VCU Department of Family Medicine

An interactive preventive health record (IPHR) to promote patient-centered care

Start date: September 2007
Principal investigator: Alexander H. Krist, M.D., M.P.H.
Funding: Department of Health and Human Services, Agency for Healthcare Research and Quality

Hypothesis

We posit that an interactive preventive health record, designed to provide patients with preventive health information from their clinician’s electronic medical records and link patients to educational resources, decision aids and a tailored list of prevention recommendations, will increase the delivery of recommended screening tests, immunizations and counseling. We propose to test four specific aims in a randomized controlled trial.

Aims

Our study evaluates whether an invitation from a patient’s primary care clinician to use the IPHR, versus the usual delivery of preventive care, results in the following outcomes for adult patients:

1. Increased delivery of age- and gender-appropriate clinical preventive services.
2. Use of the IPHR.
3. Increased shared decision-making for preventive services.
4. Improved clinician-patient communication about preventive needs.

Description

We are conducting a randomized controlled trial involving 5,500 patients (2,750 intervention and 2,750 control patients) randomly selected from the practice population. Intervention patients receive a tailored postal request from their personal clinician to visit the IPHR for assistance with managing their preventive care, while control patients receive usual preventive care. Outcomes being investigated include both the delivery of preventive care (whether patients are up-to-date on age- and gender-appropriate preventive services) and specific domains of patient-centered care (the patient’s perspective on the care experience). Outcomes are assessed from two separate patient postal surveys (a Preventive Services Survey to assess delivery of preventive care and the CAHPS Clinician and Group Survey to evaluate patient-centered care measures), EMR data queries and automated reports from the IPHR about patient and clinician use of the HIT tool. To limit survey length and ensure adequate response rates, we are selecting two separate cohorts of study participants for outcomes measurement. We are mailing each cohort a different postal survey — the Preventive Services Survey for 4,500 patients and the CAHPS Survey for 1,000 patients — in January 2008 (baseline), January 2009 (six months after the intervention) and January 2010 (18 months after the intervention). We plan a pre-post cohort analysis of outcomes, comparing the change from baseline to six and 18 months for the intervention and control groups. Patient and practice perspectives about implementation of the IPHR are further assessed by qualitative analysis of focus groups.

Quality performance measurement

Start date: Oct. 1, 2007
Principal investigator: Daniel L. Longo, Sc.D.
Funding: Agency for Healthcare Research and Quality

Aims

This contract’s main objective is to produce a comprehensive report on issues involved in supporting primary care practices in collecting and reporting quality performance data, current effective strategies that practices have implemented to collect and report quality data, and potential innovations in the field as described in the tasks and sub-tasks in AHRQ’s Task Order Number Four. We are identifying barriers and facilitators to data reporting and collecting, as well as potential solutions and strategies for primary care offices. AHRQ Conference on Health Care Data Collection and Reporting: Collecting and Reporting Data for Performance Measurement serves as the task order’s foundation and guides the final report format.

Description

The Virginia Ambulatory Care Research Outcomes Network intervention is using a combination of comprehensive literature review, on-site focus group visits and consultative and peer mentoring approaches. To guide our work and analyses, our task order project utilizes a conceptual framework derived from three lines of inquiry including quality of care with an emphasis on performance reporting and provider behavior change, diffusion of innovation theory and competing demands in primary care practice. Nine VACORN practices are undergoing detailed assessment regarding data measurement and utilization, and staff and consultants work with six small practices selected from the nine. Using qualitative research methods, we are developing six case studies including “member checks,” conducting an in-depth literature review and synthesis, performing environmental scanning and synthesizing all project findings. Finally, we are focusing on the results of the task order’s identification, examination and recommendations on current challenges, strategies for overcoming barriers and facilitating solutions in collecting and reporting data for performance measurement. Innovative dissemination strategies using case studies are employed in a variety of venues to reach practicing primary care clinicians, administrative and office staff and policy-makers.

Comprehensive practice-friendly model for promoting healthy behaviors

Start date: April 2005
Principal investigators: Steven H. Woolf, M.D., M.P.H., Alexander H. Krist, M.D., M.P.H., project director
Funding: Robert Wood Johnson Foundation

Hypothesis

We posit that practice systems to promote healthy behaviors must combine five attributes to be effective and sustainable. They must be comprehensive (addressing multiple behaviors and the “Five As”), flexible (offering options), applicable to ordinary practices, practice-friendly (limiting burden) and apply the Chronic Care Model. We are testing the effectiveness and implementation of an innovative “packaged” intervention with these features.

