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Service Delivery Innovation Profile

Primary Care Patients Use Interactive Preventive Health Record Integrated With Electronic Health Record, Leading to Enhanced Provision of Preventive Services


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Snapshot

Summary

Patients served by 14 medical practices in Virginia use an interactive preventive health record to learn about their preventive health needs and access related educational information and tools. Patients sign on to the system before each visit to view health information drawn from the practice’s electronic health record and complete a health risk assessment. The system then generates a summary page that lists the dates of past preventive services and associated test results, highlights missing information, and makes evidence-based recommendations on needed preventive services, thus allowing the patient to discuss these needs with the doctor at the upcoming visit. Patients also view personalized lists and detailed information about prevention needs linked to tools, resources, and support so that they can better act on the recommendations. The patient’s information is automatically transmitted back to the electronic health record, making it easy for clinicians to identify and discuss the patient's preventive care needs during the visit. The process has improved the provision of preventive health services, including cancer screenings (for colorectal, breast, and cervical cancer) and immunizations (e.g., tetanus, pneumococcal), and generated high levels of satisfaction among providers.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial and observational cohort studies evaluating the system's ability to identify preventive care needs and comparing the provision of various preventive care services in IPHR users and nonusers, along with post-implementation feedback from clinicians whose patients used the system.
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Developing Organizations

RTI International; Virginia Ambulatory Care Outcomes Research Network (ACORN); Virginia Commonwealth University Department of Family Medicine
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Date First Implemented

2009

Problem Addressed

Many Americans do not receive preventive health services that can improve their health and reduce health care costs. Electronic personal health records that are integrated with electronic health records (EHRs) can improve the provision of such services, yet few patients have access to these systems.
  • Low uptake of preventive health services: Preventive health services such as screening tests, immunizations, and health behavior counseling can meaningfully reduce morbidity, mortality, and health care costs.1,2,3,4 Yet Americans receive only one-half of all clinical preventive services recommended for them based on well-established guidelines.5 For example, 24 percent of eligible women have not had a mammogram in the past 2 years, and 14 percent have not had a pap smear in the past 3 years; 31 percent of seniors have not had an influenza vaccine in the past year; almost one-half (47 percent) of individuals older than age 50 have never had a colonoscopy or sigmoidoscopy; and 36 percent of seniors have never had a pneumococcal vaccine.6
  • Unrealized potential of integrated, online personal health records: A personal health record, particularly one integrated with the provider's EHR, can provide patients with health information, reminders, decision aids, and tailored advice that encourage and enable them to discuss preventive care needs with their clinicians.7 Such systems can also facilitate patient-physician collaboration and communication7 and prompt clinicians about services that patients need. However, although 79 percent of Americans believe that an online personal health record would provide major health benefits, fewer than 3 percent have access to one.8

What They Did

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Description of the Innovative Activity

