Patient-Centered Medical Home Cyberinfrastructure Current and Future Landscape Joseph Finkelstein, MD, PhD, Michael S. Barr, MD, Pranav P. Kothari, MD, David K. Nace, MD, Matthew Quinn, MBA Abstract: The patient-centered medical home (PCMH) is an approach that evolved from the understanding that a well-organized, proactive clinical team working in a tandem with wellinformed patients is better able to address the preventive and disease management needs in a guideline-concordant manner. This approach represents a fundamental shift from episodic acute care models and has become an integral part of health reform supported on a federal level. The major aspects of PCMH, especially pertinent to its information infrastructure, have been discussed by an expert panel organized by the Agency for Healthcare Research and Quality at the Informatics for Consumer Health Summit. The goal of this article is to summarize the panel discussions along the four major domains presented at the summit: (1) PCMH as an Evolving Model of Healthcare Delivery; (2) Health Information Technology (HIT) Applications to Support the PCMH; (3) Current HIT Landscape of PCMH: Challenges and Opportunities; and (4) Future HIT Landscape of PCMH: Federal Initiatives on Health Informatics, Legislation, and Standardization. (Am J Prev Med 2011;40(5S2):S225–S233) © 2011 American Journal of Preventive Medicine

Introduction

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he efforts to promote PCMH principles are especially important in the light of recent healthcare reform initiatives that call for greater emphasis on health promotion and disease prevention. The delivery of preventive services has been shown to improve in primary care practices enhanced by HIT. Based on the recent demonstration projects, this article provides an overview of major requirements for HIT infrastructure needed to support successful PCMH implementation and describes barriers that will be potentially addressed by the recent federal legislation on electronic health records (EHRs), health informatics, and standardization. The patient-centered medical home (PCMH) is an approach to providing comprehensive primary care that facilitates partnerships between individual health consumers and their primary care clinicians. This approach represents a fundamental shift from episodic acute care From the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University School of Medicine (Finkelstein), Baltimore; Agency for Healthcare Research and Quality (Quinn), Rockville, Maryland; American College of Physicians (Barr), Washington DC; Renaissance Health (Kothari), Cambridge; and McKesson Health Solutions (Nace), Newton, Massachusetts Address correspondence to: Joseph Finkelstein, MD, PhD, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University School of Medicine, 2024 East Monument Street, Room 2-615, Baltimore MD 21205. E-mail: jfı[email protected]. 0749-3797/$17.00 doi: 10.1016/j.amepre.2011.01.003

© 2011 American Journal of Preventive Medicine. All rights reserved.

models and has become an integral part of health reform supported on a federal level. The major aspects of PCMH, especially pertinent to its information infrastructure, have been discussed by an expert panel organized by the Agency for Healthcare Research and Quality (AHRQ) at the Informatics for Consumer Health Summit.1 The goal of this article is to summarize the panel discussions along the four major domains presented at the summit: (1) PCMH as an Evolving Model of Healthcare Delivery; (2) Health Information Technology (HIT) Applications to Support the PCMH; (3) Current HIT Landscape of PCMH: Challenges and Opportunities; and (4) Future Health IT Landscape of PCMH: Federal Initiatives on Health Informatics, Legislation, and Standardization.

The Patient-Centered Medical Home: an Evolving Model of Healthcare Delivery Gaps in Primary Care Delivery Multiple studies have demonstrated that health care provided across the U.S. is highly variable with respect to both cost and quality.2– 4 Where there is a higher ratio of primary care physicians to specialists, higher-quality care appears to be provided at the same or lower cost.5 Internationally, countries that have a more robust primary care foundation for their healthcare systems have lower per capita healthcare costs and deliver better-quality care than the U.S. healthcare system.6 These data and addiAm J Prev Med 2011;40(5S2):S225–S233

