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Context: The Health Information Technology for Economic and Clinical Health (HITECH) Act set ambitious goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes. With HITECH's grant funding now mostly exhausted but statutory authority for standards remaining, this article looks back at HITECH's experience in the first 5 years to assess its implementation, remaining challenges, and lessons learned. Methods: This review derives from a global assessment of the HITECH Act. Earlier, we examined the logic of HITECH and identified interdependencies critical to its ultimate success. In this article, we build on that framework to review what has and has not been accomplished in building the infrastructure authorized by HITECH since it was enacted. The review incorporates quantitative and qualitative evidence of progress from the global assessment and from the evaluations funded by the Office of the National Coordinator for Health Information Technology (ONC) of individual programs authorized by the HITECH Act. Findings: Our review of the evidence provides a mixed picture. Despite HITECH's challenging demands, its complex programs were implemented, and important changes sought by the act are now in place. Electronic health records (EHRs) now exist in some form in most professional practices and hospitals eligible for HITECH incentive payments, more information is being shared electronically, and the focus of attention has shifted from adoption of EHRs toward more fundamental issues associated with using health information technology (health IT) to improve health care delivery and outcomes. In some areas, HITECH's achievements to date have fallen short of the hopes of its proponents as it has proven challenging to move meaningful use beyond the initial low bar set by Meaningful Use Stage 1. EHR products vary in their ability to support more advanced functionalities, such as patient engagement and population-based care management. Many barriers to interoperability persist, limiting electronic commkunication across a diverse set of largely private providers and care settings. Conclusions: Achieving the expansive goals of HITECH required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, some better positioned to move forward than others. To date, it has proven easier to get providers to adopt EHRs, perhaps in response to financial incentives to do so, than to develop a robust infrastructure that allows the information in EHRs to be used effectively and shared not only within clinical practices but also across providers. Effective exchange of data is necessary to drive the kinds of delivery and payment reforms sought nationwide.

Animal models that accurately reflect COVID-19 are vital for understanding mechanisms of disease and advancing development of improved vaccines and therapeutics. Pigs are increasingly recognized as valuable models for human disease due to their genetic, anatomical, physiological, and immunological similarities to humans, and they present a more ethically viable alternative to non-human primates. However, pigs are not susceptible to SARS-CoV-2 infection which limits their utility as a model. To address this, we have developed transgenic pigs expressing human ACE2 that are susceptible to SARS-CoV-2 infection. Following challenge, clinical signs consistent with COVID-19, including fever, coughing and respiratory distress were observed, with virus replication detected in the nasal turbinates, trachea and lungs up to the study endpoint, seven days post-infection. Notably, examination of tissues revealed immunopathology in the lungs consistent with histological changes observed in fatal human COVID-19 cases. This study establishes human ACE2 transgenic pigs as a large animal model that accurately reflects many aspects of COVID-19 disease. Long Fung Chau and colleagues report the generation of transgenic pigs expressing human ACE2, and show that they exhibit clinical signs and immunopathology consistent with COVID-19 following infection with SARS-CoV-2, suggesting that human ACE2 transgenic pigs are a viable large animal model for COVID-19.

In enacting the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act, Congress set ambitious goals for the nation to integrate information technology into health care delivery. The provisions called for the electronic exchange of health information and the adoption and meaningful use of health information technology in health care practices and hospitals. We examined the marketplace and regulatory forces that influence HITECH's success and identify outstanding challenges, some beyond the provisions' control. To reach HITECH's goals, providers and patients must be persuaded of the value of health information exchange and support its implementation. Privacy concerns and remaining technical challenges must also be overcome. Achieving HITECH's goals will require well-aligned incentives, both visionary and practical pursuit of exchange infrastructure, and realistic assumptions about how quickly such wholesale change can be accomplished. The use of metrics to show adoption proceeding at a reasonable pace, increased flow of data across parties, and evidence that care is improving, at least in areas with robust systems, will be essential to persuade stakeholders that the initiative is progressing well and warrants continued investment. [PUBLICATION ABSTRACT]

Background: Many reports have focused attention on the rising percentage of adults in the United States without health insurance. This hides the fact that the uninsured rate for non-Hispanic nonelderly adults has held fairly steady since 1983, while the rate for Hispanics has increased. Objectives: To document the trends in the coverage rate by source of coverage for different population groups between 1983 and 2003 and suggest how changes in the composition of these groups have contributed to these trends. Research Design: We stack panels of the Survey of Income and Program Participation to create a nationally representative 20-year pooled cross-section of nonelderly adults. We calculate actual trends in insurance coverage as well as 2 hypothetical time series that disentangle the effect of the decreasing coverage rate for Hispanics from the growth of the Hispanic adult population. Results: Although the increase in uninsured rate is largest for Hispanic noncitizens, US-born Hispanics also have a significant upward trend, primarily driven by a decrease in private coverage, with little change in public coverage. Although the increase in the Hispanic population contributed to the increase in the number of uninsured adults, the widening coverage disparity was more important. Conclusions: Hispanic nonelderly adults, both US-born and immigrants, have fallen behind non-Hispanic nonelderly adults in insurance coverage. Although combinations of economic growth and private and public insurance policy changes have maintained, and in some cases improved, overall coverage rates for non-Hispanics, these changes have not helped Hispanic adults, leading to increased disparities in coverage.

