Using Health Information Technology to Improve Ambulatory Chronic Disease Care

Coordinating chronic disease care, which is often fragmented, requires new systems to manage information between providers and enhance communication with patients. In this project, the Family Medicine and General Internal Medicine practices at the University of Missouri–Columbia conducted a phased implementation of selected ambulatory care health information technology (IT) systems designed to improve chronic disease performance indicators and patient-provider communication. The project used a combination of formative and summative evaluation to study improvements in care and outcomes that resulted from the new system functionalities.

The specific aims of this project were to:

• Evaluate the change in patient care processes and outcomes following introduction of health IT-generated clinician quality performance reports across differences in practices and peers.
• Evaluate the effectiveness and changes associated with an interactive Web-based patient interface software system (IQ Health), including in-home medication reconciliation.
• Evaluate the use of in-home "smart" diagnostic devices (e.g., blood pressure cuffs, glucometers) connecting patients with their care teams.
• Disseminate information regarding the development and impact of the interventions through Web teleconferences, professional meetings, educational lectures, and peer-reviewed journals.

Each function of the system was evaluated separately to understand its impact. The new tools included diabetes performance reports and dashboard; a patient portal for secure communications; and home monitoring of blood glucose and blood pressure. The dashboard, which provided information on eight quality indicators, was evaluated with a usability study. The project team found that the dashboard improved efficiency and quality of diabetes care. Unexpectedly, 55 percent of physicians printed copies of the patient summary dashboards to give to patients as a patient handout.

The patient portal was evaluated with pre- and post-implementation surveys. Before implementation, 64 percent of physicians were concerned that the portal would increase their workload. However, post-implementation, only 13 percent felt that their workload had actually increased. Prior to implementation, 55 percent of physicians believed the quality of care would improve with use of the portal; post-implementation, only 33 percent believed that quality had actually improved.

For the in-home medication reconciliation portion of the project, issues were noted with the provider-entered medication lists maintained in the electronic medical record (EMR). Only some errors in these lists were noted by patients; when providers were informed of the errors by the patients, not all providers responded. The project team concluded that their findings support the need for better processes to ensure the accuracy of medication lists in EMRs.

A randomized trial with 108 patients was conducted to evaluate the effectiveness of remote data collection and patient transmission of blood glucose and blood pressure to the practices. The study showed no statistically significant differences between the intervention and control participants on either HbA1c or systolic blood pressure.

Practices that showed improvements in the second year of the project had several common characteristics: strong leadership, a culture of common purpose, and an information-sharing environment amongst clinicians and staff. The project team noted that these findings support the concept of “adaptive reserve,” or the capacity for change.