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tional observations about the failure to deliver evidencebased care for important clinical scenarios,7 coupled with evidence of positive impact of HIT on quality of care,8,9 highlight the opportunity to utilize HIT at the point of care to support new models of evidence-based care delivery such as the PCMH.10 The PCMH concept evolved from the understanding that a well-organized, proactive clinical team working in a tandem with well-informed patients is better able to address the preventive and disease management needs in a guideline-concordant manner. First described in 1967 by the American Academy of Pediatrics’ Council of Pediatric Practice for children with special needs, the medical home model has served as the historical basis for the development of the PCMH.11 The PCMH is congruent with Chronic Care Model (CCM), which was developed by a team led by Wagner et al.12 at the MacColl Institute for Healthcare Innovation. A recent summary of the existing evidence highlights the potential for this method of delivery to positively affect healthcare quality and cost.13 Building on the CCM14 and evolving concepts of patient-centered care,15–18 the PCMH principles introduced in 2007 by medical professional societies19 including the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA) have generated substantial activity with multiple private payer and state Medicaid demonstration projects underway or in development across the U.S.20 Beginning with the Tax Relief and Health Care Act of 2006 (HR 6111, Title II, Sec 204), the federal government has had the authorization to test the PCMH model but efforts have been delayed. With the passage of the Patient Protection and Affordable Care Act (PPACA), the Centers for Medicare & Medicaid Services will organize a Center for Medicare & Medicaid Innovation (CMI) to test various healthcare delivery and payment options— among them the PCMH.21

cost-effective, and safe health care. Other defınitions have been adopted to suit the needs of specifıc demonstration projects or in response to a perceived need to address particular elements of the original Joint Principles of PCMH.23–25 AHRQ adopted a defınition of PCMH describing it “not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care” including patient-centeredness, comprehensive care, coordinated care, superb access to care, and a systems-based approach to quality and safety.26 One of the challenges posed to the professional societies by payers and employers interested in testing the model was how to determine, for purposes of enhanced reimbursement, whether a practice is capable of performing as a PCMH. This need led to the introduction of the National Committee for Quality Assurance’s (NCQA) recognition process, which was released in January 2008.27 With input from AAFP, AAP, ACP, and AOA, NCQA modifıed the existing Physician Practice Connections (PPC) recognition program to suit the needs of the growing number of PCMH demonstration projects. Based on almost 2 years of experience, the PPC–PCMH is now undergoing updates and revisions through an NCQA-led multi-stakeholder review process. Other entities such as URAC28 and the Joint Commission29 are introducing alternative recognition programs. While the fınal versions of new programs are currently under development, there are several essential components of the PCMH that need to be assessed. Among them are whether the practices: ●

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Defining the Patient-Centered Medical Home At its core, the PCMH model is about delivering on the intent of the IOM’s six aims for improving health care (i.e., making health care safer and more effective, patientcentered, timely, effıcient, and equitable).22 Since the release of the Joint Principles of the Patient-Centered Medical Home, much has been written about how to defıne and implement the model.19 The Joint Principles start with the premise that primary care should be based on a delivery system in which every individual has a personal physician operating in a team-based, multidisciplinary practice that is oriented to provide patient-centered, easily accessible services that balance evidence-based algorithms with clinical judgment to generate high-quality,

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provide easily accessible services during and outside normal business hours including both in-person and virtual connections (e.g., email, phone, text messaging, web-based connections); have systems in place to help identify patients needing different types of clinical or social interventions (e.g., past-due screening tests, drug-level monitoring, overdue visits) and to manage specifıc populations of patients that might benefıt from systematic efforts to improve care and clinical outcomes; coordinate care through organized and effıcient human and technology processes that facilitate timely bi-directional exchange of information with other aspects of the healthcare system; utilize key elements of available technology such as electronic prescribing, clinical decision support, patient-tracking and registry functions, and secure email/web-based information sharing with patients (and families when appropriate); engage patients (and families) in developing care/treatment plans with trained healthcare professionals while www.ajpm-online.net

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also providing interactive support through personal health records (PHRs) and other technology such as remote monitoring, education, and counseling; ● track and trend performance of the practice and individual clinicians with respect to clinical quality, patient experience/satisfaction, and use of resources. Several published articles discuss the promises and challenges of the PCMH model30 as well as some of the early results.31 Recent demonstration projects provided evidence that PCMH redesign can be associated with improvements in care delivery.31–34 For example, a 2-year evaluation of the Group Health Medical Home showed improvements in patient experience, clinician burnout, quality of care, and decreases in urgent care utilization and overall cost.32 Another 2-year PCMH evaluation conducted by the National Demonstration Project (NDP) showed improvements in conditionspecifıc quality of care.33,34 HIT played a major role in implementing the PCMH model. The lessons learned from using HIT to support PCMH are discussed below.

