The Medication Metronome Project (Massachusetts)

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Summary:

A major goal of primary care is to reduce the morbidity and mortality associated with chronic diseases such as hypertension, type 2 diabetes, and hyperlipidemia. However, national and local data indicate that the United States health care system is falling significantly short of evidence-based goals for these three conditions. Lack of timely medication intensification and inadequate safety monitoring among patients taking prescription medications have been identified as two prevalent and potentially modifiable barriers to effective and safe chronic care.

The Medication Metronome Project tested a medication management system that enables specific clinical actions, such as the decision to initiate or adjust medications, independent of the office visit. Additionally, the Medication Metronome system enables providers to schedule future laboratory tests related to a specific set of medications for glycemic, cholesterol, and blood pressure management. As these lab test dates become due, the Medication Metronome system reminds patients via letter and informs providers if a test is not performed.

The specific aims of this project were as follows:

  • Develop the Medication Metronome system. 
  • Conduct a randomized controlled trial of the Medication Metronome system. 
  • Evaluate the impact of the Medication Metronome visit-independent care model on both the frequency and content of office-based visits. 

The Medication Metronome was evaluated with a randomized trial at the provider level. Patients whose physicians were allocated to the intervention had earlier low-density lipoprotein (LDL) laboratory assessment compared to patients of control physicians. Among patients with elevated baseline LDL, there was a slight decrease in time to achieving the LDL goal for the intervention group; however, the finding was not statistically significant. There were no significant differences between study arms in time spent at the LDL or Hemoglobin A1c goals. Medication safety monitoring was infrequently performed and not statistically different between study arms.

The project team concluded that systems like Medication Metronome, that support clinical care outside of the traditional in-person visit, will have greater adoption and clinical impact as primary health care evolves.

The Medication Metronome Project - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018648
  • Project Period: 
    September 2010 – July 2014
  • AHRQ Funding Amount: 
    $1,151,376
  • PDF Version: 
    (PDF, 265.43 KB)

Summary: One goal of primary care is to reduce the morbidity and mortality of chronic diseases such as hypertension, type 2 diabetes, and hyperlipidemia. However, national and local data indicate that the United States health care system is falling significantly short of evidence-based goals for these three conditions, both in terms of risk-factor control and in monitoring adverse drug events. Novel uses of health information technology (IT) are needed to support more effective medication management for chronic diseases in the primary care setting.

The Medication Metronome Project is testing a model of chronic disease medication management in which specific clinical actions, such as the decision to initiate or adjust medications, are performed independently of the office visit. The study conducted a randomized controlled trial using an existing electronic health record (EHR) at Massachusetts General Hospital (MGH) to evaluate the value of an IT system that supports between-visit medication safety monitoring and dose adjustment. This “Medication Metronome” is designed to enable providers to schedule future laboratory tests related to a specific set of medications for glycemic, cholesterol, and blood pressure management. As these lab test dates become due, the Medication Metronome system reminds patients via letter and informs providers when the tests are “missing.”

The goal of this intervention is to implement an efficient, visit-independent system to ensure that patients are rapidly and safely brought to evidence-based treatment goals and to prevent delays in planned laboratory monitoring. This will be achieved through an iterative process of medication adjustments so that risk- factor control is not entirely dependent upon face-to-face office visits. The broader goal is to foster greater patient-physician connectedness by combining independent medication management with more productive visit-based care. This research is relevant to nationwide efforts to demonstrate the most effective ways to implement new IT-based delivery models that expand care beyond the traditional clinic visit.

Specific Aims:

  • Develop the Medication Metronome system. (Achieved)
  • Conduct a randomized controlled trial of the Medication Metronome system. (Ongoing)
  • Evaluate the impact of the Medication Metronome visit-independent care model on both the frequency and content of office-based visits. (Upcoming)

2012 Activities: The project team focused on the final testing of the Medication Metronome health IT system and launching the randomized controlled trial. A key requirement prior to initiating the system was the implementation of computerized lab order entry into participating practices. The lab order entry module was finalized in March 2012 and onsite training sessions were conducted for staff at the study sites. The randomization of 44 primary care providers (PCPs) who consented to participate in the trial occurred in April 2012. Provider randomization was stratified by practice, panel size, and years since graduation. This resulted in 22 PCPs in each study arm. Following testing of the lab module, the Medication Metronome interface was re-tested and finalized and released to intervention group providers in May 2012.

