Using an Electronic Personal Health Record to Empower Patients with Hypertension (Georgia)

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Using An Electronic Personal Health Record To Empower Patients With Hypertension - 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 017234
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,181,369
  • PDF Version: 
    (PDF, 211.01 KB)

Summary: Patient- and family-centered care (PFCC) represents a new paradigm for health care delivery, in which patients and their families take an active role in their health care management and decisionmaking. Evidence shows that PFCC improves outcomes by reducing medication errors, increasing compliance, and improving disease management. However, implementation of patient-centered care in the ambulatory setting remains elusive for most clinical practices in the United States. An electronic personal health record (ePHR) can help overcome barriers to adoption of PFCC by maximizing patient-clinical collaboration, self-management, and related health outcomes.

The project examined the feasibility, acceptability, and impact of an ePHR for patients with hypertension. The project used Cerner Health's ePHR, My HealthLink through the Medical College of Georgia (MCG). To foster personal wellness and chronic condition management, My HealthLink allowed consumers to log entries into their ePHR, track progress against their customized care plan, complete health assessments, communicate securely with providers, access health education content, and check for interactions between medications.

The project team worked with Cerner to customize My HealthLink by incorporating the experiences, perspectives, and insights of patients and their families in the design of the ePHR. Patients from the MCG Medical Center were enrolled and researchers conducted two iterative pilot beta tests to evaluate the modified ePHR. Each beta test session had participants use the ePHR for 2 weeks. Subsequent acceptability interviews were conducted and analyzed to identify common themes. Once the modifications suggested by the beta test participants were fully incorporated, a clustered randomized controlled trial was conducted to compare a group using My HealthLink with those receiving usual care. The effectiveness of My HealthLink was evaluated through questionnaires and biological measurements, including patient activation and perception of care; biological markers, specifically blood pressure, body mass index, and lipid levels; collaborative patient-physician communication; congruence of medication treatment with guidelines; and frequency-of-use of medical services. The team also evaluated, via surveys and in-depth interviews, physician and staff perceptions of the ePHR and attitudes towards patient- and family-centered practices.

Specific Aims:

  • Improve the application of PFCC elements in an existing ePHR system. (Achieved)
  • Implement and test the effectiveness of the revised ePHR (My HealthLink) with patients who are being treated for hypertension by a team of physicians, mid-level practitioners, nurse clinicians, and support staff in two ambulatory settings. (Achieved)
  • Monitor the shift in provider and support staff awareness and incorporation of PFCC concepts as a result of the implementation of the ePHR. (Achieved)

2011 Activities: Data collection and analysis were the major focus during the remainder of the project's no-cost extension period. Post-trial interviews with participating physicians and staff were completed. A total of 13 physicians completed the post-study structured interview and patient empowerment scale (PES). Four focus groups involving a total of 14 staff and nurses were conducted. Two members of the team focused on identification of themes within all post-trial interviews and they completed analysis of the post-trial PES data. The results from this analysis were prepared for dissemination and the project staff developed and submitted a manuscript that addressed differences among qualitative themes of providers and patients, pre-ePHR use and post-ePHR changes in patients on the PES scale, and PES differences between providers and patients. All these differences affect perceptions of patient empowerment as a result of ePHR use. Information from the chart audits was analyzed for use in the final data comparisons and dissemination of results.

All patient-physician recordings were transcribed. Qualitative analysis was conducted on patient-physician transcriptions and email communications. The 2005, 2008, and 2010 PFCC Institutional Survey results were analyzed and prepared for dissemination.

As last self-reported in the AHRQ Research Reporting System, project progress and activities were on track and project spending was on track. The project was completed in August 2011 at the completion of the 12-month no-cost extension.