Patients served by 14 medical practices in Virginia use an Interactive Preventive Health Record (IPHR) to track preventive health needs and access related educational information. In advance of each visit, patients review and update health information drawn from the practice’s EHR and complete a health risk assessment (HRA). Based on this information, the system generates a summary page that lists recent preventive services and associated test results, highlights missing information, and makes evidence-based recommendations on needed preventive services. Patients also view personalized lists and detailed information about prevention needs linked to tools, resources, and support so that they can better act on the recommendations. The patient’s information is automatically transmitted back to the EHR, making it easy for clinicians to identify preventive care needs and discuss them with patients. Key program elements include the following:
  • Marketing program and registering patients: Participating practices inform patients about the IPHR through various mechanisms, including brochures, flyers, mailed invitations, e-mails, and physician-patient discussions. Interested patients sign on to the IPHR (available at www.mypreventivecare.org) and create a password-secured account. As of October 2012, more than 34,000 patients in the 14 practices had registered for and regularly used the IPHR.
  • Using interactive system in advance of visit: Registered users generally sign on to the interactive system in advance of a visit to review and update their most recent health-related information and complete an HRA. Based on this information, the system generates a summary page that highlights needed preventive services. More details about each step in this process are provided below:
    • Completing HRA: Patients receive a reminder via e-mail to update their HRA at least once a year (more frequently for patients with more complex health issues), with the reminder typically sent in advance of a scheduled medical visit. (Reminders are also sent every 6 to 12 months if the patient is overdue for care.) The patient completes the HRA, answering questions related to sociodemographics; family history; health behaviors; and previous abnormal results for screening tests entered into the EHR as free text (which cannot be imported), such as Pap smears, mammograms, and biopsies.
    • Reviewing prepopulated health information: The HRA reminder also prompts patients to review health information that is prepopulated in the record. This information is drawn from 167 clinical data elements extracted from the EHR at the physician practice where the patient regularly receives care.
    • Reviewing tailored recommendations for preventive services: Based on the HRA and EHR-generated information, the IPHR produces a personally tailored summary page for the patient, including dates and test results for the patient's most recent preventive services, and evidence-based recommendations related to needed preventive services. The IPHR system uses internal clinical algorithms based on United States Preventive Services Task Force (USPSTF) guidelines to generate the recommendations. The summary page lists needed services and explains the rationale behind the recommendations, including references to relevant information and findings in the patient’s medical history (such as previous laboratory test results). The summary page also lays out next steps in obtaining recommended care. When guidelines do not offer clear recommendations in a given circumstance, patients receive information explaining the relevant issues, with the goal of assisting the patient in making a decision based on his or her personal risks, preferences, and values.
    • Linking to additional resources: By clicking on a health indicator or preventive health service listed on the summary page, patients can access more detailed information, including educational materials and tools, decision aids, and relevant community resources.
  • Communication of recommendations to physicians: The IPHR automatically forwards a summary of the patient’s HRA and recommendations to the EHR. The summary includes a list of patient-inputted updates/corrections and health behaviors, along with a list of overdue preventive services. The physician and/or nurse reviews the summary by opening the patient’s EHR, and then can discuss (and, as possible, address) preventive care needs with the patient at the visit and update the EHR accordingly.

Context of the Innovation

Virginia Commonwealth University sponsors the Virginia Ambulatory Care Outcomes Research Network (ACORN), a practice-based research network made up of more than 50 physician practices. ACORN research activities often focus on using information technology (IT) to improve preventive care. The impetus for the IPHR project came from ACORN physicians, who expressed a desire for the following: (1) automation of decision support tools that could support patients in making treatment, behavior change, and other decisions, (2) improvement in practices’ abilities to manage patient populations, and (3) provision of personalized information to patients at the right time in their decisionmaking processes. The 14 Virginia-based practices within ACORN that implemented the IPHR program vary widely in terms of size, geographic location, patients served, experience with health IT, and practice ownership structure. The 14 practices use 3 different EHRs.

Did It Work?

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Results

The IPHR successfully identified needed preventive care services, increased the provision of such services (as compared to patients not using the system), and generated high levels of clinician satisfaction.
  • Identification of needed services: A randomized controlled trial and two observational cohort analyses found that practices using the IPHR identified the need for preventive services in large proportions of patients.6,7,9 For example, an observational cohort analysis found that a high proportion of patients needed 1 or more preventive services, including a screening test (needed by 49 percent of patients), vaccination (56 percent), counseling on health behaviors (91 percent), and consideration of a preventive medication (55 percent). In addition, the IPHR found that 35 percent of patients had inadequate control of a chronic condition.7
  • Greater provision of preventive services: A randomized controlled trial involving 2,250 patients in 8 primary care practices found that the proportion of IPHR users who were up-to-date with all recommended preventive services increased by 11.5 percent in the 16 months after implementation, well above the 2.2-percent increase among nonusers during the same time period.9 The provision of many preventive services increased more for users than nonusers. For example, after 4 months, rates of colorectal, breast, and cervical cancer screening increased by 19.2, 15.0, and 11.7 percent, respectively, among IPHR users, compared to 3.9, 2.8, and 0.5 percent among nonusers.9 Similarly, rates of tetanus and pneumococcal immunization increased by 13.3 and 14.2 percent, respectively, among IPHR users, compared to increases of just 4.6 and 8 percent among nonusers.9 Both observational cohort analyses yielded similar findings; for example, one analysis found that, compared to nonusers, IPHR users were more likely to receive a tetanus vaccination (60 versus 38.9 percent) and screening for colon cancer (51.9 versus 33.6 percent), cervical cancer (58.1 versus 38.6 percent), elevated cholesterol (89 versus 64.8 percent), and diabetes (93.2 versus 80.8 percent).7
  • High clinician satisfaction: Clinician feedback indicates strong satisfaction with the IPHR. Clinicians report that the program has led to improvements in patient engagement, documentation, and preventive care, along with reductions in their workload.6,7,10

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial and observational cohort studies evaluating the system's ability to identify preventive care needs and comparing the provision of various preventive care services in IPHR users and nonusers, along with post-implementation feedback from clinicians whose patients used the system.