Most proposals to improve access for uninsured adults focus on removing financial barriers to health care. Health services researchers have long recognized, however, that access to care is a multidimensional concept consisting of both financial and nonfinancial dimensions. While financial barriers faced by those without health insurance have been well-documented, it is not known to what degree nonfinancial barriers limit access for those without coverage. In this study we sought to identify the types and frequencies of nonfinancial access barriers faced by low-income uninsured adults, as well as determine how frequently nonfinancial barriers coexist with financial access barriers in this population. We conducted a telephone survey of 1,118 low-income uninsured adults in Alameda, California, Austin, Texas, and Southern Maine who had enrolled in local access programs funded through the Robert Wood Johnson Foundation's Communities in Charge initiative. Financial barriers were the most often cited barrier to access in each of the three groups, though nonfinancial barriers were often cited as well. Across all three populations, one-third to one-half of respondents with financial access barriers also cited one or more nonfinancial barriers as contributing to their problems accessing health care. Our results suggest that many uninsured adults face nonfinancial health care barriers in addition to their well-documented financial challenges. Health reform efforts must address both types of barriers in order to maximally improve access for the uninsured population.

The purpose of this study was to qualitatively explore clinical instructors' (CIs) perceptions of students' behaviors that comprise entry-level clinical performance, as well as how those perceptions were integrated into their decision making. The participants were 21 physical therapists who were CIs for physical therapist students. Using a grounded theory approach, we conducted interviews, asking the question, \"What is it about students' performance that makes you see them as entry-level therapists?\" We determined common themes among the interviews and developed a schema to explain the decision-making process. Participants identified 7 attributes that, when demonstrated to a sufficient degree, illustrated to them students' ability to practice at the entry level. Those attributes were knowledge, clinical skills, safety, clinical decision making, self-directed learning, interpersonal communication, and professional demeanor. Participants viewed these attributes in concert to form a subjective \"gut feeling\" that a student demonstrated entry-level performance. A final theme emerged suggesting a definition of entry-level performance as \"mentored independence.\" Participants reported evaluating students' performance based on attributes similar to those suggested by the American Physical Therapy Association's Physical Therapist Clinical Performance Instrument and previous research. However, subjectivity also was involved in their decision about whether students were able to practice at the entry level. Participants also concluded that entry-level students need not be independent in all clinical situations.

From 2001 to 2008, the Robert Wood Johnson Foundation funded the Economic Research Initiative on the Uninsured (ERIU), housed at the University of Michigan. The goals of ERIU were to increase, diversify, and improve the quality and quantity of economics research on the uninsured, and to translate that research into the type of resources that are useful to policymakers, policy analysts, researchers, and members of the media. One of the primary objectives of ERIU was to fund research projects that explored economic issues about the uninsured in new, yet rigorous and interesting ways. ERIU began by commissioning six critical syntheses of the existing research. These syntheses were intended to inform researchers of what we know and what we don't know about the uninsured.¹ In eight years, ERIU funded more than 50 new research projects on a variety of coverage topics aimed at addressing the gaps in knowledge highlighted in these syntheses. These projects, involving more than 100 researchers, resulted in over 70 conference and seminar presentations worldwide and approximately 40 articles published in peer-reviewed journals.²

The combination of rising numbers of unemployed workers, high and rising health insurance premiums, and tightening state budgets has led many analysts to predict an increase in the number of people without private or public health insurance. Using data from the 1999 Medical Expenditure Panel Survey (MEPS), this paper calculates the percentage of hospital inpatient, emergency department, and outpatient visits that are accounted for by uninsured people, and predicts how those shares would change under three different scenarios. It is found that although the burden of the uninsured would remain a severe problem for some hospitals, it would not likely increase much for most of them. This finding reflects the relatively low utilization rates among those most likely to lose coverage: nonelderly, nonpregnant, and nondisabled workers and their families.

From 2001 to 2008, the Robert Wood Johnson Foundation funded the Economic Research Initiative on the Uninsured (ERIU), housed at the University of Michigan. The goals of ERIU were to increase, diversify, and improve the quality and quantity of economics research on the uninsured, and to translate that research into the type of resources that are useful to policymakers, policy analysts, researchers, and members of the media. One of the primary objectives of ERIU was to fund research projects that explored economic issues about the uninsured in new, yet rigorous and interesting ways. ERIU began by commissioning six critical syntheses of the existing research. These syntheses were intended to inform researchers of what we know and what we don't know about the uninsured. In eight years, ERIU funded more than 50 new research projects on a variety of coverage topics aimed at addressing the gaps in knowledge highlighted in these syntheses. These projects, involving more than 100 researchers, resulted in over 70 conference and seminar presentations worldwide and approximately 40 articles published in peer-reviewed journals.

This study estimates the effects of an increase in an outpatient prescription drug copayment using a natural experiment based upon a large firm that implemented such an increase. The findings suggest that the primary effect of a copayment increase is attenuation of the trend in prescription drug utilization. We also find an initial reduction in expenditures, with the effects on spending diminishing. Employees with an existing chronic illness and those without a chronic illness show a similar, inelastic response to a copayment increase; employees with a newly diagnosed chronic illness have a more inelastic response.