Improving Care Through AHRQ Health IT Tools (Text Version)
On September 28, 2010, Alexander Krist made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (2.4 MB).
Improving Care Through AHRQ Health IT Tools
MyPreventiveCare—A Personalized Portal to Promote Patient-Centered Preventive Care
Image: The MyPreventiveCare logo.
Research Team and Partners
- Steven Woolf
- Stephen Rothemich
- Daniel Longo
- Anton Kuzel
- Robert Johnson
- Tina Cunningham
- Eric Peele (RTI)
- William Kerns
- John Loomis
- Paulette Kashiri
- Steve Mitchell
- Melissa Hayes
- Kristin Schmidt
Images: The RTI International, Bon Secours Health System, Fairfax Family Practice, and Virginia Commonwealth University (VCU) logos.
Personal Health Records (PHRs)
- High perception of value—79% of Americans believe a PHR could provide major benefit in managing health.
- High interest—47% of Americans expressed interest in using an online PHR.
...But only 2.7% of adults have an electronic PHR
2008 Markel Foundation
Integrated PHRs Are Needed for Meaningful Use... this is Just Stage 1
- Send patients reminders.
- Provide patients with electronic copies of their health information.
- Provide patients timely electronic access to their health information.
- Provide clinical summaries for patients.
- Provide patient specific education resources.
- Implement and track clinical decision support.
Problems with Integrated PHRs: Content is Not in Patient Language
Image: A patient's medical problem list listing prostate cancer, reactive airway disease, skin neoplasm of uncertain behavior, taking a high-risk medication, tangier disease, temporomandibular joint-pain dysfunction syndrome, vaccines prophylactic need and visit ICD codes.
Problems with Integrated PHRs: Information is Often Out of Date
Image: A patient's medication list with medications currently taken but also listed are medications the patient no longer takes.
Problems with Integrated PHRs: Lab Normal Ranges Are Wrong
Image: A patient's lab result showing that the goal for an LDL cholesterol is 0-99 and the patient's LDL cholesterol is 130.
Guidelines are Increasingly Complex
Image: Summary of the most recent U.S. Preventive Services Task Force recommendations for aspirin use to prevent strokes.
...Yet Every Practice Must Recreate Its Own PHR Clinical Recommendations
Image: An example of some recommendations that one health system created within their EMR for preventive care.
How MyPreventiveCare Works
- Integrated PHR-EMR.
- Clinician and patient created for needs and workflow.
- Focused on preventive care and chronic disease.
- Clinical decision support logic integrated:
- USPSTF, JNCVII, NCEP, ADA, 2005 Dietary, and ACIP guidelines.
- Individually tailored patient messages and educational links.
- Partnered with ODPHP.
- Patient and clinician reminders system.
Preventive Services Addressed
- Colon cancer
- Prostate cancer
- Breast cancer
- Cervical cancer
- Chlamydia screening
- Hypertension screening
- Hyperlipidemia screening
- AAA screening
- ASA chemoprophylaxis
- Diabetes screening
- Osteoporosis screening
- Tetanus vaccination
- Influenza vaccination
- Pneumococcal vaccination
- Weight loss
1. Patient is instructed to go to MyPreventiveCare
May access directly on the Web:
May access through an existing PHR:
- Link to MyPreventiveCare within a PHR that passes on patient information (single sign on).
- MyPreventiveCare skin modified for seamless user experience.
Image: A screen shot of the patient home page for MyPreventiveCare.
2. Patient answers a brief health risk assessment
- Because MyPreventiveCare uses EMR data, the patient only needs to answer a few health risk questions:
- 11 questions for men and 12 for woman.
- Questions are about data not stored well in EMRs:
- Race/ethnicity, health behaviors, family history, and some abnormal test results.
Image: A screen shot of three health risk assessment questions from the MyPreventiveCare Web site that address health behaviors.
3. MyPreventiveCare receives patient-specific EMR data, patient reviews, and updates information.
- Thousands of EMR data elements are used that include:
- Demographics, vital signs, diagnoses, orders, results, management plans, medications, and immunizations.
- MyPreventiveCare is able to extract and understand this information from multiple EMRs.
Image: The MyPreventiveCare Web site page that shows a patient his or her health information.
4. MyPreventiveCare categorizes the patient's status and gives a personal list of recommendations
Logic is based on 8 sets of national guidelines with a focus on U.S. Preventive Services Task Force recommendations.
MyPreventiveCare reconciles conflict between guidelines and deals with limited evidence by presenting information to patients and letting them and their doctor decide.
The list quickly and simply shows patients what they need, what they are doing well with, and what they need to think about.
Image: A screen shot of a patient's MyPreventiveCare list of services that they need now and services that they should learn more about.
5. A patient can learn more about any of their specific needs
Patients can click on any topic in their summary list to see more detailed information.
