemic staffing pressures, health system leaders need an up-to-date understanding of changes in family physicians’ experiences of burnout, determinants of burnout, and how to enhance the family physicians’ experience. Objective To evaluat...

Although electronic health record (EHR) documentation burden is known to be associated with reduced clinician well-being and burnout, it may have even worse unintended consequences if documentation work also crowds out other high-value EHR tasks. We examined this possibility by assessing the relationship between documentation burden and a high-valu...

While thousands of health systems have begun to implement the Age-Friendly Health System’s 4Ms Framework to improve care for older patients, an important phase of work is achieving consistent adherence to 4Ms care processes. Identifying mechanisms that may lead to higher versus lower adherence serves to guide efforts to achieve consistent, equitabl...

Importance Electronic health record (EHR) work has been associated with decreased physician well-being. Understanding the association between EHR usability and physician satisfaction and burnout, and whether team and technology strategies moderate this association, is critical to informing efforts to address EHR-associated physician burnout. Objec...

In late 2023, the Office of the National Coordinator for Health Information Technology launched the Trusted Exchange Framework and Common Agreement (TEFCA) to enable nationwide health information exchange. Regional, local, and state health information organizations (HIOs) will be key components of nationwide exchange, and TEFCA could broaden HIOs'...

Objectives Efforts to reduce documentation burden (DocBurden) for all health professionals (HP) are aligned with national initiatives to improve clinician wellness and patient safety. Yet DocBurden has not been precisely defined, limiting national conversations and rigorous, reproducible, and meaningful measures. Increasing attention to DocBurden m...

BACKGROUND The COVID-19 pandemic revealed major gaps in public health agencies’ (PHAs) data and reporting infrastructure which limited public health officials’ ability to conduct disease surveillance, particularly among racial/ethnic minorities disproportionally affected by the pandemic. Leveraging existing Health Information Exchange Organizations...

Objectives Despite the proliferation of dashboards that display performance data derived from Qualified Clinical Data Registries (QCDR), the degree to which clinicians and practices engage with such dashboards has not been well described. We aimed to develop a conceptual framework for assessing user engagement with dashboard technology and to demon...

Objective To identify impacts of different survey methodologies assessing primary care physicians' (PCPs’) experiences with electronic health records (EHRs), we compared three surveys: the 2022 Continuous Certification Questionnaire (CCQ) from the American Board of Family Medicine, the 2022 University of California San Francisco (UCSF) Physician He...

Preparing patients for posthospital care may improve readmission risk. Alternative payment models (APMs) incent hospitals to reduce readmissions by tying payment to outcomes. The impact of APMs on preparation for discharge is not well understood. We assessed whether patient-reported preparation for posthospital care was associated with reduced read...

This Viewpoint examines the potential problems of clinician reliance on the use of artificial intelligence (AI) in health care and offers suggestions on how AI could be designed to promote clinician vigilance.

Importance Enabling widespread interoperability—the ability of health information technology systems to exchange information and to use that information without special effort—is a primary focus of public policy on health information technology. More information on clinicians’ experience using that technology can serve as one measure of the impact...

Objective Understand public comfort with the use of different data types for predictive models Materials and Methods We analyzed data from a national survey of US adults (n = 1436) fielded from November to December 2021. For three categories of data (identified using factor analysis), we use descriptive statistics to capture comfort level. Result...

Objectives This study sought to capture current digital health company experiences integrating with electronic health records (EHRs), given new federally regulated standards-based application programming interface (API) policies. Materials and methods We developed and fielded a survey among companies that develop solutions enabling human interacti...

Objectives National attention has focused on increasing clinicians’ responsiveness to the social determinants of health, for example, food security. A key step toward designing responsive interventions includes ensuring that information about patients’ social circumstances is captured in the electronic health record (EHR). While prior work has asse...

This study assesses US trends in e-visit billing using national all-payer claims.

Background To support implementation of the 4Ms framework and more rigorous evidence of 4Ms impact, we translated Institute for Healthcare Improvement's (IHI's) recommended 4Ms routine care practices into electronic health record‐based, encounter‐level adherence measures and then implemented measures at a large academic medical center. Methods We...

Introduction Research on how people interact with electronic health records (EHRs) increasingly involves the analysis of metadata on EHR use. These metadata can be recorded unobtrusively and capture EHR use at a scale unattainable through direct observation or self-reports. However, there is substantial variation in how metadata on EHR use are reco...

Objective: To use more precise measures of which hospitals are electronically connected to determine whether health information exchange (HIE) is associated with lower emergency department (ED)-related utilization. Materials and methods: We combined 2018 Medicare fee-for-service claims to identify beneficiaries with 2 ED encounters within 30 day...

