Technology for Optimizing Population Care in a Resource-limited Environment

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DESCRIPTION (provided by applicant): Our health care system is frequently seen as too costly, fragmented, inefficient, and unsafe. Efforts to improve health care in the primary care setting can be facilitated by patient registries and information technology (IT) that expand care beyond traditional one-on-one visits. However, the most effective and efficient approaches to implementing health IT systems for primary care population management are not currently known. We propose to test the hypothesis that an IT platform that integrates electronic health record data can efficiently leverage the unique knowledge clinicians have about their patients to enhance care. Specifically, we will examine the value of matching the "right" provider for a given patient within a novel informatics platform that facilitates cancer prevention between office visits. This hypothesis will be tested in a randomized clinical trial of preventive breast, cervical, colorectal and prostate cancer screening within our primary care practice based research network (PBRN). In intervention practices for eligible patients overdue for screening, clinicians (physicians and clinical population managers) will use a web-based tool to review their patient list, and with "one click" select a screening decision based upon the patient's unique risk profile. Tailored outreach, including letters, shared decision making aids, practice personnel or patient navigator contact, will efficiently improve screening rates by better linking outreach to the patient's needs compared to control patients. For the control group, we will define a standard of augmented care that mimics current population-level reminder systems supplemented by the use of automation. This will involve a centralized process to mail letters to all patients who appear overdue for screening without provider review. The system will automatically track completed tests and only notify practice personnel to contact patients if screening is not completed within a specified time. For patients remaining overdue, patient navigators will evaluate and contact only high risk control patients. The following Specific Aims will be tested: Specific Aim 1: To design, develop, and implement a novel cancer screening intervention program called Technology for Optimizing Population Care in A Resource-limited Environment (TOP-CARE) that facilitates the identification, individualized contact, and subsequent tracking of patients overdue for screening. Specific Aim 2: To conduct a practice randomized trial of the TOP-CARE program within our PBRN assessing its impact on cancer screening rates in eligible patients. Specific Aim 3: To prospectively collect data during the randomized trial about the costs, preferences, and clinical and process outcomes to inform a subsequent formal cost-benefit analysis. This research is relevant to nationwide efforts, such as the patient-centered medical home, to rigorously demonstrate the most effective and efficient ways to implement novel IT-based health delivery models to provide high quality population-based primary care within resource-limited health care settings.