Health Information Technology to Support Integration of Self-Management Support in Primary Care Delivery

In 2007, the Indian Health Service (IHS) Chronic Care Initiative (CCI) began to implement strategies within HIS to improve the health status of patients and populations affected by chronic conditions and to reduce the prevalence and impact of those conditions. Efforts focused on developing patient- and family-centered care processes that apply to multiple chronic conditions, instead of separately managing individual diseases. This work was done with the Improving Patient Care for the Indian Health Service (IPC- IHS), a learning community collaborative. IPC- IHS is designed to close the gap between what is known through evidence and what is practiced.

Self-management support (SMS) is care and encouragement to help people with chronic conditions understand their own role in managing their illness, make informed decisions about care, and adapt healthy behaviors. It requires patients and care providers to share information and create an appropriate care plan, and is a key component of patient-centered health care and the chronic care model. This project is designed to support the improvement of the delivery of prevention and care management services through the IHS CCI.

Two questions arising from IPC work on SMS are:

1. What elements (e.g., goal setting, action planning, followup) can be integrated into the electronic health record (EHR) to help prompt and document SMS within a newly designed model of care; and 
2. What key measure(s) should be collected from the EHR to drive performance improvement. 

This 2-year project helped to answer these questions and to understand, develop, and test EHR elements to improve the delivery, documentation, and tracking of SMS services in the IPC care model. The project team also developed a personal health record (PHR) to give patients access to their medical record information in the electronic system and allow them to enter their individual health goals.

Although the project period ended in 2012, the project team is continuing to develop and test EHR elements to improve the delivery, documentation, and tracking of SMS services in the IPC care model. In the short-term, the project team is focused on allowing the patient goals to be displayed and interfacing with a Web site to enable a patient to set a goal, which is then sent as a secure message to the health care team for entry into the EHR system. Long-term goals include the integration of the patient goals component into the PHR, and identifying an additional service that will have bidirectional communication.