Evaluation of a Computerized Clinical Decision Support System and Electronic Health Record (EHR)-linked Registry to Improve Management of Hypertension in Community-based Health Centers (New York)

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Evaluation of a computerized clinical decision support system and Electronic Health Record (EHR)-linked registry to improve management of hypertension in community-based health centers - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality through Clinician Use of Health IT (R18)
  • Grant Number: 
    R18 HS 017167
  • Project Period: 
    September 2007 - September 2011
  • AHRQ Funding Amount: 
    $1,132,569
  • PDF Version: 
    (PDF, 213.94 KB)

Summary: Hypertension affects millions of adults in the United States, many of whom are among the underserved populations that bear a disproportionate burden of chronic disease and illness. Community health centers (CHCs) are a major source of care for the underserved. This project was designed to analyze the efficacy of office-based electronic decision support and provider feedback in improving hypertension control in CHCs. Dr. Kopal and her team hypothesized that a clinical decision support system (CDSS) and electronic registry-linked performance feedback would be more effective at improving hypertension control than a standard-care electronic health record (EHR) in CHCs that serve low-income, primarily Latino patients.

Project collaborators included Partners Primary Care Development Corporation (PCDC); Open Door Family Health Center (Open Door), a not-for-profit organization that operates four primary care sites serving low-income, primarily Latino immigrants; New York University College of Dentistry and School of Medicine; and the Columbia University Mailman School of Public Health. The large number of minority and low-income patients served by Open Door CHCs, as well as the existing practice-based research infrastructure provided by PCDC and Open Door, offered a unique opportunity to target an underserved, hard-to-reach immigrant population and investigate the efficacy of these interventions.

The study team used qualitative and quantitative methods to meet three overarching goals: 1) assess the impact of health information technology (IT) on outcomes in ambulatory settings; 2) investigate novel methods and evaluate existing strategies for clinician use of health IT in ambulatory settings; and 3) devise strategies for safe, successful health IT adoption. Specifically, the team analyzed the effects of a multicomponent, technology-driven quality improvement intervention on hypertension control. A pre- and post-intervention comparison on blood pressure (BP) outcomes and clinical process measures was conducted. On a monthly basis, the project team extracted data from the eClinicalWorks EHR and estimated the effect of the intervention using Autoregressive Integrated Moving Average modeling. The team evaluated changes in BP control using an ANOVA test for significance of the BP trends over the 36-month study period. Additionally, pre- and post-intervention surveys and structured interviews of providers were conducted.

Specific Aims:

  • Test whether an office-based EHR with decision support and registry-linked provider performance feedback is more effective in improving hypertension control than a standard EHR alone. (Achieved)
  • Assess the implementation process, and delineate factors that influence adoption of the EHR-supported quality improvement intervention. (Achieved)

2011 Activities: Due to a minor delay in data analysis, the project was underspent in the latter part of 2010; therefore, the project team used a 12-month no-cost extension to complete the analysis and record the results. As last self-reported in the AHRQ Research Reporting System, project progress was on track and the budgeted funds were somewhat underspent. However, with the focus of activity in 2011 on completing the qualitative analysis, developing an implementation manual, drafting three separate manuscripts for potential publication, and developing a final report, the project spending was on track at the completion of the project in September 2011.

Impact and Findings: Patients had an average of 8.84 (SD=6.62) clinic visits during the 36-month study period (mean of five visits both pre- and post-intervention). Hypertension control was significantly greater post-intervention compared with the baseline period. Process measures also improved significantly. Logistic regression with generalized estimating equations showed that patients were 1.5 times more likely to have BP controlled post-intervention than pre-intervention. Participants found different components useful, but overall this study showed improved adherence to guidelines and more aggressive, systematic, and focused attention on a priority condition - hypertension - on the part of providers using CDSS.

