Patient-Centered Informatics System to Enhance Health Care in Rural Communities (Utah)

Project Final Report (PDF, 408.37 KB) Disclaimer

Summary:

This demonstration project was conducted to evaluate whether the Unified Health Resource (UHR) led to more patient-centered care in rural communities in the Intermountain West. The UHR combines a personal health record, an electronic medical record (EMR), and a communication system to promote shared-decisionmaking, patient activation, and health management. It provides patients with enhanced control of their own health data, increased options for solving personal health issues, and improved access and continuity of clinical care. This health information technology supports a new model of interaction between clinicians and patients, aiming to increase the patient-centeredness of care.

The aims of the project were to:

  • Recruit two rural primary care clinics that use UHR and two primary care clinics that us an alternative, non-UHR EMR system to participate in a 3-year research demonstration project. 
  • Apply formative evaluation methods to assess and improve usability, usefulness, and adoption of the UHR personal health system by patients. 
  • Enroll patients from the four participating rural clinics into a prospective cohort study to assess the impact of the UHR personal health system on patient-centered care. 
  • Examine patterns of use of the UHR personal health system. 
  • Increase awareness, confidence, and skills to use PHRs and Internet health resources among rural community residents, leveraging local libraries and health departments.

Primary care clinics in five rural communities were recruited to participate in the study. Three clinics used the UHR and two used an alternative EMR. Efforts to promote use of the UHR were systematically implemented. Evaluation methods included usability testing, measurement of adoption, and analysis of patterns of use. 

User feedback led to significant improvements in the design of the UHR. Distribution of physician letters to patients was an effective method of recruiting UHR users. Almost half of the individuals who used the UHR once used it again, sometimes frequently.  An analysis of UHR sessions indicated that medication refill, reconciliation functions, drug safety, and adverse event components were the most frequently accessed and most favorably reviewed. Communication functions and medication management tasks were associated with more intensive use of the UHR.

Patient-Centered Informatics System to Enhance Health Care in Rural Communities - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017308
  • Project Period: 
    September 2007 - September 2011
  • AHRQ Funding Amount: 
    $1,199,999
  • PDF Version: 
    (PDF, 201.32 KB)

Summary: This was a demonstration project to evaluate whether integrating the functions of an electronic medical record (EMR), personal health record (PHR), and a communication system leads to more patientcentered care in rural communities in Utah. This system, the Unified Health Resource (UHR), provided disease information and decision-support tools for patient self-management of acute and chronic diseases, supported the reconciliation of medication lists, and enabled exchange of information between clinicians and patients through a series of structured, bidirectional communication channels.

The EMR and PHR function independently from each other. The UHR software developer, CaduRx, designed an interface that allows each side to view and import changes to reflect updates made by the other. Patients were able view items such as physician notes, diagnoses, and diagnostic test results in their PHR. Physicians, granted access by their patients, were able to view and import the patient's information, including new prescriptions, symptoms, or diseases from the PHR to the EMR. In addition, there were several types of structured e-visits that patients could use to communicate with clinics and clinicians. Patients could request medication refills online as well as input results of home monitoring tests, such as blood sugar levels and blood pressure measurements, into their PHR. Through extensive usability testing, the project team ensured that the vocabulary used in the PHR was understood by patients, clinically significant to providers, linkable to International Classification of Diseases and clinical modification codes, and able to be coded for clinics' record keeping and billing purposes.

To assess the effect of the UHR on patient-centered care, the team conducted a prospective cohort study among adult patients at one of the clinics that use the UHR. Of the patients recruited, 25 percent did not have a chronic disease diagnosis and 75 percent had one or more of the following chronic illnesses: diabetes mellitus, hypertension, chronic heart disease, and chronic obstructive pulmonary disease. Measures of patient activation, involvement in decision-making, self-management behaviors, medication management, and preventive practices were taken at baseline and follow-up. The team analyzed data abstracted from the UHR and conducted a manual review of the patients' medical records to compare the provider assessment of patient disease management to the patient's self report. A formative evaluation of the UHR assessed and improved usability, usefulness, and adoption.

