Using Health Information Technology to Improve Ambulatory Chronic Disease Care (Missouri)

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Using Health Information Technology to Improve Ambulatory Chronic Disease Care - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory and Safety Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017035
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,192,603
  • PDF Version: 
    (PDF, 205.53 KB)

Summary: Coordinating fragmented chronic disease care requires new systems to manage information between providers and enhance communication with patients. To improve patient care quality and safety, the Family Medicine and General Internal Medicine practices at the University of Missouri-Columbia (MU) conducted a phased implementation of selected ambulatory care health information technology (IT) systems and functions. This project used a formative (in-process evaluation aimed at improvement) and summative (final overall) evaluation of health IT innovations (described below) designed to improve chronic disease care in the ambulatory primary care practices at MU. These innovations are the result of collaboration between MU clinicians from the Department of Family and Community Medicine and the Cerner Corporation, MU's Certification Commission for Health Information Technology-certified medical record vendor.

Specific strategies for this project included providing physicians with comparative performance reports in one of three formats (patient panel performance through the EHR, patient panel performance level via email, or individual patient-only performance through the EHR), and providing patients with access to a Web-based interactive software system that features secure messaging, in-home reconciliation of all medications, and use of in-home "smart" diagnostic devices to send patient data directly to the care team.

The project used a multi-method evaluation of health IT innovations, including qualitative interviews, surveys, and analysis of outcome data, designed to enhance the quality of primary care for chronic diseases. The innovations were implemented differently in various practices and with different associated care systems. This variation in care processes provided an extraordinary opportunity to evaluate factors that influence health IT innovations' effects on performance-based quality improvement, care coordination, and patient self-management.

Specific Aims:

  • Evaluate the change in patient care processes and outcomes following introduction of health IT-generated clinician quality performance reports across differences in practices and peers. (Achieved)
  • Evaluate the effectiveness and changes associated with an interactive Web-based patient interface software system (IQ Health), including in-home medication reconciliation. (Achieved)
  • Evaluate the use of in-home "smart" diagnostic devices (e.g., blood pressure cuffs, glucometers) connecting patients with their care teams. (Achieved)
  • Disseminate information regarding the development and impact of the interventions through Web teleconferences, professional meetings, educational lectures, and peer-reviewed journals. (Achieved)

2011 Activities: The evaluation of the impact of health IT-generated clinician quality performance reports on diabetes care was completed in 2011. Physicians were randomized to view diabetes performance reports through: 1) the electronic medical record (EMR); 2) a report emailed directly to them; 3) both venues; or 4) not at all. The evaluation compared the patient outcomes based on the type of performance report physicians received. Using qualitative methods, the research team investigated contextual factors, such as local barriers to and facilitators of achieving better performance measure scores, to determine their effect on practice outcomes.

The research team analyzed the data from the evaluation of the use of in-home "smart" diagnostic devices. This included analysis of the impact of the use of in-home devices on patient outcomes and patient's and provider's perspectives on use. Seventeen nurses and physicians were interviewed on their perceptions of the smart devices and the transmission of data from the devices to the practice.

The evaluation of the online medication verification process evolved considerably over the course of the project. In the final iteration, participants were asked to review their medication list and generate a message to their provider to notify them of any changes or additions made at the time of a pharmacist home visit. The messages were preferably sent through Healthe (a Web-based patient portal) or regular email. The team then compared information that patients sent with the pharmacist's "gold standard" evaluation. Additionally, the team evaluated the nature of problems identified (e.g., incorrect listing of medications in the EMR) and the providers' responses to these messages.

The evaluation of patient and provider expectations and perceptions concerning patient access to a Web portal for secure messaging, medical record review, and appointment scheduling was completed. The Web portal included secure messaging (including prescription requests), medical record review (including medication list and selected laboratory reports), and appointment scheduling. The team analyzed surveys to assess providers' perceptions and experiences of using IQHealth and on-line surveys of patients who enrolled in IQHealth.

As last self-reported in the AHRQ Research Reporting System, project progress and activities were on track and project spending was on target. The project team used a 1-year no-cost extension to complete the evaluation. This project was completed in August 2011.

Impact and Findings: The diabetes quality performance reports in the format of a dashboard were efficient and improved accuracy. A composite measure of eight diabetes care-quality indicators improved in practices able to access performance information in the electronic record. Practices improving in the second year showed strong leadership, sharing of information, and exhibited adaptive reserve. Initial use of the patient portal was relatively limited but physicians felt better about its impact after use. In-home medication reconciliation is potentially limited by incomplete information from patients and failure to update records by providers. Home monitoring did not improve outcomes, but qualitative findings pointed to important implementation principles.

