Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions between Care Settings (Virginia)

Project Final Report (PDF, 804.8 KB)

Project Details - Ended

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Summary:

Personal health records (PHRs) integrated with electronic medical records (EMRs) have the potential to promote patient-centered care and ultimately improve health outcomes. The interactive PHR (IPHR) gives patients direct access to information in their clinician’s electronic health record (EHR), displays tailored recommendations, provides links to online educational resources, delivers individualized self-management resources, and generates patient and clinician reminders.

In order to identify and assess the best methods of implementing an advanced, patient-centered IPHR, this project assisted and observed as six practices implemented an IPHR called MyPreventiveCare. The practices ranged in geographic locations, including rural, suburban, and urban, and varied in size from two-to-10 providers. Practices were assisted via a series of seven learning collaboratives conducted at each site; three before and four after the IPHR was implemented. These collaboratives were audio-recorded and transcribed for qualitative analysis and further study.

The main objectives of the project were to:

  • Determine whether the study sites can begin implementing the IPHR.
  • Measure the utilization and effectiveness of the IPHR.
  • Determine the necessary steps and procedures that practices need to follow or avoid in order to implement the IPHR successfully.

The project team measured the IPHR’s utilization as the proportion of practice patients who established an IPHR account; and measured its effectiveness as the proportion of patients who were up-to-date with preventive services before versus after implementing the IPHR for users and non-users. Qualitative and quantitative findings were linked in order to understand each practice’s implementation process and the impact on utilization and effectiveness.

All six practices successfully implemented the IPHR, with varying rates of utilization ranging from 0.8 percent over 9 months in one practice, to 22.2 percent over 15 months in another practice. Users versus non-users of the IPHR had a statistically greater amount of colon and cervical cancer screenings, cholesterol screening, and tetanus vaccinations 4 months following an office visit. Practices that had greater proportions of patients using the IPHR had greater percentage increases in patients who were current with preventive services. 

Factors associated with increased patient use of the IPHR included multiple staff members engaging patients about the IPHR during a visit; nurses, rather than physicians, primarily engaging patients; practice leadership buy-in; and a clear understanding of the IPHR’s functionality among staff. Confusion and competing demands from fielding multiple patient portals significantly limited practices’ ability to induce patients to use the IPHR.

At the completion of the project, the team produced a how-to guide, the Handbook for Using Patient-Centered Personal Health Records To Promote Prevention (PDF, 804 KB), to assist other practices implement an IPHR. The team was awarded a grant from the National Cancer Institute to implement MyPreventiveCare in 300 practices in 13 states, and thus will continue their work and research in this area.

Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions Between Care Settings - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    Primary Care Practice-Based Research Network (PBRN)
  • Contract Number: 
    290-07-10011-3
  • Project Period: 
    September 2009 - March 2012
  • AHRQ Funding Amount: 
    $499,982
  • PDF Version: 
    (PDF, 160.89 KB)

Summary: There is a major discrepancy between the American public’s perceived value of personal health records (PHRs) and the actual use of PHRs. This less-than-optimal use of health information technology (IT) occurs at a time when the Nation is looking at health IT as an essential tool to reform health care, improve quality of care, coordinate care delivery, and reduce costs. For small- to medium-sized primary care practices implementing health IT, financial and technical resource limitations often require the adaptation of technology that is already available.

This project assessed methods of creating PHRs from existing electronic medical record (EMR) systems at small- to medium-sized primary care practices. For this project, a PHR is defined as a nonproprietary, prevention-focused patient record. When integrated with a clinician’s EMR, it is termed an “interactive preventive health care record” (IPHR). This IPHR, called MyPreventiveCare, incorporated clinical decision support software, a reminder system, tailored educational materials, and decision aids into one package for patients and clinicians. A previous AHRQ-funded study showed IPHRs to enhance clinician-patient communication and increase the delivery of recommended preventive services by 3-to-12 percent. The current study built on those findings to evaluate whether the IPHR can be applied in health care settings that use different EMRs.

The study was conducted in six practices that cover a range of service areas (rural, suburban, and urban), and sizes (from 2-to-10 clinicians). Through a series of learning collaboratives, study staff guided practices to create a shared vision for IPHR implementation. Separate learning collaboratives were conducted at each practice before and after IPHR implementation. The study team worked toward eight components to help engage practices and create change: 1) securing leadership buy-in and support; 2) creating a culture that is conducive to change; 3) establishing a sense of priority; 4) forming a guiding coalition; 5) developing and communicating a shared vision; 6) empowering members to act on the vision; 7) planning for short-term wins; and 8) consolidating and institutionalizing improvements.