How They Did It

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Planning and Development Process

Selected steps in implementing an IPHR include the following:10
  • Assess readiness: Practices should first assess whether they have the cultural factors and practice infrastructure to support IPHR implementation. Practices ready to adopt an IPHR will have a culture that emphasizes preventive care and organizational improvement, leadership support, an existing EHR, and some expertise with health IT.
  • Create technical link between EHR and IPHR: IT staff should create a link between the EHR and IPHR so that patient data and other information can be transferred between the two as needed. Data transfer must be secure and comply with Health Insurance Portability and Accountability Act regulations.
  • Form implementation team: Practices should consider creating an implementation team made up of between 4 and 10 individuals representing all practice personnel. Teams should meet on an ongoing basis to oversee implementation and maintenance of the system. Team responsibilities may include mapping practice workflow for preventive care, developing plans to change this workflow after IPHR implementation, ensuring data quality, developing a training program for practice staff, developing a strategy to engage patients in the program, troubleshooting implementation problems, revising the workflow based on feedback, and tracking results.

Resources Used and Skills Needed

  • Staffing: Some IT staff time will be needed during the setup phase. Ongoing operation of the IPHR system requires no new staff, as existing staff incorporate information generated by the system into their daily routines. Practices that want to use the system to facilitate rapid, meaningful improvements in population-based care may choose to add dedicated staff to monitor preventive health needs closely and proactively address identified gaps.
  • Costs: Grants to develop and evaluate the IPHR system totaled approximately $2 million. Programmers at Virginia Commonwealth University and RTI International created the IPHR. Individual practices did not incur any implementation costs, other than minimal IT staff time as noted above.
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Funding Sources

Agency for Healthcare Research and Quality; National Center for Advancing Translational Sciences
The Agency for Healthcare Research and Quality (AHRQ) provided funding for this program through the following grants: HHSA 290-07-100113 to 17, 5R21 HS018811-02, and R18 HS17046-03. This project was also supported by the National Center for Advancing Translational Sciences (CTSA Grant Number UL1TR00058).end fs

Tools and Other Resources

A guide for using personal health records to improve preventive care (An Interactive Preventive Care Record: A Handbook for Using Patient-Centered Personal Health Records to Promote Prevention) is available from AHRQ at: http://healthit.ahrq.gov/KRIST-IPHR-Guide-0612.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

USPSTF guidelines are available at: Agency for Healthcare Research and Quality. The Guide to Clinical Preventive Services 2012: Recommendations of the U.S. Preventive Services Task Force. Available at: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide
/guide-clinical-preventive-services.pdf.

Adoption Considerations

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Getting Started with This Innovation

  • Obtain buy-in by emphasizing patient care benefits: Successful implementation requires the support of various stakeholders, including organizational leaders, clinicians, and IT and other staff. To secure such support, emphasize the program's ability to enhance quality, patient satisfaction, and patient health. Special attention should be paid to garnering support from busy physicians and nurses, who may resist new care processes. Nurse enthusiasm about IPHRs can be especially important, as it can lead to greater use of the system by patients.
  • Evaluate data quality: Ensure that EHR data are accurate and complete before creating a link to the IPHR; transferring inaccurate or incomplete data may undermine patient trust in the practice.
  • Incorporate IPHR into work processes: To the extent possible, build IPHR-related activities into existing work processes, and adjust job descriptions as necessary to ensure accountability. Physicians may also benefit from suggestions about how to incorporate IPHR reports into patient visits with minimal disruption.
  • Choose strategies to engage patients: Practices have multiple options for encouraging patients to sign up for the IPHR and should decide which one(s) to use early in the implementation process. Options include providing information about IPHR signup before the patient visit, having patients create an IPHR account while in the office, training staff to advise patients to create an account, and automatically creating IPHR accounts for patients and then providing them with login information (including how to create a new password). Practices can also create posters and brochures, and/or include notices on mailed visit reminders or bills that highlight the IPHR and its benefits.
  • Create clear message for patients: Regardless of the strategy or strategies chosen, adopting practices need to create a clear, consistent message that clinicians and staff can convey when discussing the IPHR with patients.