Each message is individually tailored to the specific patient's needs.
Each message includes specific patient data.
Messages were created with assistance from the Office of Disease Prevention and Health Promotion.
Image: A screen shot of a patient's personalized MyPreventiveCare detailed message about cholesterol highlighting "Your Information" "The Basics" "The Benefits" "Your Next Steps" and "Information to Guide Your Next Steps"—all highly personalized with individual patient information.
6. At the end of each detailed message are links to more resources
Links are meant to be like the patient's clinician showing the patient where to go on the Web for more information.
Resources include educational material, risk calculators, health tools, local resources, and decision aids.
Links are individually tailored to each specific patient.
Resources are evidence-based from trusted, non-commercial, national organization.
Image: A screen shot of a link to the National Cholesterol Education Program's patient brochure, provided to a patient by MyPrevenitveCare.
7. MyPreventiveCare sends a patient summary to the patient's clinician
Summaries come in the EMR similar to a lab result.
- Any information that the patient updates.
- A list of the patient's health behaviors.
- A list of the patient's needs.
Research Supporting MyPreventiveCare
Image: A map of the state of Virginia showing the location of practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) with pictures of a rural, suburban, and urban family practice office showing the range of ACORN practices.
- Evaluate whether using the system increases prevention.
- 5500 patients randomized to a MyPreventiveCare-invitation vs. usual care.
- R18 HS17046-01.
- Assess best method of implementing the system.
- Mixed methods:
- Repeated measures analysis of use/delivery.
- Learning collaboratives.
- Workflow redesign.
Image: A graph showing the use of MyPreventiveCare over time. At the end of the study, which coincides with their third mailing, more than 450 patients are using MyPreventiveCare of the 2,250 patients offered use of the system.
Preventive Care Needs
- Users are up-to-date with 53% of preventive care.
- Only 2.2% of users are up-to-date on all services.
- Not up-to-date users need an average of 4.6 services.
Image: A bar graph showing the types of preventive services that MyPreventiveCare users are overdue for. Services include 49% of patients overdue for a screening test, 91% who need to change a health behavior, 56% who need a vaccination, 55% who need a preventive medication, and 35% who need better chronic disease care.
Process Impact of MyPreventiveCare
Clinician summary led practices to:
- Update 59% of patient's medical records.
- Contact 84% of patients:
- Schedule a wellness visit for 27% of patients.
- Schedule a chronic care visit for 17% of patients.
- Get a specific service for 19% of patients.
Users More Up-to-Date than Non-users
Image: A bar graph showing that patients who use MyPreventiveCare have a greater increase in being up-to-date on preventive services than patients who do not use the system. Overall users have a 4.7% increase in all preventive services. Other services that increased include: colon cancer screening: 12.3%; breast cancer screening: 16.1%; cervical cancer screening: 12.3%; influenza vaccine: 5.4%; and pneumonia vaccine: 8.1%.
More Needed To Redesign Work Flow
A workflow diagram that shows one practices plan to modify their workflow to use MyPreventiveCare. The notable feature of this diagram is that the practice is not modifying their workflow adequately to take full advantage of MyPreventiveCare. They plan to mainly have nurses and Call Center staff inform patients of MyPreventiveCare. They are not changing staff roles to allow nurses to deliver preventive care through standing orders or to allow patients a mechanism to receive services outside of encounters in which a doctor orders the service.
Its All About the Data
- Quality of EMR data is highly variable:
- Dependent on EMR database structure.
- Dependent on practice data entry.
- Little adherence to standardized data exchange by EMR vendors (e.g. CCR/CCD).
- Practices improvise and record information in strange ways.
- Standardized data exchanges are inadequate for prevention and chronic care.
- Lacks range of information (e.g. family history).
- Lacks longitudinal historical perspective.
Patient Functionality—More Is Needed
- Patients want the system to be highly sophisticated and comprehensive. They want MyPreventiveCare to:
- Centralize their health information from all sources in a secure but easy to use internet-based platform.
- Be highly personalized and directive.
- Prioritize and highlight critical information.
- Make recommendations.
- Involve their clinician (communicate and integrate).
National Needs—Technical and Cultural Challenges
- Fixing these challenges requires difficult policy decisions:
- Mandate interoperability? Require data standardization?
- Create support for integration and information exchange?
- Resource practices differently to support new care models?
- Redefine roles of public, private, academic, and clinical sectors?
- Break down silos and share knowledge?
National Needs—Move Past Adoption
- PHR functionality needs major advances:
- Great potential to improve patient outcomes.
- Development cannot be left to IT vendors alone:
- Clinical entities need to create clinical content.
- Guideline developers need to operationalize their recommendations.
- Policy makers need to align content with priorities and resources.
- Researchers need to ensure systems improve outcomes.
Thank you for your time and consideration