Project Objectives:

  • Determine whether the study sites can begin implementing the IPHR. (Achieved)
  • Measure the utilization and effectiveness of the IPHR. (Achieved)
  • Determine the necessary steps and procedures that practices need to follow or avoid in order to implement the IPHR successfully. (Achieved)

2012 Activities: The study team analyzed collaborative transcripts and finished cleaning EMR data to evaluate delivery of preventive services pre- and post- MyPreventiveCare implementation. Qualitative themes were linked to quantitative findings to better understand the project impact. During the year, a Handbook for Using Patient-Centered Personal Health Records To Promote Prevention (PDF, 804 KB) was developed and posted on the AHRQ Health IT Web Site. The team presented study findings at the 2012 American College of Preventive Medicine’s Annual Prevention Conference. Based on this work, Dr. Krist received a grant from the National Cancer Institute to field MyPreventiveCare to 300 practices in 13 States.

The project was completed in 2012.

Impact and Findings: Within 6 months, an average of 14.4 percent (ranging from 1.5 to 28.3 percent) of practice patients used the IPHR. All six practices were able to overcome technical and cultural barriers to adopt the IPHR and begin offering it to patients. By the end of the study period all six practices had varying rates of utilization ranging from 0.8 percent over 9 months in one practice to 22.2 percent over 15 months in another. Statistically and clinically greater increases were observed in colon and cervical cancer screening, cholesterol screening, and tetanus vaccinations for IPHR users compared to non-users 4 months after an office visit. Factors associated with increased patient use of the IPHR included multiple staff members engaging patients with the IPHR during a visit; nurses rather than clinicians primarily engaging patients; practice leadership buy-in; and a clear understanding of the IPHR’s functionality among staff. Confusion and competing demands from fielding multiple patient portals significantly limited practices’ ability to induce patients to use the IPHR. Practices that had greater proportions of patients using the IPHR had greater percentage increases in patients with up-to-date preventive services.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions, and the electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions between Care Settings - 2011

Summary Highlights

Summary: There is a major discrepancy between the American public's perceived value of personal health records (PHRs) and the actual use of PHRs. This less-than-optimal use of health information technology (IT) occurs at a time when the Nation is looking at health IT as an essential tool to reform health care, improve quality of care, coordinate care delivery, and reduce costs. For small- to medium-sized primary care practices implementing health IT, financial and technical resource limitations often require the adaptation of technology that is already available.

This project is assessing methods of creating PHRs from existing electronic medical record (EMR) systems at small- to medium-sized primary care practices. For this project, a PHR is defined as a nonproprietary, prevention-focused patient record. When integrated with a clinician's EMR, it is termed an "interactive preventive health care record" (IPHR). The IPHR called MyPreventiveCare incorporates clinical decision support software, a reminder system, tailored educational materials, and decision aids into one package for patients and clinicians. A previous study showed IPHRs to enhance clinician-patient communication and increase the delivery of recommended preventive services by 3-to-12 percent. The current study builds on those findings to evaluate whether the IPHR can be applied in health care settings that use different EMRs.

The study is being conducted in six practices that use Epic or A4 EMRs and cover a range of service areas (rural, suburban, and urban), and sizes (from two-to-10 clinicians). Through a series of learning collaboratives, study staff are guiding practices to create a shared vision for IPHR implementation. Separate learning collaboratives are being conducted at each practice before and after IPHR implementation. The study team is working toward eight components to help engage practices and create change: 1) securing leadership buy-in and support; 2) creating a culture that is conducive to change; 3) establishing a sense of priority; 4) forming a guiding coalition; 5) developing and communicating a shared vision; 6) empowering members to act on the vision; 7) planning for short-term wins; and 8) consolidating and institutionalizing improvements.

Project Objectives:

  • Determine whether the study sites can begin implementing the IPHR. (Ongoing)
  • Measure the utilization and effectiveness of the IPHR. (Ongoing)
  • Determine the necessary steps and procedures that practices need to follow or avoid in order to implement the IPHR successfully. (Ongoing)

2011 Activities: All core programming tasks, including the addition of laboratory functionality, were completed. The seventh learning collaborative was completed. MyPreventiveCare continues to be utilized by the six study sites and all wish to do so indefinitely. The research team completed the formal observation of all study sites. The contract was extended due to delays in site implementation to provide additional time to obtain post-implementation EMR datasets from all of the study sites. This was a substantial data query that included information about all patients in the past 2 years at the six study sites. The process of cleaning the data for formal analysis was initiated.

All of the collaboratives' audio recordings were transcribed and site observation field notes were compiled for every site. Transcripts were coded for the qualitative analysis. The research team completed a draft implementation guide.

Extensive dissemination activities, including presentations to the Virginia Commonwealth University Health IT Committee, the Agency for Healthcare Research and Quality Practice Based Research Network Annual Conference, Centers for Disease Control and Prevention's public forum discussion on Development of a Health Risk Assessment Guidance, and National Institute of Health and the Society of Behavioral Medicine. Additional manuscripts are being developed and published.