Target Population: Adults, Chronic Care*, Elderly*

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 Health Information Technology to Improve Ambulatory Chronic Disease Care - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory and Safety Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017035
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,192,603
  • PDF Version: 
    (PDF, 410.74 KB)


Target Population: Adults, Chronic Care*, Elderly*

Summary: Coordinating fragmented chronic disease care requires new systems to manage information between providers and enhance communication with patients. To improve patient care quality and safety, the Family Medicine and General Internal Medicine practices at the University of Missouri–Columbia (MU) are conducting a phased implementation of selected ambulatory care health information technology (IT) systems and functions. This project proposes a formative (in-process evaluation aimed at improvement) and summative (final overall) evaluation of health IT innovations designed to improve chronic disease care in the ambulatory primary care practices at MU. These innovations are the result of collaboration between MU clinicians from the Department of Family and Community Medicine and the Cerner Corporation, MU’s Certification Commission for Health Information Technology-certified medical record vendor.

Specific strategies in this health IT project include providing physicians with comparative performance reports in one of three formats, and providing patients with access to a Web-based, interactive software system that features secure messaging, in-home reconciliation of all medications, and use of in-home "smart" diagnostic devices to send patient data directly to the care team.

The project proposes a multi-method evaluation of health IT innovations designed to enhance the quality of primary care for chronic diseases, including qualitative interviews, surveys, and analysis of outcome data. The innovations are being implemented differently in various practices and with different associated care systems. This variation in care processes provides an extraordinary opportunity to evaluate factors that influence health IT innovations’ effects on performance-based quality improvement, care coordination, and patient self-management.

Specific Aims:

  • Evaluate the change in patient care processes and outcomes following introduction of health IT-generated clinician quality performance reports across differences in practices and peers. (Ongoing)
  • Evaluate the effectiveness and changes associated with an interactive Web-based patient interface software system (IQ Health), including in-home medication reconciliation. (Ongoing)
  • Evaluate the use of in-home "smart" diagnostic devices (e.g., blood pressure cuffs, glucometers) connecting patients with their care teams. (Ongoing)
  • Disseminate information regarding the development and impact of the interventions through Web teleconferences, professional meetings, educational lectures, and peer-reviewed journals. (Ongoing)

2010 Activities: Preliminary analysis of the impact of access to reports on performance indicators, such as systolic blood pressure

The development of summary screens is also part of the Cerner-MU collaboration. The summary screens allow the clinician to view multiple elements of a patient record, such as laboratory values and medications for a diabetic patient, on a single screen. They also provide quality indicator data on that specific patient. A survey was distributed to clinicians to evaluate the usability of the summary screens and the results were written into a manuscript that was submitted for publication in 2010.

The evaluation of the Web-based patient interface was completed through a survey of patients and providers who used IQ Health and the next generation health IT system, Healthe. The Web portal includes: secure messaging (including prescription requests), medical record review (including medication list), and appointment scheduling. This qualitative information will inform development of improved patient interface software. Two manuscripts have been prepared; one focusing on patients, the other on providers. In addition, this evaluation includes assessment of the medication verification feature of the Web-based systems. Pharmacists visited participating patients and coached them on reviewing their medication list. Patients were asked to review their medication list and generate a message to their provider through Healthe (preferably) or regular e-mail to notify them of any changes or additions. This message did not include an all-inclusive list of patient medications, only the changes patients felt the provider needed in order to update the patients’ medical record. The team then evaluated the information the patient sent, the nature of problems identified (e.g., incorrect listing of medications in the electronic medical record), and the response of providers to these messages.

To understand the uptake and use of Healthe, the project evaluated patterns of enrollment or non-enrollment and use of the Web portal. A manuscript that addresses patient expectations, perceptions, and use of the Web portal is under development.

The evaluation of the use of in-home “smart” diagnostic devices (home blood pressure and blood glucose monitors) continued throughout 2010 and will be completed early in 2011. There were delays due to incompatibility between patients’ diagnostic equipment and computers during software releases, and the shift to upgrade telephone lines to digital cable. Patients were given a survey at enrollment and intervention patients received an additional survey at the conclusion of their participation in the study (3 months). Data collection continued for actively-participating patients through December 2010. Qualitative interviews with nurses and physicians regarding their perceptions of the smart devices began at the end of August and are expected to be completed early in 2011.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Progress is mostly on track and the project budget is somewhat underspent due to a delay in some project activities.

Preliminary Impact and Findings: The project team presented results on the use of the single-summary screens for summarizing diabetes care at the September 2009 Agency for Healthcare Research and Quality annual meeting. The evaluation of the summary screens determined that providers were able to retrieve information more quickly, with fewer mouse clicks, and improved accuracy. Qualitatively, the providers embraced the new tool and agreed that rapid access to information is critical. If identifying data is too time consuming, providers may give up, ask the patient to recall information, and if necessary, repeat exams. Initial data on the summary screen indicate that this tool accelerates information retrieval.

In 2010, the project team began to analyze the data to measure the change in patient care processes and outcomes following introduction of health IT-generated performance and comparison reports on quality of care. Preliminary analysis suggests that overall performance is improving in most clinics on most measures. During the initial phase (through February 2010), when only some clinics received pull reports, it appeared that, over time, having access to pull reports was associated with improvement. However, there are differences between clinics that overlap differences in the kind of report that was received; analysis of this data continues.

