Self Management & Reminders with Technology: SMART Appraisal of an Integrated Personal Health Record (Pennsylvania)

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Summary:

Cardiovascular disease is the leading cause of mortality in the U.S. and as the population ages, the disease and its risk factors are increasing. Many of these risk factors, including elevated lipids, hypertension, obesity, and diabetes, are responsive to preventive and therapeutic interventions. There is evidence, however, that many patients do not receive appropriate preventive care nor appropriate care for this and other chronic conditions. When patients are actively involved in their own management, their outcomes improve. The use of personal health records (PHRs) to activate and inform patients with cardiovascular disease has substantial potential to improve their outcomes.

This project modified an existing passive PHR to become active and interactive. In this case, the passive PHR allowed patients to view portions of their electronic medical record and send secure electronic messages to their physician's office. The enhancement was designed to improve health care outcomes by promoting patient self-management and increasing compliance to care recommendations. The enhanced PHR electronically notifies patients to check a secure Web site when self-management tasks or preventive services need to be performed. The PHR presents the patient with a list of prevention and care “gaps” in their care, and the action needed to close those gaps. Patients who had either cardiovascular disease or two risk factors for the development of cardiovascular disease were eligible for participation in the study.

The specific aims of this project were to:

  • Develop a patient-specific, active and interactive component to an existing electronic PHR for patients with complex illnesses and conditions that contribute to the development of cardiovascular disease.
  • Conduct a randomized controlled trial of the effectiveness of passive and active PHR systems for improving adherence and clinical outcomes of these patients in an ambulatory environment.
  • Enumerate and catalog the barriers and facilitators to implementation and use of an electronic PHR among providers and patients in an ambulatory setting.

A randomized controlled trial of patients using the enhanced PHR versus those using the standard passive version was conducted. Primary outcomes included the closure of prevention and treatment gaps. Secondary outcomes included calculations of 10-year cardiovascular risk, changes in cardiovascular risk prediction biomarkers, and patient satisfaction and barriers to use of a PHR.

Overall, users of the active PHR did not reduce their cardiovascular risk versus the control group at 1 year from the trial’s start. While patients did use the active PHR and responded to requests for prevention and treatment gap closure, there was no difference in gap-closure rates at 1 year between the intervention and control groups. The number of gap closures was significantly higher in the control group than anticipated, which may have been due to an increase in the pay-for-performance incentives for adherence to these recommendations by two insurers in the area. Improvements in gap-closure rates were seen in practices with lower compliance to guidelines. Patients indicated that the enhanced PHR was a significant improvement in the way they were able to participate in their own care and communicate with their care providers.

Self-Management & Reminders with Technology: SMART Appraisal of an Integrated Personal Health Record - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018167
  • Project Period: 
    October 2009 – September 2013
  • AHRQ Funding Amount: 
    $1,183,337
  • PDF Version: 
    (PDF, 234.15 KB)

Summary: The Self-Management & Reminders with Technology: SMART Appraisal of an Integrated Personal Health Record project was designed to improve health care outcomes in complex patients who have or are at high risk of developing cardiovascular disease by promoting patient self-management through the use of an active and interactive personal health record (PHR) integrated into an electronic health record (EHR). Specifically, the project sought to help determine if the use of an active patient self-management version of an existing PHR could reduce cardiovascular risk factors and improve outcomes.

The project modified an existing passive PHR to become active and interactive. The standard passive version allowed patients to view portions of their EHR, including problem lists, medication lists, and test results, to communicate electronically with their physician’s office and track home-monitored blood pressure and glucose values. The active version had the features of the passive PHR, but also electronically advised patients to check a secure Web site when disease self-management tasks or preventive services were necessary. Once logged in, patients saw a list of prevention tips, “gaps” in their care, and the action needed to close those gaps.

A randomized controlled trial of patients using the enhanced PHR versus those using the standard pass version was conducted. Participants were recruited from the University of Pittsburgh Medical Center practices that use the EHR, and were then randomized to the passive (n = 585) or active (n = 584) version the PHR. Primary outcomes included the closure of prevention and treatment gaps. Secondary outcomes included calculations of 10-year cardiovascular risk, changes in cardiovascular risk prediction biomarkers, and patient satisfaction with and barriers to use of a PHR.

Specific Aims:

  • Develop a patient-specific, active component for an existing electronic PHR for patients with complex illnesses and conditions that contribute to the development of cardiovascular disease. (Achieved)
  • Conduct a randomized controlled trial of the effectiveness of passive and active PHR systems for improving adherence and clinical outcomes of these patients in an ambulatory environment. (Achieved)
  • Enumerate the barriers to and facilitators of implementation and use of an electronic PHR among providers and patients in an ambulatory setting. (Achieved)

Impact and Findings: The primary data source for the study was the EHR. Data for the secondary outcomes came from a computerized baseline data form, a health literacy questionnaire, a computer literacy assessment, a patient satisfaction survey, a health utilization form, a PHR feature evaluation form an assessment tool that asked about barriers to patient self-management, and PHR utilization data.