Impact and Findings: The project staff observed no impact of the ePHR on blood pressure, patient activation, patient perceived quality, or medical utilization in the intention-to-treat analysis. Sub-analysis of intervention patients who self-identified as active ePHR users showed a 5.25-point reduction in diastolic blood pressure. Younger age, greater computer skills, and more positive provider communication ratings were associated with increased frequency of ePHR use. Institutional culture improved over time and was highly correlated with increasing use of patient advisors throughout the health care system. Simply providing an ePHR has limited impact on patient blood pressure, empowerment, satisfaction with care, or use of health services.

Inclusion of patients and patient and family advisors in the development of an existing ePHR did improve certain elements of acceptability, but ePHR use remained low overall with those enrolled in the ePHR arm of the randomized trial. Overall, minimal differences between patients in the intervention group and those in the control group were found. Weight, body mass index, waist circumference, high-density lipid levels, PES total empowerment scores, consumer assessment of health care providers and systems (CAHPS) global doctor rating, composite doctor communication rating, and CAHPS composite office staff rating were significant but none of the raw effect sizes were of sufficient magnitude to imply clinically meaningful differences between groups.

Both patients and providers reflected positively on the ePHR in terms of patient empowerment, pre-visit preparation, recognizing medical errors, adherence, and sense of personal control. Providers expressed concern about patient worry, confusion, and the potential for offense by documentation comments. Results from the PFCC Institutional Survey support an increase in positive attitudes and awareness toward PFCC practices from 2005 to 2008 to 2010. These results corresponded to increasing PFCC implementation throughout the health care system, though this cannot be attributed to the ePHR project alone since it is only a minor part of the system.

Target Population: Adults, Chronic Care*, Hypertension

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

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

Using An Electronic Personal Health Record To Empower Patient With Hypertension - 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 017234
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,181,369
  • PDF Version: 
    (PDF, 361.17 KB)


Target Population: Adults, Chronic Care*, Hypertension

Summary: Patient- and family-centered care (PFCC) represents a new paradigm for health care delivery, where patients and their families take an active role in their health care management and decisionmaking. Evidence shows that PFCC improves outcomes including reduction of medication errors, increased compliance, and better disease management. However, implementation of patient-centered care in the ambulatory setting remains elusive for most U.S. clinical practices. An electronic personal health record (ePHR) helps overcome barriers to adoption of PFCC by maximizing patient-clinical collaboration, self-management, and related health outcomes.

The project examines the feasibility, acceptability, and impact of an ePHR for patients with hypertension. The project is using Cerner Health’s ePHR, My HealthLink, under the Medical College of Georgia (MCG). To foster personal wellness and chronic condition management, My HealthLink allows consumers to log entries into their ePHR, track progress against their customized care plan, complete health assessments, communicate securely with their providers, access health education content, and check for interactions between medications.

The project team worked with Cerner to iteratively modify My HealthLink to customize it for their local use. The team incorporated the experiences, perspectives, and insights of patients and their families in the design of the ePHR. Patients were enrolled from the MCG Medical Center and researchers conducted two iterative pilot beta tests to evaluate the modified ePHR. Each beta-test session had participants use the ePHR for two weeks. Subsequently, acceptability interviews were conducted and identified themes emerged from the feedback received. Once the modifications suggested by the beta-test participants are fully incorporated, a clustered, randomized controlled trial to compare a group using My HealthLink with those receiving usual care will be conducted. The effectiveness of My HealthLink will be evaluated through questionnaires and biological measurements, including: patient activation and perception of care; biological markers, specifically blood pressure, body mass index, and lipid levels; collaborative patient-physician communication; congruence of medication treatment with guidelines; and frequency-of-use of medical services. The team will also evaluate, via surveys and in-depth interviews, physician and staff perceptions of the ePHR and attitudes towards patient- and family-centered practices.

