Health Information Technology to Support Integration of Self-Management Support in Primary Care Delivery - 2012

Summary: In 2007, the Indian Health Service (IHS) Chronic Care Initiative (CCI) began to implement strategies within 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 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.

Project Objectives:

• Develop and test electronic integration of clinical decision support and tracking into the IHS electronic health record system. (Achieved)
• Implement electronic support for clinical decision and tracking for SMS services. (Achieved)
• Publish a manuscript describing the work of IHS to improve the provision of primary care services as it relates to this work and IPC. (Achieved)

2012 Activities: Activities focused on completing the Centers for Medicare & Medicaid Services EHR Incentive Program’s Meaningful Use Certification testing of the PHR. However, this process introduced some obstacles for the project team because having additional information, such as patient goals, in the system resulted in testing errors. The PHR architecture had to be completely redesigned and the technical requirements for integrating the patient goals component are still being developed.

Impact and Findings: 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.

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.