Patient enrollment for audiotaped baseline interviews was completed in June 2012 with 49 patients from the participating practices. Baseline clinical encounters between study physicians and their patients were recorded in order to conduct content and frequency analyses. These baseline visits will be compared to followup visits approximately 1 year later. The transcription of the baseline recordings was completed in October 2012. The study team obtained patient scheduling data from the online patient scheduling system and is contacting enrolled patients to confirm visit dates for audiotaping of the followup encounters.

As last self-reported in the AHRQ Research Reporting System, the progress and activities are completely on track and project budget funds are moderately underspent. Initial underspending was related to the 10-month budget in the first year of the project and the short time frame from notification of grant award and time associated with billing for personnel costs for work performed. One major change made in the second year of the budget that has helped to decrease some of the underspending was increasing Dr. Atlas’s level of effort to 20 percent full-time equivalent as he assumed the role of principal investigator (PI) after the previous PI took another position.

Preliminary Impact and Findings: The project has no findings to date.

Target Population: Chronic Care*, Diabetes, Hypertension

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

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

The Medication Metronome Project - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018648
  • Project Period: 
    September 2010 - July 2013
  • AHRQ Funding Amount: 
    $1,151,054
  • PDF Version: 
    (PDF, 194.83 KB)

Summary: One goal of primary care is to reduce the morbidity and mortality of chronic diseases such as hypertension, type 2 diabetes, and hyperlipidemia. However, national and local data indicate that the United States health care system is falling significantly short of evidence-based goals for these three conditions, both in terms of risk-factor control and in monitoring adverse drug events. Novel uses of health information technology (IT) are needed to support more effective medication management for chronic diseases in the primary care setting.

The Medication Metronome Project is testing a model of chronic disease medication management in which specific clinical actions, such as the decision to initiate or adjust medications, are performed independently of the office visit. The study is implementing a randomized controlled trial using an existing electronic health record (EHR) at Massachusetts General Hospital (MGH) to evaluate the value of an IT system that supports between-visit medication safety monitoring and dose adjustment. This "Medication Metronome" is designed to enable providers to schedule future laboratory tests related to a specific set of medications for glycemic, cholesterol, and blood pressure management. As these lab test dates become due, the Medication Metronome system reminds patients via letter and informs providers when the tests are "missing."

The goal of this intervention is to implement an efficient, visit-independent system to ensure that patients are rapidly and safely brought to evidence-based treatment goals and to prevent delays in planned laboratory monitoring. This will be achieved through an iterative process of medication adjustments so that risk-factor control is not entirely dependent upon face-to-face office visits. The broader goal is to foster greater patient-physician connectedness by combining independent medication management with more productive visit-based care. This research is relevant to nationwide efforts to demonstrate the most effective ways to implement new IT-based delivery models that expand care beyond the traditional clinic visit.

Specific Aims:

  • Develop the Medication Metronome system. (Ongoing)
  • Conduct a randomized controlled trial of the Medication Metronome system. (Upcoming)
  • Evaluate the impact of the Medication Metronome visit-independent care model on both the frequency and content of office-based visits. (Upcoming)

2011 Activities: The focus of activity was on the development of the Medication Metronome health IT system. This has involved both health IT development and qualitative evaluation of design prototypes to create a system that supports timely medication intensification, improves safety, and meets both patient and provider needs. In April and May 2011, iterations of the system architecture with mock-ups of the user interface were presented to the project's primary care external advisory board, a group of practice providers representing all 12 primary care practices within MGH's primary care Practice Based Research Network. An all-investigator research meeting was also convened in June to review feedback from clinicians.

Since then, a medication prescription user interface has been developed to ensure compatibility among Metronome-identified clinics. A key requirement for implementation of the Medication Metronome system is the implementation of computerized laboratory order entry into these practices. The project team has been working on the interface to ensure that electronically generated laboratory slips match the MGH blood laboratory knowledge base. Development of the orders module was completed at the end of 2011, with final testing and planned release in early 2012.