Specific Aims:
  • Improve the application of PFCC elements in an existing ePHR system. (Achieved)
  • Implement and test the effectiveness of the revised ePHR (My HealthLink) with patients who are being treated for hypertension by a team of physicians, mid-level practitioners, nurse clinicians, and support staff in two ambulatory settings. (Achieved)
  • Monitor the shift in provider and support staff awareness and incorporation of PFCC concepts as a result of the implementation of the ePHR. (Ongoing)

2010 Activities: Two types of patient visits were audio recorded during this period for qualitative data collection. The first type is patient-physician communication recordings in which the actual medical visit is recorded and the second type is the end of the study interview visit with study participants. A total of 51 patient-physician communication visits and 126 Visit 4 end of study interviews were recorded, all of which have been transcribed and will undergo qualitative analysis. Patient follow-ups for visits 2, 3, and 4 were completed during 2010.

Post-trial interviews with participating physicians and staff are complete. A total of eight physicians completed the post-study structured interview and physician perspective of patient empowerment scale (PES-P). Additionally, four staff and nurse focus groups with a total of 14 participants were conducted. A qualitative analysis of the structured interviews and focus groups began as well as an analysis of the post trial PES-P data.

The 2010 culture survey was disseminated in July 2010 (sample= 2,500) and was open until mid-August 2010. Seven hundred, sixty-two people responded and started the survey and 550 completed the survey. Data are being analyzed and will be compared with the 2005 and 2008 culture surveys. In addition, a total of 355 charts were audited by the end of the 2010. Data from the chart audits were entered into a database, have under gone preliminary analysis, and will be used accordingly in the final main trial data comparisons and dissemination of results.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress and spending are mostly on track. The project is progressing as expected, focusing on continuing implementation activities, collecting, and analyzing data.

Preliminary Impact and Findings: No impacts or findings have yet been reported.

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

*AHRQ Priority Population.

Project Details - Ended

Project Categories

Summary:

Patient and family-centered care (PFCC), in which patients and their families take an active role in health care management and decisionmaking, has been a focus of the Georgia Health Sciences University Health System (GHSU) since the late 1990s. GHSU has actively worked to integrate PFCC within the infrastructure of the entire organization. The organization has previously adopted a personal health record (PHR) in order to help increase the adoption of PFCC by increasing patient-clinical collaboration, self management, and related health outcomes.

For this project, the PHR was modified using the PFCC approach, which incorporated the experiences, perspectives, and insights of both patients and their family members who were using the system. The modified PHR provides access to clinical data, educational materials, and contact with the clinical team. With these tools, an individual is able to accumulate and manage their own health data, establish health goals, track their steps and progress towards those goals, manage their medications, and coordinate other aspects of their care.

The main objectives of this project were to:

  • Improve the application of PFCC elements in an existing PHR system.
  • Implement and test the effectiveness of the revised PHR (My HealthLink) with patients who are being treated for hypertension by a team of physicians, mid-level practitioners, nurse clinicians, and support staff in two ambulatory settings.
  • Monitor the shift in provider and support staff awareness and incorporation of PFCC concepts as a result of the implementation of the PHR.

The project team used a randomized trial to compare the impact of using the modified PHR compared to usual care. The primary outcome measure was blood pressure (BP); secondary outcome measures were patient empowerment and quality of care.

There was no difference noted in BP, patient activation, patient perceived quality, or medical utilization between the two groups. A sub-analysis that looked at those patients who self-identified themselves as active users of the PHR showed that these patients did have a reduction in diastolic blood pressure. Characteristics associated with more frequent PHR use included younger age, greater computer skills, and more positive provider communication ratings. The project team concluded that there is limited impact from the use of a PHR when simply providing it for patient use. They recommended further research in order to describe meaningful PHR use to clarify the viability of PHRs to change health outcomes.

Using an Electronic Personal Health Record to Empower Patients with Hypertension - Final Report

Citation:
Wagner PJ. Using an Electronic Personal Health Record to Empower Patients with Hypertension - Final Report. (Prepared by Georgia Health Sciences University under Grant No. R18 HS017234). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 431.33 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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