Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD) (Massachusetts)

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Summary:

Failure to followup on abnormal tests results and failure of care providers to adhere to recommended guidelines are common quality concerns in primary care. For many physicians, there is no reliable method to ensure that tests are completed and results adequately tracked. Prior research supports the importance of patient-clinician collaboration to agree on treatment goals to manage chronic health problems, communicate about the provision of preventive services, and promote medication adherence. Current systems lack comprehensive, practical approaches to translating a model of collaborative, patient-centered care that engages patients, clinicians, and practices in the explicit creation and execution of shared clinical care plans. In response, this project designed Ambulatory Care Compact to Organize Risk and Decision-making (ACCORD), primary care delivery system to transform care within the Massachusetts General Primary Care Practice-Based Research Network (MGPC-PBRN) by involving patients and families in the design of tools to foster shared decisionmaking, invigorate patient-clinician partnerships, and share care plans visibly. The project aims were to:

  • Design a model for patient-centered primary care that facilitates patient-clinician partnerships and results in documented followup care plans that can be tracked reliably to reduce the risk of care plans being lost to followup in busy primary care networks. 
  • Develop a health information technology architecture and software (ACCORD) to support the patient-centered care delivery model designed in the first aim. 
  • Implement and evaluate ACCORD in a randomized controlled study within the MGPC-PBRN.

Two series of patient-provider focus groups were conducted as part of the iterative design effort. Implementation of the ACCORD systems included the definition of ACCORD temporal concepts; determination of representative use cases and business rules; definition of the ACCORD template and population of the ACCORD template library; development of the ACCORD authoring tool and definition of authoring guidelines; implementation of the ACCORD event detection engine and scheduler; and integration with provider and patient systems. A randomized controlled trial to evaluate the ACCORD system in the largest primary care practice at Massachusetts General Hospital was planned at the end of the project. 

The preliminary results from the focus groups showed the need for a model that would support a high variability in patient-provider collaborative decisionmaking styles, rather than imposing an ideal concept of shared decisionmaking. A comprehensive software system for authoring, proposing, and accepting the ACCORD system was implemented based on a usability and model evaluation.

Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD) - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care Through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017190
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $923,783
  • PDF Version: 
    (PDF, 200.61 KB)

Summary: Increased emphasis on care guidelines and efforts that focus on a relatively narrow set of quality measures to improve quality of care have transformed the practice of medicine in ways that are both good and bad for patients and clinicians. Standardized care algorithms attempt to promote uniform compliance with evidence-based care. Underutilization of standardized care algorithms may be due to their inability to accommodate individual patient and clinician preferences and values. With greater access to health information via the Internet and other media, patients are increasingly involved in the medical decisionmaking process. At the same time, advances in health information technology (IT) have ushered in electronic health records (EHRs), increasing capacity to identify and track patient populations within a health system. These advances facilitate the design of new models of primary care delivery that employ system-level health IT tools to promote patient and clinician partnerships.

This project involved designing, developing, implementing, and evaluating a comprehensive, practical, and innovative model of care delivery to support the process of shared decisionmaking. The system, titled Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD), allowed patients to collaborate with clinicians to establish, monitor, and track shared clinical care plans. ACCORD interfaced with the Massachusetts General Primary Care Practice-Based Research Network's preexisting internally developed EHR system.

The project team developed ACCORD to help providers and patients manage followup activities for primary care visits. The team selected the following domains for ACCORD maintenance: preventive health screenings, abnormal findings followup, and medication monitoring. ACCORD enabled patientspecific care plan development to reduce miscommunication between providers and patients by presenting care plans as explicit "compacts" or agreements between provider and patient, and provided explanatory information about the risks of not adhering to the plans.

The project activities were organized into three stages. In Stage 1, the team designed, built, and tested the system to develop a usable method of compact authoring and tracking. In Stage 2, they tested the tool to determine if providers and patients were comfortable creating compacts and if the tool was effective in this capacity. In Stage 3, the team conducted a randomized controlled trial (RCT) in a primary care practice and an institution-wide cohort study in another primary care practice to examine system adoption and process measures. The RCT examined differences in outcomes, such as preventive screening test completion, chronic disease management, patient engagement, patient knowledge, patient-provider communication, patient and clinician satisfaction, and various system-utilization metrics.

