Health Information Technology to Support Integration of Self-Management Support in Primary Care Delivery - 2010
Project Name
Principal Investigator
Organization
Contract Number
IAA 10-663F-10
Project Period
June 2010 – May 2012
AHRQ Funding Amount
$300,000
Summary Status as of
December 2010
Target Population: Adults, Chronic Care*, Racial or Ethnic Minorities*: American Indian/Alaska Native
Summary: In 2007, the Indian Health Service (IHS) Chronic Care Initiative (CCI) began to implement strategies within the IHS 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 across multiple chronic conditions, instead of separately managing individual diseases. This work is done in the Innovations in Planned Care for the Indian Health System (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 the care and encouragement of people with chronic conditions to help them understand their central role in managing their illness, make informed decisions about care, and engage in healthy behaviors. SMS requires collaboration between patients and care providers to share information and create an appropriate care plan. SMS 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 will help answer these questions and to understand, develop, and test EHR elements that improve the delivery, documentation, and tracking of SMS services in the IPC Care Model.
Project Objectives:- Develop and test electronic integration of clinical decision support and tracking into the IHS electronic health record system. (Ongoing)
- Implement electronic support for clinical decision and tracking for SMS services. (Upcoming)
- Publish a manuscript describing the work of IHS to improve the provision of primary care services as it relates to this work and IPC. (Upcoming)
2010 Activities: Prior to developing a patient goal setting component for the Resource and Patient Management System (RPMS) EHR, a careful analysis of current documentation data elements and desired data fields was conducted among numerous stakeholders. Requirements were gathered and integrated into a prototype that was refined over the course of months until all stakeholders reached an agreement on design, both in terms of the process for documenting and viewing patient goals, as well as the appropriate data fields that would be used to document this information. The goal-setting component has entered the development lifecycle; however, the intrusion of EHR certification to achieve meaningful use has delayed development and release. The component is currently scheduled for release in May 2011.
In addition to EHR development, the IHS has begun developing a personal health record (PHR) to provide patients with access to their medical record information in the RPMS. Currently, data is unidirectional, allowing patients to view their medications list, allergies, problem list, and recent labs. Development of a bidirectional data exchange, utilizing the patient goals component, is under investigation. The PHR team will develop a technical and clinical process to allow patients to enter their goals into their RPMS medical record via the PHR. This information will be flagged as patient-entered data and a notification system for the patient’s designated clinician will be enabled to promote prompt followup, support, and refinement of the patient’s goals in order to facilitate an achievable and positive outcome.
Preliminary Impact and Findings: This project has no findings to date.
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: Knowledge Creation