Health Information Technology Applications to Support the PatientCentered Medical Home Recent demonstration projects illustrated need in a comprehensive HIT infrastructure to achieve the goals of PCHM and provided insight on major capabilities and functionalities of HIT that are needed to build the PCMH cyberinfrastructure in the future.31–34 For example, implementation of the PCMH model in the Group Health Cooperative heavily relied on HIT including an EHR, electronic registries, health maintenance reminders, bestpractice alerts, secure e-mail messages, patient access to test results, health-risk appraisals, “after visit summaries,” and online prescription refılls.32 The PCMH implementation in the NDP project included fıve HIT components: EHR, e-prescribing, population management registry, practice website, and patient portal.33,34 While integration of the HIT components into clinical practice workflow faced various challenges31–34 in the recent PCMH demonstration projects (described in the next section), there is a consensus among key stakeholders that HIT play pivotal role in PCMH implementation.35 Major PCMH recognition programs, such as PPC–PCMH by NCQA, require implementation of specifıc IT components27 including disease registries, electronic communication, and prescribing. Moreover, there is an overwhelming recognition that, instead of isolated IT applications, a comprehensive HIT infrastructure is required to fully implement successful PCMH solutions allowing sustainable improvement of primary care delivery.37,38 Such an approach is supported by AHRQ that May 2011

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“recognizes the central role of HIT in successfully operationalizing and implementing the key features of the medical home.”26 Several publications reviewed current and future HIT infrastructure for PCMH.35–38 These reviews described a variety of HIT components implemented as a part of PCMH including EHR, fully secured remote access, electronic patient notes, scheduling, billing, chronic disease management registries, open-access scheduling, computerized physician order entry, e-prescribing, asynchronous communication with patients, ongoing populationbased quality improvement using EHR, use of preventive care registries, and practice-based research and predictive modeling using EHR. In a comprehensive review of the future of HIT in PCMH, Bates et al.35 concluded that further development is required in order to improve effıciency, quality, and safety of primary care delivery. This review called for particular attention to seven major areas for future development: telehealth, measurement of quality and effıciency, care transitions, PHRs, and, most important, registries, team care, and clinical decision support for chronic diseases. The review conducted by the Patient-Centered Primary Care Collaborative (PCPCC), rather than attempting to provide an exhaustive list of various PCMH HIT components, introduced a more systematic approach by describing the capabilities and functionality that HIT ought to provide in order to support a successful PCMH practice.38 Such an approach is, indeed, wiser as it does not depend on particular suppliers of HIT and on everchanging defınitions of particular HIT components. Following this approach, a summary was made of the existing literature in Table 1 to describe capabilities and functionality of HIT infrastructure required to support a medical practice to become a successful medical home. In addition, Table 1 includes references to research articles providing further evidence that the capabilities and functionality listed in the table improve quality, safety, and effıciency of clinical care delivery.

Current Health Information Technology Landscape of Patient-Centered Medical Home: Challenges and Opportunities As was shown above, HIT is a critical foundation to support a fully functioning PCMH that effıciently operates within a medical neighborhood context at the community level. However, to date, there have been only scattered examples of robust, fully integrated HIT within implemented medical homes. Currently, a limited number of physicians in the U.S. use outpatient EHR, although it appears that most would like to begin using them.60 In the recent national survey of ambulatory

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Table 1. Capabilities and functionality of HIT infrastructure to support PCMH38 HIT capabilities needed to support PCMH

Importance for PCMH

Sample HIT applications

Systematic collection, storage, management, and exchange of relevant personal health information

Collects standardized, accurate, and essential data elements Incorporates data from outside systems (particularly pharmacies, inpatient stays, laboratories, and imaging centers)

Enables data to be analyzed and shared in a consistent manner Facilitates effective coordination of care across clinicians (external data must be standardized and machine-interoperable if it is to be incorporated into quality measures and decision support)

EHRs, PHRs, and e-Prescribing software products and services39–41; population registries are also examples of HIT that can provide or improve this capability42–44

Comprehensive communication of providers, patients and other members of a person’s health team in the process of care delivery and care management

Offers support for care coordination Facilitates medication reconciliation, especially between prescribed medications and pharmacy records Offers registry reporting/community view Offers linking to community resources