As last self-reported in the AHRQ Research Reporting System, the progress and activities are completely on track and project budget funds were moderately underspent. Initial underspending was related to the 10-month budget in the first year of the project and the short time frame from notification of grant award and time associated with billing for personnel costs for work performed. Spending is anticipated to increase in upcoming quarters as several project activities commence. The project team anticipates that all approved funds will be spent upon successful completion of the project.

Preliminary Impact and Findings: The project has no findings to date. However, feedback from the clinician training sessions resulted in the addition of the "Do Now" function, a key design update. This function allows a patient who is in the doctor's office for another reason, on a day close to the original laboratory due date, to change the due date to the current day to have their blood drawn "early" and more conveniently. Clinicians believe this feature has potential to increase blood-draw compliance.

Target Population: Chronic Care*, Diabetes, Hypertension

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

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

The Medication Metronome Project - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 018648
  • Project Period: 
    September 2010 – July 2013
  • AHRQ Funding Amount: 
    $383,049
  • PDF Version: 
    (PDF, 333.9 KB)


Target Population: Chronic Care*, Diabetes, Hypertension

Summary: One goal of primary care is to reduce the morbidity and mortality of chronic diseases such as hypertension, type 2 diabetes, and hyperlipidemia. However, national and local data indicate that the U.S. health care system is falling significantly short of evidence-based goals for these three conditions, both in terms of risk-factor control and in monitoring adverse drug events. Novel uses of health information technology (IT) are needed to support more effective medication management for chronic diseases in the primary care setting.

The Medication Metronome Project is testing a model of chronic disease medication management in which specific clinical actions, such as the decision to initiate or adjust medications, are performed independently of the office visit. The study will implement a randomized controlled trial using an existing electronic health record (EHR) at Massachusetts General Hospital (MGH) to evaluate the value of an IT system that supports between-visit medication safety monitoring and dose adjustment. This “Medication Metronome” will be designed to enable providers to schedule future laboratory tests related to a specific set of medications for glycemic, cholesterol, and blood pressure management. As these lab test dates become due, the Medication Metronome system will remind patients via letter and inform providers when the tests are “missing.” The goal of this intervention is to implement an efficient, visit-independent system to ensure that patients are rapidly and safely brought to evidence-based treatment goals and to prevent delays in planned laboratory monitoring.

The goal of the intervention is to facilitate an iterative process of medication adjustments so that risk-factor control is not dependent upon face-to-face office visits. The broader goal is to foster greater patient-physician connectedness by combining independent medication management with more productive visit-based care. This research is relevant to nationwide efforts to demonstrate the most effective ways to implement new IT-based delivery models that expand care beyond the traditional clinic visit.

Specific Aims:
  • Develop the Medication Metronome system. (Ongoing)
  • Conduct a randomized controlled trial of the Medication Metronome system. (Upcoming)
  • Evaluate the impact of the Medication Metronome visit-independent care model on both the frequency and content of office-based visits. (Upcoming)

2010 Activities: The project began in September 2010. The primary focus of activity during the first quarter of the project was on administrative and personnel activities. The project team was assembled and includes health IT developers within the MGH Laboratory of Computer Science (LCS), directed by Dr. Henry Chueh, Co-Investigator and LCS Director. A kick-off meeting attended by the entire project team was conducted in November 2010 to discuss an overview of the project. A monthly newsletter, sent via e-mail, has also been initiated as a mechanism to chart progress and keep all members informed.

The health IT development process began with the presentation of the conceptual framework to the primary care external advisory board on November 19, 2010. This board represents all 12 primary care practices within the Practice-Based Research Network, which is a group of ambulatory practices devoted principally to the primary care of patients. Feedback from this meeting informed use cases, default settings, and user-interface development. In addition, the project team conducted three one-on-one meetings with clinicians to establish workflow for using the Medication Metronome interface and to identify additional use cases. The iterative process of sharing information between developers and users will continue until a final product is created.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The project is completely on track to meet its aims and milestones. The project is currently under budget but expenses are expected to increase as system development continues and testing begins.

Preliminary Impact and Findings: There are no project findings at this time.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

*AHRQ Priority Population.

The Medication Metronome Project - Final Report

Citation:
Atlas S. The Medication Metronome Project - Final Report. (Prepared by Massachusetts General Hospital under Grant No. R18 HS018648). Rockville, MD: Agency for Healthcare Research and Quality, 2014. (PDF, 850.24 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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