Technology for Optimizing Population Care in a Resource-Limited Environment (Massachusetts)

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Summary:

Using health information technology (IT) in the management of primary care populations will likely improve efficiencies; however ways to use technology in this area is not well understood. The use of an automated reminder system to prompt patients of the need for preventive maintenance and screening may improve efficiencies by occurring outside patient visits and bypassing clinicians. However, it is unknown whether having clinician input into these reminders is more efficient than purely automated systems.

The Technology for Optimizing Population Care in a Resource-limited Environment (TopCare) project designed, developed, implemented, and evaluated a system for automated reminders for breast, cervical, and colorectal cancer screening within the Massachusetts General Primary Care Practice Based Research Network (MGPC-PBRN). The goal of this project was to improve clinical decision support and enhance preventive cancer screening. It compared involving primary care physicians (PCPs) in the screening process to a fully automated process in order to determine whether screening rates differed when outreach was linked to the patient’s needs.

The specific aims of this project were to:

  • Design, develop, and implement a novel cancer screening intervention program (TopCare) that facilitates the identification, individualized contact, and subsequent tracking of patients overdue for screening. 
  • Conduct a practice-randomized trial of the TopCare program within the MGPC-PBRN assessing its impact on cancer screening rates in eligible patients. 
  • Collect data prospectively throughout the randomized trial on costs, preferences, and clinical and process outcomes to inform a subsequent formal cost-benefit analysis. 

A randomized controlled trial of 18 practices was conducted. The screening program was integrated with electronic health record data to assess whether clinical decision support could efficiently enhance preventive care in a primary care setting. In the intervention practices, PCPs were given lists of their patients who were overdue for screening. They determined if screening was needed, and customized contact with patients by letter, practice delegate, or patient navigator. In the control practices, patients who were overdue for screening were automatically sent reminder letters and transferred to a practice delegate for followup. Patients in the intervention group whose PCPs failed to take action within 8 weeks were moved to the automated system.

Ninety percent of the intervention providers used the tool, reviewing nearly 8,000 patients who were overdue for at least one cancer screening. A total of 12,002 letters were sent to patients in intervention practices versus 16,378 letters in control practices. Screening rates did not differ among intervention and control practices for all cancers combined. A majority of system users reported that the system was easy to use and made time managing cancer screening more effective. Further analyses will explore whether implementation of the TopCare system resulted in higher screening rates.

This project demonstrated that population-based comprehensive screening for cancers is possible to automate with technology tools. Since the completion of the TopCare demonstration project, the system has been implemented as an operational system at Massachusetts General Hospital. The project team recommends similar research to identify preventive care and disease management scenarios that may be good candidates for automated, non-visit based models of care delivery.

Technology for Optimizing Population Care in a Resource-Limited Environment - 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 018161
  • Project Period: 
    December 2009 – July 2013
  • AHRQ Funding Amount: 
    $1,199,264
  • PDF Version: 
    (PDF, 284.17 KB)

Summary: In recent years, many organizations have designed health information technology (IT) initiatives to help provide consistent, high-quality care to everyone, thereby improving health care in the primary care setting. Despite the increasing adoption of basic health IT capabilities, studies continue to reveal low rates of appropriate preventive screening. The Technology for Optimizing Population Care in a Resource-Limited Environment (TOP-CARE) project is working to design, develop, and implement a novel cancer screening intervention program. The goal of this study is to improve clinical decision support and enhance preventive cancer screening. The screening program is being integrated with electronic health record (EHR) data to assess whether clinical decision support can efficiently enhance preventive care— specifically, breast, cervical, and colorectal screening—in a primary care setting.