Allows continual collection and management of encounter reports and test results from all of the providers who are delivering care to a patient; enables all caregivers to collaborate in the care of the patient Improves monitoring of medication adherence, helps avoid adverse drug– drug interactions, and increases prescribing efficiency Enables tracking of patients who require better care management; allows physician, practice, or institution to systematically monitor and improve care of chronic conditions; facilitates anticipatory care and patient recall Helps clinicians identify community resources that can support patients, including disease management programs offered by health plans, nutrition or exercise programs, substance abuse and mental health services, and support groups

EHRs, interactive web portals, and online communications platforms that are designed to provide communications such as secure e-mail, online scheduling, access to PHRs, and home monitoring systems45–48

Continuous collection, storage, measurement, and reporting on the processes and outcomes of individual and population performance and quality of care

Offers automated quality measurement Offers improved interfaces with Public Health Services (including automated reporting of mandatory notifiable communicable disease, and immunization information) Offers systematic outcomes evaluation

Enables practices to monitor quality improvement activities; allows insurers to compare clinicians and pay for improved preventive services and improved clinical outcomes Enhances capacity to respond to public health emergencies, facilitates monitoring of disease trends and population health, and helps identify populations in need of targeted interventions Improves post-marketing surveillance of adverse drug events, understanding the correlates of health disparities, and predictors of treatment and treatment outcomes

EHRs, patient and population registry applications or services, outcomes databases with reporting services, clinical dashboards, participation in data aggregation and reporting programs established for quality improvement, or pay-for-performance by health plans and others43,44

(conitnued on next page)

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Table 1. (continued) HIT capabilities needed to support PCMH

Importance for PCMH

Sample HIT applications

Evidence-based decision support for treatments and tests delivered by providers and their practices

Offers clinical decision support at the point of care Offers risk stratification

Combines patient data and evidence-based clinical best practices to provide decision-making assistance for priority preventive care issues Enables use of demographic and clinical information to identify at-risk patients; assists in disease management referrals, interpreting quality measurement data, and targeting anticipatory care

EHRs equipped with alerts and reminders, patient registry applications and services, PHRs that provide decision support tools, and other online services that accept and process personal health data for the purpose of evidence-based guidance for health-risk assessment and stratification, testing, treatment, and health maintenance43–44,49–51

Convenient access to health information and services for consumers and patients to be informed, educated, and literate about their health and medical conditions

Allows enhanced access via e-mail, PHR, web portals including interactive education and counseling, and shared decision making Offers support for patient–provider communication Allows consumers to manage health information

Facilitates patient-centered activities that can occur whenever it is convenient for patients and care providers Improves patient health literacy and problem solving by providing access to interactive tailored education, counseling, and feedback Helps patient understand and improve the doctor–patient relationship by supporting shared decision making, accounting for patient p, and facilitating patient–provider communication via multiple health communication channels

PHRs and web services, including some that are linked to EHRs and registry applications, that facilitate and direct patient education, information gathering, and make use of personal health data for actionable efforts to improve health and treat diseases and conditions52,53; interactive education and counseling portals driven by adult learning theories and models of behavior change54–56

On-going support of self-care and wellness management with monitoring and coaching from providers

Offers consumers self-management tools Coordinates communication Helps to inform and motivate patients In following their providers’ instructions, and to track their activities in pursuit of their goals

Helps patients and clinicians work together to improve preventive self-care and disease self-management Allows better tracking, categorization, routing, and management of all patient communications

Telemedicine and eHealth applications48,57–59

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HIT functionality

EHR, electronic health record; HIT, health information technology; PCMH, patient-centered medical home; PHR, personal health record