Specific Aims:

  • Recruit two rural primary care clinics that use UHR and two primary care clinics that use an alternative, non-UHR EMR system to participate in a 3-year research demonstration project. (Achieved)
  • Apply formative evaluation methods to assess and improve usability, usefulness, and adoption of the UHR personal health system by patients. (Achieved)
  • Enroll patients from the four participating rural clinics into a prospective cohort study to assess the impact of the UHR personal health system on patient-centered care. (Achieved)
  • Examine patterns of use of the UHR personal health system. (Achieved)
  • Increase awareness, confidence, and skills to use PHRs and Internet health resources among rural community residents, leveraging local libraries and health departments. (Achieved)

2011 Activities: The focus in 2011 was on data cleaning, analysis, and dissemination. The following analyses were conducted: 1) measurement and validation of patient activation; 2) a qualitative assessment of patients' perceptions of and experiences with the UHR; 3) usage patterns of the UHR; and 4) development of models to understand the relationship between patient characteristics and patient involvement in health care decisionmaking.

Due to additional time required for study recruitment, a 1-year no cost-extension was used, allowing the research team to complete outcome evaluation and disseminate project results. As last self-reported in the AHRQ Research Reporting System, project progress was mostly on track and project budget spending was on target. The project was completed in September 2011.

Preliminary Impact and Findings: A total of 811 participants, 62 percent female, 64 percent over the age of 45, and 7 percent non-white, participated in a survey of patient activation. Participants indicated a high level of satisfaction with their care and positive relationships with their physician. On the patient activation measures, 96 percent of respondents indicate that they are responsible for managing their own health; 98 percent take an active role in their most important health factors; and 93 percent take actions to minimize or prevent symptoms.

An analysis of patient usage and UHR perceptions identified the components of the system that were ranked most favorably and may have ultimately driven patient adoption of the system. An analysis of 6,700 UHR sessions indicated that medication refill, reconciliation functions, drug safety, and adverse event components were the most frequently accessed and most favorably reviewed. The mean number of actions per session was 15 (range 1-679). For short sessions, defined as 10 actions or less, the primary task was scheduling appointments and reviewing visit notes. For long sessions, defined as more than 20 actions, the predominant actions were completion of health history items, searching for information about medications, medication reconciliation, and health maintenance activities.

In terms of UHR adoption, the research team determined that clinical staff engagement and clinic fitto- workflow were critical. Clinic staff, including providers, needed to understand the UHR's utility as well as its potential to increase office efficiency and improve patient outcomes. In order for clinic staff to promote the UHR to patients, it was necessary for the staff to recognize the relative advantages of patient use of the UHR for the clinic. As for patient adoption, the team discovered that patients were very interested in the idea of a PHR linked to their health care provider and clinic records. The challenge was making patients aware of how the tool was integrated with the clinic and how to use it correctly.

Target Population: Adults, Chronic Care*, Chronic Obstructive Pulmonary Disease, Diabetes, Heart Disease, Hypertension, Rural Health*

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 helath information to improve quality of care. 

Business Goal: Implementation and Use

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

Patient-Centered Informatics System to Enhance Health Care in Rural Communities - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017308
  • Project Period: 
    September 2007 – September 2011, Including No Cost Extension
  • AHRQ Funding Amount: 
    $1,199,999
  • PDF Version: 
    (PDF, 307.26 KB)


Target Population: Adults, Chronic Care*, Chronic Obstructive Pulmonary Disease, Diabetes, Heart Disease, Hypertension, Rural Health*

Summary: This is a demonstration project to evaluate whether integrating the functions of an electronic medical record (EMR), personal health record (PHR), and communication system leads to more patient-centered care in rural communities in Utah. This system, the Unified Health Resource (UHR), provides disease information and decision support tools for patient self-management of acute and chronic diseases; supports the reconciliation of medication lists; and enables exchange of information between clinicians and patients through a series of structured, bidirectional communication channels.

The EMR and PHR function independently of each other. The UHR software developer, CaduRx, designed an interface that allows each side to view and import changes to reflect the updates made by the other party. Patients may view items such as physician notes, diagnoses, and diagnostic test results in their PHR. Physicians, who are granted access by the patient, are able to view and import the patient’s information from the PHR into their EMR which may include new prescriptions, symptoms, or diseases. In addition, there are several types of structured e-visits patients can use to communicate with clinics and clinicians. Patients may request medication refills online as well as input results of home monitoring tests into their PHR, such as blood sugar levels and blood pressure measurements. Through extensive usability testing, the project team has ensured that the vocabulary used in the PHR is understandable to the patients, clinically significant to the providers, linkable to International Classification of Diseases, Clinical Modification codes, and able to be coded for clinics’ record keeping and billing purposes.