Sustaining This Innovation

  • Track performance data: Continually track and share data about IPHR use and its impact on the provision of needed preventive services. Seeing evidence of the program's success helps to maintain support among key stakeholders.
  • Continually remind patients to use system: Physicians and other clinical and nonclinical staff should actively encourage patients to use the IPHR by talking to them about its benefits during office visit.
  • Incorporate IPHR into other initiatives: IPHR use and data can be incorporated into other initiatives being pursued by the practice, such as pay-for-performance and patient-centered medical home initiatives.

More Information

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Contact the Innovator

Alex H. Krist, MD, MPH
Associate Professor of Family Medicine
Virginia Commonwealth University
1200 East Broad street
P.O. Box 980251
Richmond, VA 23298-0251
(804) 828-9625
E-mail: ahkrist@vcu.edu

Innovator Disclosures

Dr. Krist reported having no financial interests or business/professional affiliations relevant to the work described in this profile, other than the funders listed in the Funding Sources section.

References/Related Articles

More details about the system are available at: www.mypreventivecare.org.

Krist AH, Rothemich SF, Loomis JF, et al. Designing a patient-centered personal health record to promote preventive care. Unpublished manuscript.

Krist A, Kashiri P, Peele E, et al. Promoting use of an integrated personal health record for prevention. Unpublished manuscript.

Krist A, Rothemich S, Woolf S, et al. Using health information technology to improve healthcare quality in primary care practice and in transitions between care settings. Unpublished manuscript.

Krist AH, Woolf SH, Rothemich SF, et al. Interactive preventive health record to enhance delivery of randomized care: a randomized trial. Ann Fam Med. 2012;10(4):312-9. [PubMed]

Krist AH, Peele E, Woolf SH, et al. Designing a patient-centered personal health record to promote preventive care. BMC Med Inform Decis Mak. 2011;11(1):73. [PubMed]

Krist AH, Woolf SH. A vision for patient-centered health information systems. JAMA. 2011;305(3):300-1. [PubMed]

Footnotes

1 American Cancer Society. American Cancer Society recommendations for early breast cancer detection in women without breast symptoms. Last revised August 30, 2012. Available at: http://www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection
/breast-cancer-early-detection-acs-recs
.
2 U.S. Preventive Services Task Force. Screening for colorectal cancer: recommendation and rationale. Ann Intern Med. 2002;137(2):129-131. [PubMed]
3 U.S. Preventive Services Task Force. Guide to Preventive Services 2012. Available at: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide
/guide-clinical-preventive-services.pdf
.  Accessed June 14, 2013.
4 National Center for Immunization and Respiratory Diseases. General recommendations on immunization—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(2):1-64. Available at: http://www.guidelines.gov/content.aspx?id=25633&search=vaccination. [PubMed]
5 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45. [PubMed]
6 Krist A, Kashiri P, Peele E, et al. Promoting use of an integrated personal health record for prevention. Unpublished manuscript.
7 Krist A, Rothemich S, Woolf S, et al. Using health information technology to improve healthcare quality in primary care practices and in transitions between care settings. Unpublished manuscript.
8 Markle Foundation. Connecting for health: Americans overwhelmingly believe electronic personal health records could improve their health. Available at: http://www.markle.org/publications
/401-americans-overwhelmingly-believe-electronic-personal-health-records-could-improve-t
.
9 Krist AH, Woolf SH, Rothemich SF, et al. Interactive preventive health record to enhance delivery of randomized care: a randomized trial. Ann Fam Med. 2012;10(4):312-9. [PubMed]
10 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. Agency for Healthcare Quality and Research Publication No. 12-0051-EF. June 2012. Available at: http://healthit.ahrq.gov/KRIST-IPHR-Guide-0612.pdf.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 05, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Back Story
Cynthia Santos of Fairfax, Virginia, is one of many patients who are benefiting from a recent innovation in personal health records known as interactive preventive health records (IPHR). She uses an IPHR system called MyPreventiveCare to monitor her autoimmune disease, control her diet, and track her exercise.

The IPHR system compiles information from her...

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