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care, only 4% of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. A variety of barriers for EHR adoption have been identifıed62,63 spanning from system-level policies on a national level, to health economics and cost-effectiveness issues, lack of robust standards and ontologies, unresolved issues with information exchange and interoperability, challenges of technical implementation, slow physician and patient acceptance, and patient access to the information highway. In a recent review of real-life experiences of PCMH implementation, multiple challenges of adapting a currently available EHR to the needs of PCMH were identifıed.64 The reported challenges included sluggish and unreliable software, glitches with e-prescribing, inability to reliably interface lab systems with EHR, limitations of clinical alerts and warnings, perceived burden on physicians, and inconsistencies in managing medication lists. Current EHRs have generally been developed to support a traditional fee for service visit– driven reimbursement model, facilitating documentation to support a billing function. Anchoring the EHR in the traditional visit-based care delivery model limits the potential of the medical home to generate paradigm shifting care delivery and outcomes. An important progress barrier is around the functionality of the information held within silo-based EHRs. In a medical home (and more so in a medical neighborhood) the longitudinal health information is necessary for sustained, non-episodic care delivery. HIT and health information exchange (HIE) are inter-related—neither one without the other will truly support a patient-centered, 360-degree view of the patient’s health across a community, beyond a physician’s offıce or facilities view. Another challenge that future developers of IT solutions for PCMH face is the ability to incorporate the principles of patient-centeredness, including shared decision making and patient preferences, directly into EHR design35 instead of building stand-alone tools to support patient-centered care. Moreover, HIT in itself will not drive changes in practice or outcomes.32 HIT without workflow, process, and relationship change will not work. HIT provides foundational support to enable the workflow and process changes that ultimately will foster stronger relationships and healthcare experiences. To support a PCMH, HIT needs new capabilities, such as multiple team member access and permissions, care management workflow support, PHRs, registries, clinical decision support, measurement of quality and effıciency, and robust reporting.38 As we move to community-based Accountable Care Organizations,65– 66 it is essential that HIT further evolves and the patient information become “patient-centered,”

as described herein. There needs to be one-stop access to a common patient record of information for essential providers (physicians, care providers, and patients). In a truly PCMH, the patient record and health-related information needs to be available wherever and whenever it is needed. With the increasing use of the Internet, portals, and “cloud computing” technologies, the boundaries between HIT and HIE are rapidly becoming blurred. The value of a PCMH built on a “connected” HIT foundation will not just be the “availability” of the data, but also how functional the access, analytics, and exchanging of information will be in the real-time delivery of care. These functions can drive improvements in the quality and effıciency of care delivery, as well as improvements in the experience of care (and experience of care delivery) and overall patient outcomes. As described in the previous section, there are multiple examples in the literature of medical home implementations with HIT, both in terms of successes and challenges, using technology currently available on the marketplace.31–34 While there is not a one-size-fıts-all solution, the critical capabilities of HIT to support a connected PCMH have been articulated (Table 1). The success in nationwide implementation of these crucial HIT capabilities to a large degree depends on comprehensive nationwide policies promulgated on a federal level. The next section is devoted to covering the very promising developments in this area.

Future Health Information Technology Landscape of Patient-Centered Medical Home: Federal Initiatives on Health Informatics, Legislation, and Standardization The U.S. federal government, which both purchases care and delivers care, has the ability to support the development of the cyberinfrastructure for the PCMH. In addition to direct efforts to support infrastructure development for its own delivery systems, the federal government can provide incentives for adopting systems and processes in line with this model of care, facilitate standards harmonization, remove technical and legal barriers, and establish demonstrations and other initiatives to develop best practices in this area. A variety of federal efforts hold promise in supporting development of the cyberinfrastructure for the PCMH.67–70 Chief among these are the Health Information Technology for Economic and Clinical Health (HITECH) Act provisions of ARRA (American Recovery and Reinvestment Act), which drives adoption and meaningful use of EHR systems, provides the necessary assistance and technical support to providers, enables coordination and alignment within and among www.ajpm-online.net