To assess the effect of the UHR on patient-centered care, the team is conducting a prospective cohort study among adult patients at one of the clinics that use the UHR. Participants were recruited so 25 percent do not have a chronic disease diagnosis and 75 percent have one or more of the following chronic illnesses: diabetes mellitus, hypertension, chronic heart disease, or chronic obstructive pulmonary disease. Measures of patient activation, involvement in decisionmaking, self-management behaviors, medication management, and preventive practices are obtained at baseline and during followup. The team will also analyze data abstracted from the UHR, and conduct a manual review of the patients’ medical records to compare the provider assessment of patient disease management to the patient’s self report. A formative evaluation of the UHR is being conducted to assess and improve usability, usefulness, and adoption.

Specific Aims:
  • Recruit two rural primary care clinics that use UHR and two primary care clinics that use an alternative, non-UHR EMR system to participate in a 3-year research demonstration project. (Achieved)
  • Apply formative evaluation methods to assess and improve usability, usefulness, and adoption of the UHR personal health system by patients. (Ongoing)
  • Enroll patients from the four participating rural clinics into a prospective cohort study to assess the impact of the UHR personal health system on patient-centered care. (Achieved)
  • Examine patterns of use of the UHR personal health system. (Ongoing)
  • Increase awareness, confidence, and skills to use PHRs and Internet health resources among rural community residents, leveraging local libraries and health departments.(Achieved)

2010 Activities: The team continues to evaluate the level of adoption of the UHR in the study clinics in order to identify and respond to the needs of each clinic. This includes monthly clinic visits as well as training to support integration of the EMR into clinic workflow. The project team also helps clinic staff understand the benefits of the PHR, which has been challenging because this technology is a relatively new concept for them. These efforts to promote integration and educate providers will put the clinics in a better position to promote the UHR among their patients and increase the satisfaction and adoption among those patients who use the UHR. The team also continues to promote patient engagement with the UHR by emailing patients about features of the system and encouraging providers to discuss the system with patients as well as placing materials in the clinics to remind patients of the tool and its features.

The data collection phase of the study is complete. A two-part patient survey was administered to users of the UHR to determine experiences with the system as well as communication with their provider. A survey for minimal and nonusers was developed and administered. Thirty completed surveys were collected from each of the clinics using the UHR. The team continues to work on determining what constitutes an effective or ideal pattern of use for the PHR and EMR, as well as an inefficient pattern of use. This determination will be helpful in identifying factors that lead to adoption of the tool. Along these lines, the research team is working with the Consumer Assessment of Healthcare Providers and System Program to develop benchmark data and assess their data against national standards.

The team planned a community-wide outreach, including health education classes, involving local health departments and public libraries, on using the PHR. The local departments of health and public libraries were less receptive than anticipated; therefore, the project team focused efforts on patient outreach within the participating clinics. Patient education included information about their health and medical conditions.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Progress is mostly on track and project spending is on target. The research team continues to evaluate the level of adoption of the UHR in the study clinics and to encourage patient engagement in the system.

Preliminary Impact and Findings: An analysis of patient usage and rating of UHR components seeks to identify the components of the system that were ranked most favorably and may have ultimately driven patient adoption of the system. Preliminary analysis indicates that the medication refill, reconciliation functions, the drug safety, and adverse event components were the most frequently accessed and most favorably reviewed. The e-visit component of the system, however, was not favorably reviewed. Through recruitment of patients from the participating clinics for the usability testing, the team has discovered, anecdotally, that patients are very interested in the idea of a PHR linked with their health care provider and to their clinic records. The challenge is to make sure patients are aware of how the tool is integrated with the clinic and understand how to use it successfully. Clinic staff, including providers, need to be well informed about the UHR and understand its utility and potential to produce increased office efficiency and improved patient outcomes.

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: Implementation and Use

*AHRQ Priority Population.

Patient-Centered Informatics System to Enhance Health Care in Rural Communities - Final Report

Citation:
Samore M. Patient-Centered Informatics System to Enhance Health Care in Rural Communities - Final Report. (Prepared by the University of Utah under Grant No. R18 HS017308). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 408.37 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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