Specific Aims:

  • Design a model for patient-centered primary care that facilitates patient-clinician partnerships that results in documented followup care plans that can be tracked reliably to reduce the risk of care plans being lost to followup in busy primary care networks. (Achieved)
  • Develop a health IT architecture and software (i.e., ACCORD) to support the developed patientcentered care-delivery model. (Achieved)
  • Implement and evaluate ACCORD in an RCT within the Massachusetts General Primary Care Practice-Based Research Network. (Ongoing)

2011 Activities: The research team completed design of the RCT. Revisions were made to accommodate recruitment delays and the new scenario for initiating ACCORD from patient lists in Oncall Answers result sets, the local EHR. The study design for the RCT focused on three ACCORDs expected to be appropriate for a relatively high frequency-of-use study population. The population eligible within the study time frame was identified by query, and both the control and intervention groups were targeted for additional enrollment support. Intervention group providers were trained to use ACCORD in both the episodic, one-problem-at-a-time scenarios initially conceived, and the cohort-based scenario in which providers proposed the same range of ACCORD options to a list of patients matching specific indications.

The 1-year no-cost extension provided the necessary time to continue research activities, which were slowed due to delays in the development of the patient portal. Activities will continue past the end of the project period to complete the final aim. The project will utilize resources beyond AHRQ funding to complete this work. As last reported in the AHRQ Research Reporting System, project progress was mostly on track and project budget spending was on target. The project period ended in August 2011.

Impact and Findings: Focus group findings centered on: 1) patient and provider perception of decisionmaking; 2) strategies patients and providers use to improve shared decisionmaking; 3) desired characteristics of the ACCORD system from the patient and provider perspectives; and 4) perceived benefits and concerns of the ACCORD system. Desired characteristics reported by patients included integration with specialists, assistance with support for topic-specific communication, and access to vetted information authored in- and outside Massachusetts General Hospital. Desired characteristics reported by providers included integration with clinical information systems and workflow and support for post-visit review that includes automated detection of events suitable for ACCORD, such as detecting that a chest X-ray report contains mention of a "solitary pulmonary nodule." Patients and providers alike wanted the system to facilitate the preparation of topics for upcoming visits.

Patients' reports on the usefulness of the reminders varied, since many already use a variety of personal systems. Providers cited "always on" reminders to patients and adjustable reminders to providers as a desired characteristic of the ACCORD system. Patients believed that ACCORD had the potential to provide more direct access to the information patients need, reduce barriers to communicating with their physician, and clarify care plans. Providers felt that a mechanism to expose patients to appropriate topics and educational materials prior to a visit would allow patients to participate more effectively in decisionmaking. Chronic disease management, preventive health care, medication management, and followup of non-urgent but potentially concerning findings were all areas reported as amenable to shared decisionmaking.

Participants noted concerns about the security of health information accessible via the Internet, the difficulty of locating relevant and up-to-date consumer health information, the potential limited utility of the system for patients with low computer literacy, and the need for integration of ACCORDs with care plans created by patients with other care providers not participating in ACCORD. Both providers and patients expressed concerns about the time it would take for providers and patients to use the ACCORD system during visits.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ’s priority populations.

Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD) - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care Through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017190
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $923,783
  • PDF Version: 
    (PDF, 325.08 KB)


Target Population: Adults

Summary: Primary care in our current health system is fragmented, inefficient, and frequently unsafe. Efforts to improve quality of care, focusing on a relatively narrow set of quality measures, and increasing emphasis on care guidelines have transformed the practice of medicine in ways that are both good and bad for patients and clinicians. Standardized care algorithms attempt to promote uniform compliance with evidence-based care, but are underutilized. This may be due to their inability to accommodate individual patient and clinician preferences and values. With greater access to health information via the Internet and other media, patients are increasingly involved in the medical decisionmaking process. At the same time, advances in health information technology (IT) have ushered in electronic health records (EHRs), increasing capacity to identify and track patient populations within a health system. These advances will facilitate the design of new models of primary care delivery that employ system-level health IT tools to promote patient and clinician partnerships.

This project’s objectives are to design, develop, implement, and evaluate a comprehensive, practical, and innovative model of care delivery to support the process of shared decisionmaking. The system, titled Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD), will allow patients to collaborate with clinicians to establish, monitor, and track shared clinical care plans. ACCORD will interface with the Massachusetts General Primary Care Practice-Based Research Network’s preexisting, internally developed Computer Stored Ambulatory Record EHR system.

The project team is developing ACCORD to help providers and patients manage followup activities determined at primary care visits. The team selected the following domains to maintain through ACCORD: preventive health screenings, abnormal findings followup, and medication monitoring. ACCORD will enable patient-specific care plan development to reduce miscommunication between providers and patients by presenting care plans as explicit “compacts” or agreements between provider and patient, and by providing explanatory information about the risks of not adhering to the plans. The project team is working to ensure that patients and providers are comfortable proposing the care plans in this manner.