Description

Six VACORN-affiliated practices are adopting a brief, three-minute routine to deliver A1-3 (Ask, Advise, Agree) in the office and offering patients four options for intensive assistance (Assist [A4], Arrange [A5]) outside the office. Patients can select nine months of online, telephone or group counseling, or usual care. An electronic health record expedites the in-office intervention and referrals. Outcome measures include health behaviors, derived from 7,200 surveys administered pre-intervention and three and nine months post-exposure, and implementation, derived from EHR data, “counselee” surveys and patient/staff interviews.

We hypothesize that implementing this novel “package” of interventions will be associated with improved health behaviors, using the Common Measures for physical activity, diet, smoking and alcohol use. EHR-captured data will measure RE-AIM parameters, including Reach (14 sub-measures), Adoption and Maintenance. Surveys and qualitative analysis of semi-structured interviews with patients and office staff explore implementation issues and suggested improvements.

We hope to demonstrate that this innovative intervention not only promotes healthy behaviors but is feasible and sustainable in primary care. Accomplishing these goals requires a delicate balancing act — deploying evidence-based strategies that are effective in lifestyle change but limit demands for new staff, training or time. We strike this balance by harnessing effective technologies and tools and by leveraging resources outside the practice. If our intervention helps patients change unhealthy behaviors and is appealing to ordinary practices, we envision the potential for widespread adoption and substantial population health benefits.

Colorectal cancer screening barriers study

Start date: May 5, 2005
Principal investigators: Steven H. Woolf, M.D., M.P.H., Resa M. Jones, Ph.D., project director
Funding: National Cancer Institute and Agency for Healthcare Research and Quality

Hypothesis

Colorectal cancer is the second leading cause of cancer-related deaths in the U.S. An estimated 148,610 new cases of CRC and 55,170 deaths will occur in 2006. Screening for all Americans age 50 and older is uniformly recommended by at least one of four screening options: fecal occult blood testing, flexible sigmoidoscopy, colonoscopy or double-contrast barium enema. A major factor limiting screening effectiveness is the low proportion of the eligible population that undergoes screening. Understanding the relative importance of screening determinants is essential to prioritize potential public health, clinical and policy strategies to enhance CRC screening.

Description

The primary aim of this study is to describe the factors that patients identify as their reason(s) for not undergoing screening for CRC and the relative importance they assign to each factor. The primary outcome of this study is a profile of CRC screening barriers that patients identify in their responses to the postal survey.

QuitLink: A leveraging solution to tobacco counseling

Start date: May 2005
Principal investigator: Stephen F. Rothemich, M.D., M.S.

Hypothesis

Providing a new configuration of existing tools to identify smokers and connect them with community resources will increase rates of smoking-cessation counseling provided in primary care settings and will increase the number of smokers who receive community-based counseling to stop smoking.

Aim 1

To test whether delivery of A3-5 (Assess, Assist, Arrange) will be enhanced by a practice support system that combines (1) an expanded smoking as a vital sign intervention, (2) fax referral of preparation-stage patients for telephone counseling and (3) feedback to the provider.

Aim 2

To assess contextual factors that might affect implementation of the intervention and account for its ultimate success or failure. In particular, to assess: 1) environmental and practice-level factors that affect practices’ ability to successfully implement and use the intervention and 2) patient characteristics beyond readiness to change (i.e., age, gender, race/ethnicity) that affect willingness to use the quit line and complete counseling.

Description

The primary purpose of this project is to test whether the delivery of A3-5 (Assess, Assist and Arrange) is enhanced by a system that combines (1) an expanded vital sign intervention with (2) fax referral of preparation-stage patients for telephone counseling provided by the American Cancer Society (ACS) and (3) feedback to the provider. The question is examined in a randomized trial, with practices as the unit of analysis and with a control intervention consisting of a conventional vital sign intervention. The experiment therefore compares what intervention and control practices accomplish beyond simply identifying patients who use tobacco. The secondary purpose of this study is to assess contextual factors that might affect implementation of the intervention and account for its ultimate success or failure. In particular, to assess: (1) environmental and practice-level factors that affect practices’ ability to successfully implement and use the intervention and (2) patient characteristics beyond readiness to change (i.e., age, gender, race/ethnicity) that affect willingness to use the quit line and complete counseling. The study is conducted at 16 diverse family practices in Virginia.