Three aspects of this study appear to stand out as critical to improving hypertension care and outcomes:

  1. A multicomponent intervention that included CDSS and provider performance feedback promoted adherence to hypertension clinical guidelines and was associated with improvements in blood pressure control. Among the CDSS features, there was something that worked for everyone. The evidence suggests it was the synergy of the intervention components that lead to the positive outcomes.
  2. The process of working with providers and tailoring the intervention allowed for the best fit between the goals of the intervention and practice conditions. The project team selected features of the intervention that did not mandate practice patterns. Rather, features were selected based on how easy they would be to build within the current eClinicalWorks platform; on skills, resources, and preferences of the clinic; and the on usability, acceptability, and ease of use from the provider's perspective.
  3. In an effort to improve health outcomes, this CDSS intervention was implemented in the context of a quality improvement effort, one component of practice change needed to reach the targets for each quality indicator. Several additional factors were also identified as facilitators of success. They included organization culture, leadership, rigorous implementation process, provider engagement, and the health care setting's ability to process patient data. Strength in these areas helps make health IT interventions successful.

Target Population: Hypertension, Low-SES/Low Income*, Medically Underserved, Racial or Ethnic Minorities*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management. 

Business Goal: Implementation and Use

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

Evaluation of a computerized clinical decision support system and EHR-linked registry to improve management of hypertension in community-based health centers - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017167
  • Project Period: 
    September 2007 – September 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,132,569
  • PDF Version: 
    (PDF, 310.19 KB)


Target Population: Hypertension, Low SES/Low Income*, Racial or Ethnic Minorities*: Latino

Summary: Hypertension affects millions of adults in the United States, many of whom are among the underserved populations that bear a disproportionate burden of chronic disease and illnesses. Community Health Centers (CHCs) are a major source of care for the underserved. The goal of this project is to analyze the efficacy of office-based electronic decision support and provider feedback in improving hypertension control in CHCs.

Partners Primary Care Development Corporation (PCDC), Open Door Family Health Center (Open Door) (a not-for-profit organization that operates four primary care sites serving low-income, primarily Latino immigrants), New York University College of Dentistry and School of Medicine, and the Columbia University Mailman School of Public Health are analyzing the effects of a multi-component, technology-driven quality improvement intervention on hypertension control. This collaborative effort provides a unique opportunity to target an underserved, hard-to-reach immigrant population. This project addresses the need for empirical outcome data on effective information technology strategies for improving control of hypertension among low-income immigrant populations.

The hypothesis of the study is that clinical decision support (CDS) and electronic registry-linked performance feedback will be more effective at improving hypertension control than a standard-care electronic health record (EHR) in CHCs that serve low-income, primarily Latino patients. On a monthly basis, the project extracts data from the eClinicalWorks EHR, which is certified by the Certification Commission for Health Information Technology, and estimates the effect of the intervention using AutoRegressive Integrated Moving Average modeling. The large number of minority and low-income patients served by Open Door CHCs, as well as the existing practice-based research infrastructure provided by PCDC and Open Door, offers a unique opportunity to investigate the efficacy of these interventions.

Specific Aims:
  • Test whether an office-based EHR with decision support and registry-linked provider performance feedback is more effective in improving hypertension control than a standard EHR alone. (Ongoing)
  • Assess the implementation process, and delineate factors that influence adoption of the EHR-supported quality improvement intervention. (Ongoing)

2010 Activities: Following the implementation of the CDS in 2009, the EHR data were successfully transmitted and verified in 2010. Post-intervention surveys were conducted among providers to measure attitudes on the CDS tools and use of guidelines. Analysis of the post-intervention process measurement is underway. In the meantime, a paper summarizing the baseline data and findings on the correlates of hypertension and hypertension control among minority and immigrant populations in CHCs is being finalized for journal submission. In addition, the development of a how-to manual for implementing CDS quality initiatives in CHCs is also in progress.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project is mostly on track in meeting all its aims and milestones. Moderate underspending in the budget will help facilitate the no-cost extension period, during which the post-intervention analysis will be completed and findings will be summarized.