User feedback, particularly from key stakeholders such as primary care physicians, practice contact delegates, patient navigators, and central administrative personnel, has been critical to guide the successful design of the TOP-CARE system. A practice cluster randomized trial of the TOP-CARE program provided an opportunity to assess its impact on cancer screening rates in eligible patients. Practices within the Massachusetts General Primary Care Practice Based Research Network (MGPC-PBRN) were randomly assigned to intervention or augmented standard care. This randomized clinical trial used a tailored outreach, including letters and practice personnel or patient navigator contact to see whether screening rates differ when outreach is linked to the patient’s needs. The control group received a standard of augmented care that mimics current population-level reminder systems, supplemented by the use of automation.

The data analysis for this study is on the average screening test completion rates for breast, cervical, and colorectal cancers. Dr. Atlas and his research team hope to demonstrate the use of a state-of-the-art approach to automated, cancer-specific patient reminders and its impact on involving clinicians in patient population management to facilitate between-visit, patient-centered cancer screening. This research is relevant to nationwide efforts to rigorously demonstrate the most effective ways to implement new IT-based delivery models.

Specific Aims:

  • Design, develop, and implement a novel cancer screening intervention program (TOP-CARE) that facilitates the identification, individualized contact, and subsequent tracking of patients overdue for screening. (Achieved)
  • Conduct a practice-randomized trial of the TOP-CARE program within the MGPC-PBRN assessing its impact on cancer screening rates in eligible patients. (Achieved)
  • Collect data prospectively throughout the randomized trial on costs, preferences, and clinical and process outcomes to inform a subsequent formal cost-benefit analysis. (Ongoing) 

2012 Activities: The focus of activity was on completing the randomized trial of the TOP-CARE intervention, which concluded in June 2012, and conducting the subsequent data analysis. At the close of the trial, the study included 17,618 patients in the intervention group and 17,057 in the control group, all of whom were identified as being overdue for at least one screening test. Following the intervention, analytic datasets were created to look at primary and secondary outcomes. Preliminary unadjusted analysis of the primary outcome was conducted using data from the TOP-CARE databases and hospital billing systems. However, further data abstracts from the hospital medical record system were required to complete the analysis. Follow-up surveys to providers were also administered.

The study team presented information at several conferences throughout the year using data from the TOP- CARE system at venues including the Massachusetts General Hospital Clinical Research Day 2012, the 2012 Harvard Center for Primary Care Innovations Conference, and the 2012 AHRQ Annual Conference. The team also helped collaborate on a manuscript and several abstracts detailing the preliminary results from the randomized controlled trial, the cost-effectiveness model, provider surveys, and disparities in screening.

As last self-reported in the AHRQ Research Reporting System, project progress, activities, and budget spending are completely on track. Due to a delay between the time the randomized controlled trial ended and when the hospital billing systems can provide the most accurate and up-to-date information to complete the analytic dataset, a 12-month no-cost extension period is being implemented. During this period, the research team will complete the cost-effectiveness analysis and disseminate findings.

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

Target Population: Adults

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: Knowledge Creation

Technology for Optimizing Population Care in a Resource-Limited Environment - 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 018161
  • Project Period: 
    December 2009 - November 2012
  • AHRQ Funding Amount: 
    $1,199,264
  • PDF Version: 
    (PDF, 172.86 KB)

Summary: In recent years, many organizations have designed health information technology (IT) initiatives to help provide consistent, high-quality care to everyone, thereby improving health care in the primary care setting. Despite the increasing adoption of basic health IT capabilities, studies continue to reveal low rates of appropriate preventive screening. The Technology for Optimizing Population Care in a Resource-Limited Environment (TOP-CARE) project is working to design, develop, and implement a novel cancer screening intervention program. The goal of this study is to improve clinical decision support and enhance preventive cancer screening. The screening program is being integrated with electronic health record (EHR) data to assess whether clinical decision support can efficiently enhance preventive care - specifically, breast, cervical, and colorectal screening - in a primary care setting.