Importance Understanding the drivers of electronic health record (EHR) burden, including EHR time and patient messaging, may directly inform strategies to address physician burnout. Given the COVID-19−induced expansion of telemedicine—now used for a substantial proportion of ambulatory encounters—its association with EHR burden should be evaluated....

Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive electronic health record (EHR) improvements and decrease EHR burden. Differences exist between research and vendor definitions of metrics. Process We convened three stakeholder groups (health system informatics leaders,...

OBJECTIVES In response to evidence linking social risk factors and adverse health outcomes, new incentives have emerged for hospitals to screen for adverse social determinants of health (SDOH). However, little information is available about the current state of social risk–related care practices among children’s hospitals. To address outstanding kn...

Objective: A key aspect of electronic health record (EHR) governance involves the approach to EHR modification. We report a descriptive study to characterize EHR governance at academic medical centers (AMCs) across the United States (US). Materials and methods: We conducted interviews with the Chief Medical Information Officers (CMIOs) of 18 AMC...

Thousands of health systems have adopted the 4 Ms framework, a set of evidence-based practices specific to older adults, as part of the Age-Friendly Health Systems (AFHS) initiative. However, implementation efforts have largely been setting-specific and approaches to achieve continuity of the 4 Ms during care transitions are nascent. Transitions fr...

This cohort study examines changes in physician electronic health record (EHR) documentation time before and after changes in Centers for Medicare & Medicaid evaluation and management requirements.

Background: Skilled nursing facilities' (SNFs) ability to provide optimal post-acute care depends on effective receipt of information from hospitals ("information continuity"). Little is known about how SNFs perceive information continuity and how it may relate to upstream information sharing processes, organizational context, and downstream outco...

Introduction: Missed and delayed diagnoses have received substantial attention as a quality and patient safety priority. To the extent that electronic health records, team-based care, and other mitigation strategies have been successful in improving diagnosis since the last large-scale study, we would expect that the contributing factors to diagno...

This study evaluates the adoption of clinician billing for patient portal messages as e-visits, prompted by significant increases in patient messaging after the onset of the COVID-19 pandemic.

Objective: Electronic health records (EHRs) are increasingly used to capture social determinants of health (SDH) data, though there are few published studies of clinicians' engagement with captured data and whether engagement influences health and healthcare utilization. We compared the relative frequency of clinician engagement with discrete SDH...

Prof. Adler-Milstein will present national survey results about skilled nursing facilities (SNFs) information sharing with referring hospitals. The survey, which garnered a 53% response rate, found significant gaps in information sharing. Of 471 hospital-SNF pairs, 64 (13.5%) reported excellent performance on 3 dimensions of information sharing (co...

There is a critical need to redesign the healthcare system to provide more effective and tailored care to older adults. The 4Ms Framework (What Matters, Medication, Mentation and Mobility) offers a blueprint to guide health system efforts to deliver more age-friendly care. We sought to characterize and assess real-world implementation experiences w...

The adoption of electronic health records (EHRs) and digitization of health data over the past decade is ushering in the next generation of digital health tools that leverage artificial intelligence (AI) to improve varied aspects of health system performance. The decade ahead is therefore shaping up to be one in which digital health becomes even mo...

Importance: Although Medicare accountable care organizations (ACOs) account for half of program expenditures, whether ACOs are associated with surgical spending warrants further study. Objective: To assess whether greater beneficiary-hospital ACO alignment was associated with lower surgical episode costs. Design, setting, and participants: Thi...

This Viewpoint proposes a solution to better safeguard reproductive health information in patient records that are now more complete owing to the interoperability of health information exchange networks.

Objective: To determine whether novel measures of contextual factors from multi-site electronic health record (EHR) audit log data can explain variation in clinical process outcomes. Materials and methods: We selected one widely-used process outcome: emergency department (ED)-based team time to deliver tissue plasminogen activator (tPA) to patie...

On June 24, 2022, the US Supreme Court ended constitutional protections for abortion, resulting in wide variability in access from severe restrictions in many states and fewer restrictions in others. Healthcare institutions capture information about patients’ pregnancy and abortion care and, due to interoperability, may share it in ways that expose...

Electronic health record audit logs capture a time-sequenced record of clinician activities while using the system. Audit log data therefore facilitate unobtrusive measurement at scale of clinical work activities and workflow as well as derivative, behavioral proxies (eg, teamwork). Given its considerable research potential, studies leveraging thes...

Background: Increasing electronic health information exchange (HIE) between provider organizations is a top policy priority that has been pursued by establishing varied types of networks. Objectives: To measure electronic connectivity enabled by these networks, including community, electronic health record vendor, and national HIE networks, acro...