Preliminary Impact and Findings: Preliminary findings indicate that blood pressure control among hypertensives improved as a result of the intervention. The baseline EHR data and relevant findings that focus on correlates of blood pressure control are currently being summarized for publication. Although the paper has not yet been finalized, the data tabulations have been completed.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Project Details - Ended

Project Categories

Summary:

Hypertension affects millions of adults in the United States (US) and is the most prevalent modifiable risk factor for cardiovascular disease. While effective medications and guidelines exist for the treatment of hypertension, half of US adults diagnosed with hypertension are poorly controlled. This project analyzed the efficacy of using clinical decision support (CDS) and performance feedback to improve the control of hypertension in patients treated in community health centers (CHCs).

The components of the CDS implemented included: highlighting in red elevated blood pressures; a hypertension template that lists the information a provider should obtain during visits; medication adherence forms that prompt clinical staff to ask patients about how they are taking their medications; a hypertension order set; and clinical reminders to prompt providers to screen for tobacco use or to order tests that need to be updated.

The main objectives of this project were to:

  • Test whether an office-based electronic health record (EHR) with decision support and registry-linked provider performance feedback is more effective in improving hypertension control than a standard EHR alone.
  • Assess the implementation process, and delineate factors that influence adoption of the EHR-supported quality improvement intervention.

The project was conducted at the Open Door Family Health Center, a four-site Federally Qualified Community Health Center in New York. The intervention involved a combination of both quantitative and qualitative methods. A pre- and post- study was done to evaluate changes in hypertension control over the 36-month study period. During the 15-month “EHR-only” pre-intervention period, hypertension data in the EHR was collected and analyzed, the providers and staff were surveyed and interviewed, and the intervention was developed. After 15 months, the CDS and provider feedback intervention was simultaneously implemented at all sites. A 4-month acceptance period allowed for refinement and full adoption by providers before post-intervention EHR data was collected. In addition, surveys and structured interviews with providers were conducted before and after the intervention.

This study showed improved adherence to guidelines and more aggressive, systematic, and focused attention on a priority condition – hypertension – on the part of providers using CDS. Control of hypertension was found to be significantly greater post-intervention and process measures improved significantly. Patients were 1.5 times more likely to have their blood pressure controlled after the intervention than before. The project team found six facilitators of change that were important for their implementation: leadership, organizational culture, provider engagement, rigorous implementation process, framing of intervention as quality improvement, and health center capacity to process data. The implication is that health information technology (IT) can play a central role in improving adherence to care standards and clinical outcomes when guided by organizational and cultural environments that value health IT.

Evaluation of a Computerized Clinical Decision Support System and Electronic Health Record (EHR)-linked Registry to Improve Management of Hypertension in Community-based Health Centers - Final Report

Citation:
Kopal H. Evaluation of a computerized clinical decision support system and Electronic Health Record (EHR)-linked registry to improve management of hypertension in community-based health centers - Final Report. (Prepared by Primary Care Development Corporation under Grant No. R18 HS017167). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 223.31 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.
Principal Investigator: 
Document Type: 
Medical Condition: 

Managing the Hypertensive Patient: User's Manual

PDF: Managing the Hypertensive Patient: User's Manual (PDF, 1.2 MB)

Baseline Clinician Interview Script

This is an interview guide designed to be conducted with clinical staff in an ambulatory setting. The tool includes questions to assess the current state of electronic health records.

Year of Survey: 
2008
Survey Link: 
Baseline Clinician Interview Script (PDF, 117.7 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Document Type: 
Research Method: 
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.

Healthcare Provider Survey

This is a questionnaire designed to be completed by clinical staff in an ambulatory setting. The tool includes questions to assess user's perceptions of electronic health records and clinical decision support systems.

Year of Survey: 
2008
Survey Link: 
Healthcare Provider Survey (PDF, 216.46 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
This project does not have any related story.
This project does not have any related emerging lesson.