Health Information Technology to Support Integration of Self-Management Support in Primary Care Delivery - 2011

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 Improving Patient Care for the Indian Health Service (IPCIHS), 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 own role in managing their illness, make informed decisions about care, and engage in 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, follow-up) 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 is striving to help 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.

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. (Ongoing)
• 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)

2011 Activities: Activities focused on developing and releasing the Resource and Patient Management System (RPMS), a patient goal-setting component for the IHS EHR. In addition to the EHR, IHS has their own personal health record (PHR) to provide patients with access to their medical record information in the RPMS. The PHR team is planning to develop a technical and clinical process to allow patients to enter their goals into their RPMS medical record via the PHR. The patient's designated clinician receives notification of the patient-entered data to promote prompt follow-up, 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.

Target Population: Adults, Chronic Care*, Racial or Ethnic Minorities*: American Indian/Alaska Native

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

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