Undivided attention is a clinician's superpower. Often called deep work, being in the flow, or being in the zone-- when health professionals are able to perform their responsibilities with full focus and presence, the care itself is safer and the care process is more satisfying to patients and clinicians alike. The opposite of this state is split a...

A discussion and debate on the American Medical Informatics Association’s (AMIA) Ethical, Legal, and Social Issues (ELSI) Working Group listserv in 2021 raised important issues related to a forthcoming conference in Texas. Texas had recently enacted a restrictive abortion law and restricted voting rights. Several AMIA members advocated for a boycot...

Digitization has been a central pillar of structural investments to promote organizational capacity for transformation, and yet skilled nursing facilities (SNFs) and other post-acute providers have been excluded and/or delayed in benefitting from the past decade of substantial public and private sector investment in information technology (IT). The...

The rapid adoption of electronic health records (EHRs) has created extensive repositories of digitized data that can be used to inform improvements in care delivery, processes, and patient outcomes. While the clinical data captured in EHRs are widely used for such efforts, EHRs also capture audit log data that reflect how users interact with the EH...

IMPORTANCE Policy makers envision synergistic benefits from primary care reform programs that advance infrastructure and processes in the context of a supportive payment environment. However, these programs have been operationalized and implemented separately, raising the question of whether synergies are achieved. OBJECTIVE To evaluate association...

Importance: Interoperable patient data exchange across hospitals remains an important policy goal for reducing costs and improving the quality of care. Congress designated 2018 as the goal for nationwide interoperability, and policy makers hoped that aligning financial incentives via alternative payment models (APMs) would help achieve that goal....

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulato...

Objectives: Computable social risk factor phenotypes derived from routinely collected structured electronic health record (EHR) or health information exchange (HIE) data may represent a feasible and robust approach to measuring social factors. This study convened an expert panel to identify and assess the quality of individual EHR and HIE structur...

Seamless exchange of data and information across the health system, or interoperability, is paramount to providing excellent patient care. Providers need access to comprehensive data and information on their patients, including records from providers and facilities across the city or located in another state. The COVID-19 pandemic highlighted the f...

Objective: To characterize variation in clinical documentation production patterns, how this variation relates to individual resident behavior preferences, and how these choices relate to work hours. Materials and methods: We used unsupervised machine learning with clinical note metadata for 1265 progress notes written for 279 patient encounters...

Objective Electronic Health Records (EHRs) increasingly include designated fields to capture social determinants of health (SDOH). We developed measures to characterize their use, and use of other SDOH data types, to optimize SDOH data integration. Materials and Methods We developed 3 measures that accommodate different EHR data types on an encoun...

Objective To characterize challenges and strategies related to algorithmic risk scoring for care management eligibility determinations. Materials and Methods Interviews with 19 administrators from 13 physician organizations representing over 2200 physician offices and 8800 physicians in Michigan. Post-implementation interviews were coded using the...

Objective: Despite broad electronic health record (EHR) adoption in U.S. hospitals, there is concern that an "advanced use" digital divide exists between critical access hospitals (CAHs) and non-CAHs. We measured EHR adoption and advanced use over time to analyzed changes in the divide. Materials and methods: We used 2008 to 2018 American Hospit...

After more than a decade of investment in electronic health information exchange (HIE), the Office of the National Coordinator for Health Information Technology is advancing a national framework-the Trusted Exchange Framework and Common Agreement-to connect islands of electronic data sharing. This national framework creates new potential opportunit...

Objectives Increasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs. Design Cross-sectional survey. Setting and...

In 2017, 43.9% of US physicians reported symptoms of burnout. Poor electronic health record (EHR) usability and time-consuming data entry contribute to burnout. However, less is known about how modifiable dimensions of EHR use relate to burnout and how these associations vary by medical specialty. Using the KLAS Arch Collaborative’s large-scale nat...

Background: Medical training programs across the country are bound to a set of work hour regulations, generally monitored via self-report. Objective: We developed a computational method to automate measurement of intern and resident work hours, which we validated against self-report. Design, setting, and participants: We included all electroni...

Objective: To assess longitudinal primary care organization participation patterns in large-scale reform programs and identify organizational characteristics associated with multiprogram participation. Data Sources: Secondary data analysis of national program participation data over an eight-year period (2009-2016). Study Design: We conducted a ret...

Objective To identify organizational complementarities of adoption and use of electronic health records (EHRs) and assess what organizational strategies were associated with more advanced EHR use. Data Sources Primary survey data of US hospitals combined with secondary data from the American Hospital Association Annual Survey and IT Supplement. S...

Dear JAMIA editors and readers: We appreciate Shachak’s letter regarding our article entitled “A Call for Social Informatics.”¹ In it, he argues that social informatics is a poor term to describe a field dedicated to the application of information technologies to capture and apply social data in conjunction with health data in order to advance heal...