User feedback, particularly from key stakeholders such as primary care physicians, practice contact delegates, patient navigators, and central administrative personnel, is critical to guide the successful design of the TOP-CARE system. A practice cluster randomized trial of the TOP-CARE program will provide an opportunity to assess its impact on cancer screening rates in eligible patients. Practices within the Massachusetts General Primary Care Practice Based Research Network (MGPC-PBRN) will be randomly assigned to intervention or augmented standard care. This randomized clinical trial uses tailored outreach, including letters and practice personnel or patient navigator contact to see whether screening rates differ when outreach is linked to the patient's needs. The control group receives a standard of augmented care that mimics current population-level reminder systems, supplemented by the use of automation.

Using average cancer screening test completion rates for breast, cervical, and colorectal cancers, Dr. Atlas and his research team will demonstrate the use of a state-of-the-art approach to automated, cancerspecific patient reminders and its impact on involving clinicians in patient population management to facilitate between-visit, patient-centered cancer screening. This research is relevant to nationwide efforts to rigorously demonstrate the most effective ways to implement new IT-based delivery models.

Specific Aims:

  • Design, develop, and implement a novel cancer screening intervention program (TOP-CARE) that facilitates the identification, individualized contact, and subsequent tracking of patients overdue for screening. (Achieved)
  • Conduct a practice-randomized trial of the TOP-CARE program within the MGPC-PBRN assessing its impact on cancer screening rates in eligible patients. (Ongoing)
  • Collect data prospectively throughout the randomized trial on costs, preferences, and clinical and process outcomes to inform a subsequent formal cost-benefit analysis. (Ongoing)

2011 Activities: Activities focused on the development and implementation of the TOP-CARE intervention. The randomization scheme and randomization of practices to the intervention or the automated control arm was completed in March 2011. In May, the functionality and quality control testing on the system was completed. The project team conducted data quality testing in which a comprehensive data reconciliation process was conducted between the live system in production and the retrospective data collection to identify any causes of discrepancies. During this same period, the TOP-CARE beta application was rolled out to a pilot site (Ambulatory Practice of the Future) for additional usability testing. Training sessions were provided to all primary care practices involved in the study and users of the applications - primary care physicians (PCPs), delegates, practice managers, and administrators - received more intensive training. Overview and training of the applications for PCPs and practice population managers were completed in all nine intervention and all nine control practices. On June 15th, 2011, the TOP-CARE application was launched on schedule.

Meanwhile, the study team continues to improve the TOP-CARE applications based on user feedback received after the initial launch. Training of existing navigators was completed in August. In September, all practice population managers were emailed offering a followup training session and the opportunity to meet the TOP-CARE navigator. Brief meetings were held in five intervention practices to introduce the patient navigation.

To identify the variables necessary for the cost analyses, a survey instrument for PCPs, practice delegates, and navigators was developed. The survey was administered in paper form to PCPs and practice delegates during initial meetings and training sessions. The survey will be re-administered after the completion of the randomized controlled trial.

As last self-reported in the AHRQ Research Reporting System, project progress, activities, and budget spending are completely on track.

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

Target Population: Adults

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: Knowledge Creation

Technology for Optimizing Population Care in a Resource-Limited Environment - 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 018161
  • Project Period: 
    December 2009 – November 2012
  • AHRQ Funding Amount: 
    $1,199,264
  • PDF Version: 
    (PDF, 305.97 KB)


Target Population: Adults

Summary: Health information technology (IT) initiatives have been designed by many organizations in recent years to help provide consistent, high-quality care to everyone, thereby improving health care in the primary care setting. However, despite the increasing adoption of basic health IT capabilities, studies continue to reveal low rates of appropriate preventive screening. The project team for the study titled Technology for Optimizing Population Care in a Resource-Limited Environment (TOP-CARE) is working to design, develop, and implement a novel cancer screening intervention program. The goal of this study is to improve clinical decision support and enhance preventive cancer screening. The screening program is being integrated with electronic health record (EHR) data to assess whether clinical decision support can efficiently enhance preventive care—specifically, breast, cervical, and colorectal screening—in a primary care setting.

