An Interactive Preventive Health Record (IPHR) to Promote Patient-Centered Care (Virginia)

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An Interactive Preventive Health Record (IPHR) to Promote Patient-Centered Care - 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 017046
  • Project Period: 
    September 2007 - February 2011
  • AHRQ Funding Amount: 
    $1,198,677
  • PDF Version: 
    (PDF, 181.48 KB)

Summary: While there is clear evidence supporting the health benefits of preventive care, Americans receive only 50 percent of indicated preventive services. A number of patient, clinician, and health care system barriers contribute to this gap in the delivery of quality preventive care.

The objectives of this project were to design, develop, implement, and evaluate whether linking MyPreventiveCare, an interactive preventive health record (IPHR), to an electronic medical record (EMR) would increase the number of patients who receive recommended screening tests, immunizations, and counseling. MyPreventiveCare provides tailored recommendations, links to educational resources and decision aids, and patient and clinician reminders. The PHR gave the patient a link to preventive elements of his or her EMR, a health-risk assessment, an individualized list of recommended preventive services based on risk stratification, education resources, and reminders. Reminders included messages encouraging healthy behaviors and recommended services, alerts informing patients when they become eligible for retesting or new services, and requests encouraging patients to update their profiles. MyPreventiveCare provided the clinician with a summary of the patient's risk factor information, which could be used to update the clinician's EMR.

The study involved eight primary care practices in the Virginia Ambulatory Care Outcomes Research Network. All of the practices used the Allscripts Touchworks(R) EMR. A randomly selected sample of 5,500 of the practices' 228,000 patients, stratified by age and gender, received a request from their clinicians to use MyPreventiveCare or receive "usual" preventive care. The project team used this randomized controlled trial to examine the effects of MyPreventiveCare on clinical preventive services, shared decisionmaking, and patient-physician communication. This involved the analysis of data in the EMR, utilization data from MyPreventiveCare, and data collected from patient and provider surveys.

Specific Aims:

  • Evaluate whether an invitation from a patient's primary care clinician to use MyPreventiveCare increases use of the system. (Achieved)
  • Evaluate whether an invitation from a patient's primary care clinician to use MyPreventiveCare increases delivery of age- and gender-appropriate clinical preventive services. (Achieved)
  • Evaluate whether an invitation from a patient's primary care clinician to use MyPreventiveCare increases shared decisionmaking for preventive services. (Achieved)
  • Evaluate whether an invitation from a patient's primary care clinician to use MyPreventiveCare improves clinician-patient communication about preventive needs. (Achieved)

2011 Activities: The study team used a 6-month no-cost extension to complete final project activities. Data collection, analysis, and manuscript development were the primary focus during this period. All grant activities were completed by the end of the project period.

Impact and Findings: At 4 months, the proportion of indicated preventive services that were received by eligible patients did not increase significantly among patients in the intervention group compared to the control group. Not all patients assigned to the IPHR arm used it, but statistically significant changes were observed in those who did. The proportion of indicated preventive services received increased by 5.6 percent among users, whereas non-users experienced an insignificant increase.

Over 16 months, the proportion of eligible preventive services that were up-to-date declined in both the control group and the non-user subset of the intervention population but increased among IPHR users. The proportion of patients who were up-to-date with all 18 preventive services did not change significantly over the 4 months or differ significantly between groups, in either the intention-to-treat analysis or the comparison of users and non-users. At 16 months, however, the proportion of patients who were up-todate with all preventive services was higher among intervention patients (including both users and nonusers) than among controls, but the net increase among intervention patients was demonstrably greater among users than non-users.

The primary care practices received a summary from the IPHR on all patients who used the system. The summary was transmitted electronically to the EMR task list for the patient's self-identified primary provider. A chart review and content analysis of these summaries revealed that only 2.2 percent of users were up-to-date for all preventive and chronic care services covered by the IPHR. Among users, 49 and 56 percent were due for screening tests and vaccinations, respectively; 91 and 55 percent needed health behavior counseling and preventive medications, respectively; and 35 percent had inadequate control of chronic conditions. These alerts led clinicians to update the EMR records of 59 percent of patients to fill in missing information that patients had entered into the IPHR. With few exceptions, clinicians accepted the patient's reported updates and changes as accurate. Additionally, after receiving the summaries from the IPHR, the study practices contacted 27 percent of patients to schedule a wellness visit, 17 percent to schedule a chronic care visit, and 19 percent to deliver a specific service (e.g., mail a referral for a mammogram or colonoscopy, arrange a nurse visit for an immunization).