High quality patient care through timely, precise and efficacious management depends not only on the clinical presentation of a patient, but the context of the care environment to which they present. Understanding and improving factors that affect streamlined workflow, such as provider or department busyness or experience, are essential to improvin...

Importance Patient transitions from hospitals to skilled nursing facilities (SNFs) require robust information sharing. After a decade of investment in health information technology infrastructure and new incentives to promote hospital-SNF coordination in the US, the current state of information sharing at this critical transition is unknown. Objec...

Objective Recent policymaking aims to prevent health systems, health information technology (IT) developers, and others from blocking the electronic sharing of patient data necessary for clinical care. We sought to assess the prevalence of information blocking prior to enforcement of these rules. Materials and Methods We conducted a national surve...

BACKGROUND There is widespread agreement on the promise of patient-facing digital health tools to transform healthcare. Yet there is a dramatic gap between promise and reality, with few tools in widespread use or with documented clinical effectiveness. OBJECTIVE To gain insight into the gap between the potential of patient-facing digital health to...

Background There is widespread agreement on the promise of patient-facing digital health tools to transform health care. Yet, few tools are in widespread use or have documented clinical effectiveness. Objective The aim of this study was to gain insight into the gap between the potential of patient-facing digital health tools and real-world uptake....

As evidence of the associations between social factors and health outcomes continues to mount, capturing and acting on social determinants of health (SDOH) in clinical settings has never been more relevant. Many professional medical organizations have endorsed screening for SDOH, and the U.S. Office of the National Coordinator for Health Informatio...

Crowdsourced ratings have driven increased performance transparency between consumers and suppliers. While many industries have benefitted from such transparency, crowdsourced ratings have struggled to scale in the healthcare domain. In theory, interoperability services offer an ideal setting for crowdsourced ratings: costs are high, performance is...

We sought to identify barriers to hospital reporting of electronic surveillance data to local, state, and federal public health agencies and the impact on areas projected to be overwhelmed by the COVID-19 pandemic. Using 2018 American Hospital Association data, we identified barriers to surveillance data reporting, and combined this with data on th...

Objective: The study sought to determine which patient characteristics are associated with the use of patient-facing digital health tools in the United States. Materials and methods: We conducted a literature review of studies of patient-facing digital health tools that objectively evaluated use (eg, system/platform data representing frequency o...

Background: Health systems have recently started to activate patient-facing application programming interfaces (APIs) to facilitate patient access to health data and other interactions. Objective: This study sought to ascertain health systems’ understanding, strategies, governance, and organizational infrastructure around patient-facing APIs, as w...

Objective There has been substantial growth in eHealth over the past decade, driven by expectations of improved healthcare system performance. Despite substantial eHealth investment, little is known about the monitoring and evaluation strategies for gauging progress in eHealth availability and use. This scoping review aims to map the existing liter...

Importance The electronic health record (EHR) is a source of practitioner dissatisfaction in part because of challenges with information retrieval. To improve data accessibility, a better understanding of practitioners’ information needs within individual patient records is needed. Objective To assess EHR users’ searches using data from a large in...

Electronic health record (EHR) log data have shown promise in measuring physician time spent on clinical activities, contributing to deeper understanding and further optimization of the clinical environment. In this article, we propose 7 core measures of EHR use that reflect multiple dimensions of practice efficiency: total EHR time, work outside o...

Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per bene...

The widespread implementation of electronic health records (EHRs) was predicated on hopes that they would rapidly improve care, but initial experiences have been disappointing and thought to be a key part of physician dissatisfaction and burnout. The crisis created by EHR implementation is only in part due to EHRs themselves, and might also be view...

Substantial policy effort has been directed at improving patients' ability to access and use electronic health records. Using nationwide data from 2,410 hospitals for the period 2014-16, we examined associations between patient- and hospital-level characteristics and access to and use of electronic health record data among discharged patients. On a...

Objective: One potential benefit of greater electronic health information exchange is a reduction in the effort required for patients to switch between providers. We therefore assessed whether hospital participation in health information organizations (HIOs) led to increased patient sharing. Data sources: Secondary data from 2010 to 2016. Study...

Background: Health systems have recently started to activate patient-facing application programming interfaces (APIs) to facilitate patient access to health data and other interactions. Objective: This study sought to ascertain health systems' understanding, strategies, governance, and organizational infrastructure around patient-facing APIs, as...

Objective: To assess whether an electronic health record (EHR) portal to enable health information exchange (HIE) between a hospital and three skilled nursing facilities (SNFs) reduced likelihood of patient readmission. Setting/data: Secondary data; all discharges from a large academic medical center to SNFs between July 2013 and March 2017, com...