Preliminary Impact and Findings: All six practices were able to adopt the IPHR and begin offering it to patients. The six practices had varying rates of IPHR utilization. One site had 22.2 percent of patients using the IPHR over a 15-month implementation period, while another had only 0.8 percent of patients using the IPHR over a 9-month implementation period. The project observed statistically and clinically greater increases in colon and cervical cancer and cholesterol screenings and tetanus vaccinations for IPHR-users compared to non-users 4-months after an office visit. Factors associated with increased patient use of the IPHR included multiple staff members talking to patients about the IPHR during a visit; nurses rather than clinicians primarily engaging patients; local leadership buy-in; and a clear understanding of the IPHR's functionality among staff. Confusion and competing demands from fielding multiple patient portals significantly limited practices' ability to get patients to use the IPHR.

Target Population: Adults

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

Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions between Care Settings - 2010

Summary Highlights



Target Population: Adults

Summary: There is a major discrepancy between the American public’s perceived value of personal health records (PHRs) and the actual use of PHRs. Only 2.7 percent of Americans have an electronic PHR even as 79 percent report that they believe an online PHR would “provide major benefits to managing their health.” Similarly, there are low rates of electronic medical record (EMR) use among clinicians. Only 17-to-24 percent of outpatient clinicians have an EMR, a mere four percent of which are considered fully functional. This low use of health information technology (IT) occurs at a time when the Nation is looking at health IT as an essential tool to reform health care, improve quality of care, coordinate care delivery, and reduce costs. For small- to medium-sized primary care practices implementing health IT, financial and technical resource limitations often require the adaptation of technology that is already available.

This project will assess methods of creating PHRs from existing EMR systems at small- to medium-sized primary care practices. For this project, a PHR is defined as a nonproprietary, prevention-focused record. When integrated with a clinician’s EMR, it is termed an “interactive preventive health care record” (IPHR). The IPHR called MyPreventiveCare incorporates clinical decision support software, a reminder system, tailored educational materials, and decision aids into one package for patients and clinicians. A previous study showed IPHRs to enhance clinician-patient communication and increase the delivery of recommended preventive services by 3-to-12 percent. The proposed study builds on those findings to evaluate whether the IPHR can be applied in health care settings that use different EMRs.

The study is being conducted in six practices that use Certification Commission for Health Information Technology-certified products (Epic EMR or A4 EMR), and cover a range of service areas (rural, suburban, and urban), and size (from two to 10 clinicians). Through a series of learning collaboratives, study staff will guide practices in creating a shared vision for IPHR implementation. Separate learning collaboratives will be conducted at each practice before and after IPHR implementation. In order to engage practices and create change, the study team will work toward eight components: 1) securing leadership buy-in and support; 2) creating a culture that is conducive to change; 3) establishing a sense of priority; 4) forming a guiding coalition; 5) developing and communicating a shared vision; 6) empowering members to act on the vision; 7) planning for short-term wins; and 8) consolidating and institutionalizing improvements.

Project Objectives:
  • Determine whether the study sites can begin implementing the IPHR. (Ongoing)
  • Measure the utilization and effectiveness of the IPHR. (Ongoing)
  • Determine the necessary steps and procedures that practices need to follow or avoid in order to implement the IPHR successfully. (Ongoing)

2010 Activities: The study team continued working with six study sites. MyPreventiveCare was integrated into the EMR of two sites in October 2010. These sites had all staff and providers establish MyPreventiveCare accounts for themselves and for test patients, and providers began offering MyPreventiveCare to all patients. Sites used a variety of advertising and outreach methods to encourage patient participation in MyPreventiveCare including business cards, brochures, wall posters, information on receipts, phone hold messages, Web postings, and direct encouragement from staff and providers.

The other three sites remain interested in fielding the system but were waiting to have MyPreventiveCare integrated into their EMR. As part of the programming process, the study team learned that they needed to integrate MyPreventiveCare directly into the EMR database rather than utilize the EMR’s Web services, which were incomplete. Although this uses similar patient data, the health system's compliance office wanted to reassess the privacy and confidentiality risks associated with this revised integration. Once the health system approves this process, the project will be able to complete integration and the study sites will be able to offer MyPreventiveCare to their patients.

Project staff is preparing to collect the seven months of baseline preventive care delivery data from the study sites in order to calculate preimplementation data. This information will be used to: 1) understand the effect of the implementation process of MyPreventiveCare and 2) provide the practices further information about prevention delivery rates to help inform and motivate them during the MyPreventiveCare implementation process.

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

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions, and the electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

An interactive preventive care record: a handbook for using patient-centered personal health records to promote prevention.

Citation:
Krist A, Rothemich S, Kashiri P, et al. An interactive preventive care record: a handbook for using patient-centered personal health records to promote prevention. (Prepared by Virginia Commonwealth University, Department of Family Medicine, Virginia Ambulatory Care Outcomes Research Network (ACORN), under Contract No. 290-07-10011-3 and Grant No. R18 HS017046.) AHRQ Publication No. 12-0051-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2012. (PDF, 804.8 KB)
Principal Investigator: 
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