Focus groups with patients revealed that trust and functionality were the two major themes that influenced whether they would use a health Web site and the value they obtained from doing so. Trust included whether they believed that: 1) information on the Web site was accurate; and 2) security and confidentiality of their personal information would be protected. Functionality included whether the patient expected a health Web site would be useful, the anticipated benefits of using a Web site, and the potential challenges of using a Web site. The degree to which trust and functionality (and their subthemes) mattered to patients was dependent on the relationship of their clinician to the Web site. For example, several participants noted that all information on the Internet is vulnerable, but they seemed willing "to take a leap of faith" with their personal health information and use a Web site if it had the approval of their clinician.

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

An Interactive Preventive Health Record (IPHR) to Promote Patient-Centered Care - 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 017046
  • Project Period: 
    September 2007 – February 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,198,677
  • PDF Version: 
    (PDF, 323.64 KB)


Target Population: Adults

Summary: While there is clear evidence supporting the health benefits of preventive care, Americans receive only 50 percent of indicated preventive services. A number of patient, clinician, and health care system barriers contribute to this gap in the delivery of quality preventive care.

The objectives of the project are to design, develop, implement, and evaluate whether an interactive preventive health record (IPHR) linked to an electronic medical record (EMR) will increase recommended screening tests, immunizations, and counseling. MyPreventiveCare provides tailored recommendations, links to educational resources and decision aids, and patient and clinician reminders. MyPreventiveCare gives the patient a link to preventive elements of his or her EMR, a health risk assessment, an individualized list of recommended preventive services based on risk stratification, education resources, and reminders. Reminders include messages encouraging healthy behaviors and recommended services, alerts informing patients when they become eligible for retesting or new services, and requests encouraging patients to update their profiles. MyPreventiveCare provides the clinician with a summary of the patient’s risk factor information, which can be used to update the clinician’s EMR.

The study involves eight primary care practices in the Virginia Ambulatory Care Outcomes Research Network. All of the practices use a common EMR, the Certified Commission for Health Information Technology-certified Allscripts Touchworks® EMR. A randomly selected sample of 5,500 of the practices’ 228,000 patients, stratified by age and sex, receive a request from their clinicians to use MyPreventiveCare or receive “usual” preventive care. Through this randomized, controlled trial, the project team is examining the effects of MyPreventiveCare on clinical preventive services, shared decisionmaking, and patient-physician communication. This involves the analysis of data in the EMR, utilization data from MyPreventiveCare, and data collected from patient and provider surveys.

Specific Aims:

  • Evaluate whether an invitation from a patient’s primary care clinician to use MyPreventiveCare increases use of the system. (Ongoing)
  • Evaluate whether an invitation from a patient’s primary care clinician to use MyPreventiveCare increases delivery of age- and gender-appropriate clinical preventive services. (Ongoing)
  • Evaluate whether an invitation from a patient’s primary care clinician to use MyPreventiveCare increases shared decisionmaking for preventive services. (Ongoing)
  • Evaluate whether an invitation from a patient’s primary care clinician to use MyPreventiveCare improves clinician-patient communication about preventive needs. (Ongoing)

2010 Activities: The grant team analyzed baseline and four-month post-intervention data from both the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the EMR. The team also completed the collection of both survey and EMR data for the 16-months post-intervention. In February 2010, the team mailed the preventive services survey to 4,500 predefined intervention and control patients and the CAHPS survey to an additional 1,000 predefined intervention and control patients. They prepared and transferred EMR data on all 5,500 intervention and control patients and, at the end of the calendar year, were in the process of the combined EMR and survey data analysis. The team created a detailed and extensive protocol to address data discrepancies (i.e. when EMR data and survey responses are inconsistent) and merge the datasets. These refined protocols were made consistent with the U.S. Preventive Services Task Force recommendations and the prevention recommendations that MyPreventiveCare promotes to patients.

Analysis of qualitative data included review of focus group transcripts by team members and the use of an immersion and crystallization approach to the analysis to identify key themes. Results are being written for publication. The team completed a presentation of findings at the Agency for Healthcare Quality and Research Annual Conference in September 2010.