The primary outcome analysis showed that the intervention did not improve prevention or treatment gap closure among patients with or at high risk for developing cardiovascular disease, compared to patients enrolled in the passive version of the PHR. None of the gap closure rates were significantly different in the intervention when compared to the control group, and the intervention did not have an effect on physiological variables at 1-year, nor on the calculated 10-year cardiovascular risk score. Theories behind the negative result are available in the project’s final report.

Regarding the secondary outcomes, the analysis looked at the rate at which gaps were closed in the intervention arm as a function of the specific reminder cycle of the alert sent to the patient. While the study only included three cycles, the results consistently showed that patients responded and closed gaps after multiple reminders, thereby discounting the presence of any significant alert fatigue.

Several themes arose from focus group discussions regarding potential barriers to and facilitators implementing and using the PHR. First, users found that the active portal increased their awareness of health care conditions and they felt more proactive about using and keeping track of their health care information. Second, the active portal was a facilitator of patient-driven communication, and features such as test result notification and reminders of particular prevention needs were useful. Finally, interaction with the active portal improved many patients’ preparation for meetings with providers and allowed them to be more engaged in care discussions. Further data analysis was still underway at the time of this summary.

In conclusion, while the randomized controlled trial found no significant difference in prevention and treatment gap closure rates between an active and interactive PHR and a standard, passive version, the study found that patients are interested in engaging in their healthcare through this technology. Use of the active and interactive PHR significantly improved patients’ abilities to understand their health issues and communicate with health care providers. The findings indicate that more research is needed to fully understand the impact of PHRs.

Target Population: Adults, Chronic Care*, Heart Disease

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: Knowledge Creation

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

Self Management & Reminders with Technology: SMART Appraisal of an Integrated PHR - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018167
  • Project Period: 
    October 2009 - September 2012
  • AHRQ Funding Amount: 
    $1,183,337
  • PDF Version: 
    (PDF, 196.7 KB)

Summary: The complexity of patients' medical conditions is increasing, making preventive care and disease management more difficult. There is growing interest in integrating personal health records (PHRs) with providers' electronic medical records (EMRs) to assist patient self-management and improve care for complex diseases. However, few studies currently evaluate the impact of PHRs on care outcomes.

This project is seeking to improve health care outcomes in patients who have or are at high risk for developing cardiovascular disease (CVD) by promoting patient self-management at more than 80 primary care practices, both small and large. Major activities include development of a patient-specific, active and interactive component to an existing electronic PHR; a randomized controlled trial to determine the effectiveness of passive and active PHR systems for improving adherence and clinical outcomes; and cataloging the facilitators and barriers to PHR implementation and use. The passive PHR used in this project allows patients to view portions of their EMR-including problem lists, medication lists, and test results-to communicate electronically with their physician's office and to track values of homemonitored blood pressure and glucose. This is the standard PHR form for many EMRs. The active PHR has the features of the passive PHR but also electronically advises patients to check a secure Web site when disease self-management tasks or preventive services are necessary. In this project, participants have been randomized to a passive PHR (n = 500) or an active PHR (n = 500) at four sites. Focus groups and surveys are being conducted among PHR participants, nurses, and physicians to determine the barriers to and facilitators of PHR use. Outcomes to be assessed include improvement in control of risk factors, frequency of compliance with testing guidelines, and clinical outcomes.

This project will help determine if the use of an active patient self-management version of an existing PHR can reduce cardiovascular risk factors.

Specific Aims:

  • Develop a patient-specific, active and interactive component to an existing electronic PHR for patients with complex illnesses and conditions that contribute to the development of cardiovascular disease. (Achieved)
  • Conduct a randomized controlled trial of the effectiveness of passive and active PHR systems for improving adherence and clinical outcomes of these patients in an ambulatory environment. (Ongoing)
  • Enumerate and catalog the barriers and facilitators to implementation and use of an electronic PHR among providers and patients in an ambulatory setting. (Ongoing)

2011 Activities: The project team completed the development of the interactive component to the existing PHR in 2011. Email or text alerts are transmitted to the patients in the intervention group based on the specific cardiovascular health maintenance activities for which the patient is due. The project team is preparing a demonstration for the PHR user group that will include technical details on the management of the reminder system and data on the number of and intervals between reminders in a typical ambulatory patient population.

Recruitment to the randomized controlled trial was relatively slow in early 2011 and additional recruitment strategies, including direct mail, advertising, and a monthly raffle, were initiated to improve enrollment. Since the enrollment target of 1,200 study participants was achieved mid-year, the reminder mechanism has been successfully sending electronic reminders to study participants.