User feedback is considered critical to guide the successful design of the TOP-CARE system, particularly from key stakeholders, such as: 1) primary care physicians; 2) practice contact delegates; 3) patient navigators; and 4) central administrative personnel. A practice cluster randomized trial of the TOP-CARE program will provide an opportunity to assess its impact on cancer screening rates in eligible patients. Practices within the Massachusetts General Primary Care Practice Based Research Network (MGPC-PBRN) will be randomly assigned to intervention or augmented standard care. This randomized clinical trial will use tailored outreach, including letters, and practice personnel or patient navigator contact to see whether screening rates differ when outreach is linked to the patient's needs. The control group will receive a standard of augmented care that mimics current population-level reminder systems, supplemented by the use of automation.

Using average cancer screening test completion rates for breast, cervical, colorectal, and prostate cancers, this study will demonstrate the use of a state-of-the-art approach to automated, cancer-specific patient reminders and its impact on involving clinicians in patient population management to facilitate between-visit, patient-centered cancer screening. This research is relevant to nationwide efforts to rigorously demonstrate the most effective ways to implement new IT-based delivery models. During the randomized trial, data related to the costs, preferences, and clinical and process outcomes will also be collected. While a formal cost-benefit analysis is outside the scope of this particular grant, the intention is that the data can be used in future cost analyses of the TOP-CARE study.

Specific Aims:
  • Design, develop, and implement a novel cancer screening intervention program (TOP-CARE) that facilitates the identification, individualized contact, and subsequent tracking of patients overdue for screening. (Ongoing)
  • Conduct a practice-randomized trial of the TOP-CARE program within the MGPC-PBRN assessing its impact on cancer screening rates in eligible patients. (Ongoing)
  • Collect data prospectively throughout the randomized trial on costs, preferences, and clinical and process outcomes to inform a subsequent formal cost-benefit analysis. (Upcoming)

2010 Activities: Regarding the development of the TOP-CARE system, the project team has made substantial progress on many of the aspects of system architecture and developing TOP-CARE-specific functions. Development of the permission mechanism and security layer is 85 percent complete, the interface is 75 percent complete, and the integration of patient linkage methodology is 50 percent complete. Stakeholder input was solicited frequently throughout the design process and has proven useful in the design of a functioning interface. The development of the user interface is 50 percent complete after a fifth iteration of the design. The interaction functionalities have also been designed; features include a phone line, fax line, and e-mail account by which patients can provide information stored outside of the system. The pilot phase is planned to begin in the first quarter of 2011.

Regarding the randomized controlled trial, extensive work has been done to evaluate and improve on a new real-time process of linking a patient to a specific provider. Providers were given a list of 25 patients to review whether the real-time operational linkage algorithm was successful, with results indicating that it was. Also, letter templates have been developed for notifying patients of an overdue status for one or more cancer screening exams. These complex letters differ by cancer type and by sender, whether it is the physician, case manager, or automated control. These letters will include information about the value of cancer screening, the status of a patient’s eligible screening exams, instructions for scheduling an exam, instructions for notifying a provider or practice of inaccurate information or outside tests, and additional educational material when appropriate. The randomization of practices within the MGPC-PCRN will occur in early 2011.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The research team made significant progress this year. All project milestones are being met on time and spending is roughly on target.

Preliminary Impact and Findings: In the initial process of translating the validated algorithm into a real-time operational process, there were cases of patients being linked to a specific practice but not a specific provider. Extensive work was done in 2010 to evaluate and improve the real-time process, leading to a refined real-time operational linkage algorithm. Final implementation plans for this real-time linkage process are expected to be completed in the first or second quarter of 2011.

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: Knowledge Creation

Technology for Optimizing Population Care in a Resource-Limited Environment - Final Report

Citation:
Atlas S. Technology for Optimizing Population Care in a Resource-Limited Environment - Final Report. (Prepared by Reedsburg Area Medical Center under Grant No. R18 HS018161). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 424.5 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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