In July 2010, MyPreventiveCare was officially recognized by the Centers for Medicare and Medicaid Services (CMS) as a qualified Physician Quality Reporting Initiative (PQRI) reporting registry. Obtaining recognition involved submitting a nomination letter, documenting and justifying the quality measures calculation, getting CMS approval on the data validation process, and demonstrating an ability to submit quality measures in the specified XML format. CMS PQRI approval facilitated the recruitment of six additional study sites for future work.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is completely on track, meeting all milestones on time and project spending is roughly on target. The project staff are focused on qualitative data collection and quantitative data analysis.

Preliminary Impact and Findings: Within six weeks of receiving the invitation, 292 patients (11 percent) had established an account and used MyPreventiveCare. Users were more often male and older than non-users. Although 76 percent of users had attended a wellness or chronic care visit within the past year, only three percent were up-to-date with risk factors under control for all 18 preventive services (for example influenza vaccination and diabetes screening). Among MyPreventiveCare users, 49 percent and 56 percent were due for screening tests and vaccinations respectively; 91 percent and 55 percent needed counseling for unhealthy behaviors and preventive medications respectively; and 35 percent had inadequate control of chronic conditions. Alerts to clinicians issued by MyPreventiveCare led practices to update 59 percent of patients’ records and to contact patients to schedule a wellness visit (80 patients), chronic care visit (49 patients), or an appointment for a specific preventive service (56 patients).

The team has combined EMR and patient survey data, and completed and cleaned four-month post-intervention data, which is currently being written up for publication. Overall, MyPreventiveCare increased the delivery of all preventive services by 5.4 percent; colon cancer screening by 12.3 percent; breast cancer screening by 16.1 percent; and cervical cancer screening by 12.3 percent, when comparing users to non-users.

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

Project Details - Ended

Project Categories

Summary:

The Interactive Preventive Health Record (IPHR) is a personal health record that was created and tested to make preventive information actionable for patients. The IPHR gives patients direct access to information in their clinician's electronic medical record (EMR), displays tailored recommendations, provides links to online educational resources, delivers individualized self-management resources, and generates patient and clinician reminders. This project sought to test whether a particular IPHR, MyPreventiveCare, which provided this kind of highly personalized online resource, would increase the delivery of recommended preventive services. The project used a randomized controlled trial involving 5,500 patients invited to use the IPHR or receive usual care in eight primary care practices. Outcomes were assessed using data from the practices' EMR and patient surveys.

The main objectives of this study were to:

  1. Evaluate whether an invitation from a patient's primary care clinician to use MyPreventiveCare results in use of the system.
  2. Evaluate whether an invitation from a patient's primary care clinician to use MyPreventiveCare results in increased delivery of age- and gender-appropriate clinical preventive services.
  3. Evaluate whether an invitation from a patient's primary care clinician to use MyPreventiveCare results in increased shared decisionmaking for preventive services.
  4. Evaluate whether an invitation from a patient's primary care clinician to use MyPreventiveCare results in improved clinician-patient communication about preventive needs.

This study demonstrated that MyPreventiveCare can be integrated into a variety of EMRs and into the clinical workflow of small, medium, and large practices in rural, suburban, and urban areas. Early findings show that patients who use MyPreventiveCare are on average 5 percent more up-to-date on their screenings than patients who do not use the IPHR. Screenings for colonoscopies increased by as much as 12 percent, and for mammograms by as much as 16 percent. Patients also benefited from MyPreventiveCare-generated appointments and health tips.

The project continues to look for new ways to add value to MyPreventiveCare for physicians and patients. As part of a Centers for Medicare and Medicaid Services (CMS) initiative, physicians can receive incentive payment for reporting certain data. In July 2010, MyPreventiveCare was officially recognized by CMS as a qualified Physician Quality Reporting Initiative reporting registry. As a result, it is easier for practices that use MyPreventiveCare to report CMS quality measures.

An Interactive Preventive Health Record (IPHR) to Promote Patient-Centered Care - Final Report

Citation:
Krist AH. An Interactive Preventive Health Record (IPHR) to Promote Patient-Centered Care - Final Report. (Prepared by Virginia Commonwealth University under Grant No. R18 HS017046). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 1.44 MB)

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: 
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This project does not have any related story.
This project does not have any related emerging lesson.