Improving the Management of Multiple Chronic Conditions with mPROVE (California)

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How You Feel Is Important: Making PROs Meaningful

SIGNIFICANCE AND POTENTIAL IMPACT

A tool to collect and share PROs in a primary care setting for a diverse patient population with multiple chronic conditions can potentially improve the patient-clinician relationship and improve patients’ quality of life.

Patient behaviors impact multiple chronic conditions

Originally developed for use in research, PROs collected via mobile health applications are increasingly being used by medical providers for patient care. However, PROs are often not used in real time by patients and clinicians, as information is not provided to clinicians in a meaningful way or integrated well into their workflow. Patients find recording their symptoms and sense of wellbeing to be labor intensive and of little perceived benefit, while clinicians have limited time during visits to discuss PROs in a meaningful way. This has resulted in PROs being difficult to incorporate into clinical practice. As the number of patients being treated in primary care settings for multiple chronic conditions with modifiable risk factors increases, a team of University of California at San Francisco (UCSF) researchers are thinking critically about how to integrate PROs into clinical practice in a way that will benefit the patient.

“In the Bay Area, thirty percent of the population is Asian. Technology that does not support character-based language is going to increase health disparities.”
- Dr. Sim

Using technology to capture PROs in real time

To address these issues, Dr. Ida Sim and her UCSF-based research team will develop, test, and evaluate Mobile Patient-Reported Outcomes for Value and Effectiveness (mPROVE). mPROVE will inform clinicians of a patient’s health experiences, such as pain or fatigue symptoms, between clinic visits to improve patient-centered, shared clinical decision making. Using a patient-facing iOS or Android smartphone app available in English, Spanish, and Chinese, PROs will be chosen by patients based on the symptoms most important to them. Providers will review and reflect on PRO data during clinic visits using a provider-facing dashboard.

Benefits for patients, benefits for clinicians

mPROVE will be integrated into UCSF’s clinical workflow at three internal medicine clinics. Its effectiveness will be examined in a primary care population of 120 internal medicine patients with multiple chronic conditions. By using Substitutable Medical Applications, Reusable Technologies on Fast Healthcare Interoperability Resources (SMART on FHIR®) technology, the tool may be used with any EHR, increasing its sustainability and potential for dissemination. Dr. Sim anticipates that collecting PROs in real time using a patient friendly format will result in increased self-efficacy for patients and better communication between patients and clinicians. Dr. Sim is confident mPROVE will enrich the patient-clinician relationship and help clinicians to understand what is important to patients, as well as how the patient feels between clinic visits. This will improve shared decision making and patients’ quality of life.

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A tool to collect and share PROs in a primary care setting for a diverse patient population with multiple chronic conditions can potentially improve the patient-clinician relationship and improve patients’ quality of life.

Summary:

As the US population ages, the number of patients with multiple chronic conditions (MCCs) treated in primary care settings is increasing. Defined as having two or more chronic conditions, patients with MCC account for 71 percent of all US healthcare costs. The personal behaviors of patients, such as poor nutrition, lack of exercise, and substance use, may cause and further influence these chronic conditions. The patient’s ability to manage these conditions and their personal behaviors is crucial to their care. However, management of these conditions is often complicated by complex medication regimes, unclear care goals, and differences in patient and provider expectations.

Recording patient-reported outcomes (PROs) in real time between visits, versus by patient recall during visits, allows patients to monitor and self-manage their health and capture a more comprehensive picture of their health status and overall health experience. Because of this increased understanding of the patient’s experience, PROs allow patients and providers to co-manage MCC and engage in meaningful shared clinical decision making. Despite the importance of this clinical information, PRO use in primary care is limited by challenges in PRO collection, patient engagement, and clinical workflow integration.

The Mobile Patient-Reported Outcomes for Value and Effectiveness (mPROVE) project aims to improve MCC outcomes by engaging a diverse population of patients in self-monitoring, offering PRO feedback, and improving patient self-management while informing providers of patients' health experiences and enabling patient-centered shared clinical decision making.

The specific aims of the research are as follows:

  1. Develop the mPROVE system in multiple languages for patient self-care and shared decision making. 
  2. Integrate mPROVE into the University of California San Francisco’s (UCSF) electronic health record (EHR) and into the clinical workflow of three internal medicine clinics. 
  3. Study the effectiveness of mPROVE in a multilingual primary care population of 120 internal medicine patients with MCC. 

The mPROVE project will demonstrate an original, replicable, accessible, and effective information technology and implementation strategy for bringing PROs to settings caring for diverse patients with MCC. Researchers will test patient-facing iOS and Android apps collecting information using traditional-format PRO surveys and novel visual PROs. A provider-facing dashboard will be developed and tested for provider actions and shared decision making. Once mPROVE is developed, tested, and integrated into UCSF’s EHR, workflows and policies for patient self-care and for shared decision making will be optimized. Finally, researchers will evaluate quality of care and implementation outcomes, and identify and address barriers and facilitators to implementation.