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states, establishes connectivity to the public health community in case of emergencies, and assures that the workforce is properly trained and equipped to be meaningful users of EHRs.70 The Regional Extension Centers established and supported by the HITECH legislation focus specifıcally on assisting primary care practices in the implementation of EHRs. Although the 2011 defınition of meaningful use does not address all aspects of PCMH (most importantly, comprehensive, team-based care and continuous access to care), the provision’s emphasis on employing a systems-based approach to quality and safety and other principles of the medical home model support movement of practices. The alignment between meaningful-use criteria and core features of PCMH has been described in a recent AHRQ publication.71 A recent AHRQ-supported analysis recommended three actions related to HITECH that would increase the ability of HIT to support transformation by primary care practices to the PCMH model. The report recommended developing PCMH-specifıc certifıcation criteria for EHRs; including PCMH functionalities in the meaningful-use concept; and extending the role of HITECH’s Regional Extension Centers to provide technical assistance to primary care providers on medical home principles.71 In addition to HITECH, other federal initiatives have been initiated to support development of the cyberinfrastructure for the medical home. AHRQ’s project to establish federal resources to support the PCMH26 has focused on developing policy-relevant white papers to address key gaps in conceptualization and implementation of PCMH, convening federal stakeholders to coordinate activities and collaborate on joint projects, and launching a public website (pcmh.ahrq.gov) to provide free access to these resources. Promising strategies for engaging patients and families in the medical home have been summarized in a recent AHRQ white paper.72 Because the Veteran’s Administration (VA), Health Resource Services Administration (HRSA), Center for Medicare and Medicaid Services (CMS), and other federal agencies are each embarking on medical home projects and pilots, federal collaboration around this issue is vital. Since 2004, AHRQ’s HIT Portfolio has funded over $300 million in grants and contracts to understand how HIT affects the quality of healthcare delivery. While many of the projects that AHRQ has funded predate the current focus on the medical home, these projects can help understand key HIT-related aspects of the model. For example, the evidence-based practice report on “Impact of consumer health informatics applications” provides insight on the design and use of HIT tools by different patient populations.55 AHRQ-funded projects in the areas of HIE, use of HIT to facilitate patient– clinician May 2011

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communication, care coordination, and chronic care management all support better understanding and use of best practices in implementing various aspects of the medical home model (healthit.ahrq.gov). Without technical use cases and standards to support them, a key blueprint for building the cyberinfrastructure for the medical home is missing. In recognition that all data flows that constitute the medical home model have not been fully described, especially in technical terms, AHRQ initiated a project to develop an information model to support the PCMH. This project will develop a functional defınition of the medical home with both narrative and technical descriptions of the interactions among the medical home team and medical home stakeholders. The project will identify existing standards and use cases that support PCMH as well as prioritize gaps in supporting this model.26 Much work remains to overcome barriers related to privacy and security related to linking the various stakeholders in the PCMH model. While the Health Information Security and Privacy Consortium (HISPC) sought to identify state-specifıc regulations that could hinder the exchange of health information (healthit.ahrq.gov/ privacyandsecurity), neither comprehensive nor state-specifıc regulations have addressed these barriers. AHRQ’s experience in funding a six-state and regional demonstrations in HIT26 has provided practical experience and insight into what it takes to make exchanging information among patients and providers a reality. The state HIE projects funded as part of HITECH will add to this knowledge base and require states to address and overcome privacy and security issues in a way that balances trust and the need to share information. Building the cyberinfrastructure for PCMH will ultimately require cooperation among public and private stakeholders. While the array of federal efforts to support the cyberinfrastructure for PCMH can provide incentives, overcome barriers, and establish best practices, private payers, purchasers, and care delivery systems must drive transformation.

Conclusion Health information technology has enormous potential in improving primary care delivery, and it will play a pivotal role in implementing the PCMH model. Further development of HIT infrastructure is required to fully uncover the potential of HIT in facilitating quality, effıciency, and safety of clinical care. A successful implementation of optimal HIT infrastructure will have to address multiple barriers on several levels. First, on the healthcare system level, a national health information infrastructure has to be established, allowing secure and effıcient ex-

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change of health information across all participants of healthcare delivery. Second, on a health-organization level, interoperability of various HIT components based on a comprehensive set of standards should support seamless extensions and upgrades of HIT components and intra-institutional data exchange. Third, on a provider level, exchange of clinical information among professional healthcare teams should be supported by HIT that is compliant with major usability principles and be fully integrated into the clinical workflow. Fourth, on a patient level, user-friendly HIT tools promoting patient– provider communication, health education, counseling and self-management, and enhanced access to care should become widely available. Fortunately, the “meaningful-use” regulation for EHRs introduced by the federal government69 will enable substantial progress toward addressing these challenges. We extend sincere thanks and appreciation to Teresa Zayas Cabán, PhD, for reviewing the article and providing valuable feedback. JF was supported in part by AHRQ contract HHSA290-2007-10061. Opinions and recommendations expressed in the paper are those of the authors and do not necessarily reflect the policies of their respective organizations. Publication of this article was supported by the National Institutes of Health. No fınancial disclosures were reported by the authors of this paper.

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