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:

Coordinating chronic disease care, which is often fragmented, requires new systems to manage information between providers and enhance communication with patients. In this project, the Family Medicine and General Internal Medicine practices at the University of Missouri–Columbia conducted a phased implementation of selected ambulatory care health information technology (IT) systems designed to improve chronic disease performance indicators and patient-provider communication. The project used a combination of formative and summative evaluation to study improvements in care and outcomes that resulted from the new system functionalities.

The specific aims of this project were to:

  • Evaluate the change in patient care processes and outcomes following introduction of health IT-generated clinician quality performance reports across differences in practices and peers.
  • Evaluate the effectiveness and changes associated with an interactive Web-based patient interface software system (IQ Health), including in-home medication reconciliation.
  • Evaluate the use of in-home "smart" diagnostic devices (e.g., blood pressure cuffs, glucometers) connecting patients with their care teams.
  • Disseminate information regarding the development and impact of the interventions through Web teleconferences, professional meetings, educational lectures, and peer-reviewed journals.

Each function of the system was evaluated separately to understand its impact. The new tools included diabetes performance reports and dashboard; a patient portal for secure communications; and home monitoring of blood glucose and blood pressure. The dashboard, which provided information on eight quality indicators, was evaluated with a usability study. The project team found that the dashboard improved efficiency and quality of diabetes care. Unexpectedly, 55 percent of physicians printed copies of the patient summary dashboards to give to patients as a patient handout.

The patient portal was evaluated with pre- and post-implementation surveys. Before implementation, 64 percent of physicians were concerned that the portal would increase their workload. However, post-implementation, only 13 percent felt that their workload had actually increased. Prior to implementation, 55 percent of physicians believed the quality of care would improve with use of the portal; post-implementation, only 33 percent believed that quality had actually improved.

For the in-home medication reconciliation portion of the project, issues were noted with the provider-entered medication lists maintained in the electronic medical record (EMR). Only some errors in these lists were noted by patients; when providers were informed of the errors by the patients, not all providers responded. The project team concluded that their findings support the need for better processes to ensure the accuracy of medication lists in EMRs.

A randomized trial with 108 patients was conducted to evaluate the effectiveness of remote data collection and patient transmission of blood glucose and blood pressure to the practices. The study showed no statistically significant differences between the intervention and control participants on either HbA1c or systolic blood pressure.

Practices that showed improvements in the second year of the project had several common characteristics: strong leadership, a culture of common purpose, and an information-sharing environment amongst clinicians and staff. The project team noted that these findings support the concept of “adaptive reserve,” or the capacity for change.

Using HIT to Improve Ambulatory Chronic Disease Care - Final Report

Citation:
Mehr, DR, Wakefield, D, Koopman, R, et al. Using HIT to Improve Ambulatory Chronic Disease Care - Final Report, (Prepared by University of Missouri under Grant No. R18 HS017035). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 769.48 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)
Principal Investigator: 
Document Type: 

IQ Health Survey for Clinicians

This is a questionnaire designed to be completed by nurses and physicians in an ambulatory setting. The tool includes questions to assess user's perceptions of personal health records and secure messaging.

Year of Survey: 
2008
Survey Link: 
IQ Health Survey for Clinicians (PDF, 93.87 KB)
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 

IQ Health: Patient's Enrollment Experience and Expectations

This is a questionnaire designed to be completed by patients in a home setting. The tool includes questions to assess the current state of personal health records and secure messaging.

Year of Survey: 
Created prior to 2010
Survey Link: 
IQ Health: Patient's Enrollment Experience and Expectations (PDF, 85.1 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 

Patient's Use of Computers: University of Missouri at Columbia

This is a questionnaire designed to be completed by patients in a home setting. The tool includes questions to assess the current state of patient portals and secure messaging.

Year of Survey: 
Created prior to 2009
Survey Link: 
Patient's Use of Computers: University of Missouri at Columbia (PDF, 343.77 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 

Provider Experiences with and Perceptions of Current Patients' Use of Email Communication with Their Doctor

This is a questionnaire designed to be completed by physicians in an ambulatory setting. The tool includes questions to assess user's perceptions of personal health records and secure messaging.

Year of Survey: 
2008
Survey Link: 
Provider Experiences with and Perceptions of Current Patients' Use of Email Communication with Their Doctor (PDF, 113.37 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 

Provider Pre-Implementation Survey: Information Needs and Use

This is a questionnaire designed to be completed by clinical staff in an ambulatory setting. The tool includes questions to assess functionality and needs of users electronic health records.

Year of Survey: 
2008
Survey Link: 
Provider Pre-Implementation Survey: Information Needs and Use (PDF, 154.82 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Organization: 
This project does not have any related story.
This project does not have any related emerging lesson.