The study team has also completed several preliminary activities related to cataloging the barriers and facilitators to implementation, including conducting the first PHR user focus group.

Dr. Roberts did not submit a report with a status of activities or project spending to the AHRQ Research Reporting System in 2011.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Adults, Chronic Care*, Heart Disease

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: Knowledge Creation

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

Self Management & Reminders with Technology: SMART Appraisal of an Integrated PHR - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018167
  • Project Period: 
    October 2009 – September 2012
  • AHRQ Funding Amount: 
    $1,183,337
  • PDF Version: 
    (PDF, 378.73 KB)


Target Population: Adults, Chronic Care*, Heart Disease

Summary: The complexity of patients’ medical conditions is increasing, making preventive care and disease management more difficult. There is growing interest in integrating personal health records (PHRs) with providers’ electronic medical records (EMRs) to assist patient self-management and improve care for complex diseases. However, studies that evaluate the impact of PHRs on care outcomes are few.

This project seeks to improve health care outcomes in patients who have or are at high risk for developing cardiovascular disease (CVD) by promoting patient self-management at more than 80 primary care practices, including small and large practices. Major activities include development of a patient-specific, active and interactive component to an existing electronic PHR; a randomized controlled trial to determine the effectiveness of passive and active PHR systems for improving adherence and clinical outcomes; and cataloging the facilitators and barriers to PHR implementation and use. To accomplish the first task, a user group was assembled to determine which features of an active PHR are considered to be most acceptable and useful. To facilitate the second task, target enrollment for the trial has been set at 1,200 patients with complex chronic disease leading to increased cardiovascular risk. This target allows for a 20 percent drop-out rate to arrive at a sample of 1,000 participants to be randomized to a passive PHR (n = 500) or an active PHR (n = 500) at four sites where the PHR currently is installed and in use. All participants will be surveyed using the PHR, along with nurses and physicians at the study sites. Focus groups will also be conducted among PHR participants, nurses, and physicians to determine the barriers to and facilitators of PHR use. Outcomes to be assessed include improvement in control of risk factors, frequency of compliance with testing guidelines, and clinical outcomes.

The PHR for this project, Health Trak, interfaces with EpiCare Electronic Health Record, the organization’s Certification Commission for Health Information Technology-certified EMR system. The passive PHR allows patients to view portions of their EMR—including problem lists, medication lists, and test results—to communicate electronically with their physician’s office and to track values of home-monitored blood pressure and glucose. This is the standard form of a PHR for many EMRs. The active PHR has the features of the passive PHR but also electronically advises patients to check a secure Web site when disease self-management tasks or preventive services are necessary. This project will help determine if the use of an active patient self-management version of an existing PHR can reduce cardiovascular risk factors.

Specific Aims:
  • Develop a patient-specific, active and interactive component to an existing electronic PHR for patients with complex illnesses and conditions that contribute to the development of cardiovascular disease. (Achieved)
  • Conduct a randomized controlled trial of the effectiveness of passive and active PHR systems for improving adherence and clinical outcomes of these patients in an ambulatory environment. (Ongoing)
  • Enumerate and catalog the barriers and facilitators to implementation and use of an electronic PHR among providers and patients in an ambulatory setting. (Upcoming)

2010 Activities: Patient user groups and focus groups were conducted to inform the development of the interactive component of the PHR, which was activated in 2010 in both EpicCare and Health Trak. E-mail and text alerts are being transmitted to the patients in the intervention group based on the specific cardiovascular health maintenance activities for which the patient is due. Study recruitment for the randomized controlled trial went live June 2010. In the first 6 months of recruitment, over 400 patients were enrolled. Although the rate of recruitment was slightly lower than the desired levels, active and passive recruitment strategies continue to be utilized. To help increase recruitment the project team and providers met one-on-one to answer their questions and encourage participation. The study team anticipates reaching the enrollment target by spring 2011. The task of writing the EMR reports has also been initiated. These reports will be used to extract the EMR data such as demographics, PHR usage statistics, and outcome variables.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): No reports were submitted to the AHRQ Research Reporting System in 2010. However, Dr. Roberts provided information that, as of June 2010, the project was underspent due to hiring challenges and because the data center had not yet been invoiced.

Preliminary Impact and Findings: This project has no findings to date.

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: Knowledge Creation

*AHRQ Priority Population.

Self Management & Reminders with Technology: SMART Appraisal of an Integrated Personal Health Record - Final Report

Citation:
Roberts M. Self Management & Reminders with Technology: SMART Appraisal of an Integrated Personal Health Record - Final Report. (Prepared by the University of Pittsburgh under Grant No. R18 HS018167). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 805.79 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. (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
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