The project activities are organized into three steps. Step one is to design, build, and test the system to develop a usable method of compact authoring and tracking. Step two will test the tool to determine if providers and patients are comfortable creating explicit agreements and if the tool is effective in this capacity. Step three is to conduct one or more randomized controlled trials (RCTs) in a primary care practice, and an institution-wide cohort in another primary care practice to examine system adoption and process measures. The RCTs will examine differences in outcomes, such as preventive screening test completion, chronic disease management, patient engagement, patient knowledge, patient-provider communication, patient and clinician satisfaction, and various system-utilization metrics.

Specific Aims:
  • Design a model for patient-centered primary care that facilitates patient-clinician partnerships that results in documented followup care plans that can be tracked reliably to reduce the risk of care plans being lost to followup in busy primary care networks. (Achieved)
  • Develop a health IT architecture and software (i.e., ACCORD) to support the developed patient-centered care-delivery model. (Ongoing)
  • Implement and evaluate ACCORD in an RCT within the Massachusetts General Primary Care Practice-Based Research Network. (Upcoming)

2010 Activities: Dr. Chueh and his team completed design and implementation of the ACCORD scheduling, event detection, and notification engines. Early physician feedback emphasized that ACCORD needed to integrate smoothly with clinician workflow or else it would not be used by clinicians. Integration tasks underway during this timeframe included: 1) generating clinical documentation with a coded problem and problem-linked comment for the structured problem list and 2) integrating ACCORD event notification with the clinician view of the patient schedule. The team completed the addition of associations between "observations" abstractly represented in the ACCORD templates and the actual encoded information available from data services at the institution.

The grant team began design of the randomized controlled trial. Revisions will take into account recruitment delays and the new scenario for initiating ACCORD from patient lists in Oncall Answers result sets, the local EHR. The current study design for the controlled trial focuses on three ACCORDs expected to be appropriate for a relatively high-frequency of the study population. The population eligible within the study timeframe will be identified by query, and targeted for additional enrollment support, in both control and intervention groups. Intervention group providers will be trained to use ACCORD in both the episodic, one problem at a time scenarios initially conceived, and the more recently recognized cohort-based scenario in which providers propose the same range of ACCORD options to a whole list of patients matching specific indications.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is on track in some respects. The project experienced significant delays early in the calendar year because of the delayed release of the iHealthspace patient portal to the practice where the ACCORD control trial was to be implemented. A viable plan is in place for addressing delays. Project spending is roughly on target.

Preliminary Impact and Findings: ACCORD templates provide a structured representation of the plans of care to be jointly considered by the physician and patient seeking to form an ACCORD. This structured representation includes a schedule of expected actions that could be used as the basis for automated notifications when deviations from agreed upon plans of care are detected. As the project progressed, it became clear that templates need to perform four additional functions. First, they need to be locally configured to link to the relevant, locally available knowledge resources. Second, while ACCORD templates are defined in terms of an abstracted notion of “observations”, there still needs to be a local configuration that associates observations with specific data services and the appropriate parameters (usually codes) for those data services. Third, templates need to support local configuration of information to guide linkage with clinical documentation to the appropriate sections of the locally available EHR. Fourth, each ACCORD template needs to be annotated with indications to support keyword searches for templates that will use the same terms used in clinical queries that find appropriate patient candidates.

Linkage of clinical documentation generated by ACCORD into the local EHR has shown to be more complicated than was anticipated. The ability to generate an independent “ACCORD note” to insert into the store of visit notes represents just the minimum requirement. To support the care process, the ACCORD documentation should be able to drive updates to the problem list, and place text where the plan of care for the problem usually goes. The issue regarding the project local EHR, Oncall, will be solved by enabling the clinician to specify the problem to which the ACCORD should be linked. To support faster physician choice, templates need to be linked to a list of the most likely possible problems, and a “preferred” problem. From this general list, combined with the patient-specific problem list, an ordered list of default selections emerges from which the clinician may choose one. During the last quarter in 2010, the team completed annotation of the templates in the library with lists of possible problems.

Annotating the templates with problems provided new insight into different types of ACCORDs. Some ACCORDs are easier to connect to a well-defined set of problems than others. What makes problem-linking more or less difficult is the specificity of the ACCORD template and where the ACCORD lies on the diagnostic path.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD) - Final Report

Citation:
Chueh H. Ambulatory Care Compact to Organize Risk and Decisionmaking (ACCORD) - Final Report. (Prepared by Massachusetts General Hospital under Grant No. R18 HS017190). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 857.15 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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