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

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.