Self Management & Reminders with Technology: SMART Appraisal of an Integrated PHR

描述(由申请人提供)：呈现给临床医生的患者的医疗复杂性正在增加，这种复杂性使得预防护理和疾病管理更加复杂(1)。这种复杂性在心血管疾病(CVD)中得到了体现，心血管疾病是美国死亡的主要原因。(2)患有心血管疾病或具有心血管疾病危险因素的患者，如高血压(HTN)、胆固醇升高和糖尿病(DM)，医学上很复杂，需要改变生活方式、药物治疗、定期检查疾病并发症和监测药物治疗。慢性护理模式为医疗复杂的患者提供了一种方法，强调使用健康信息技术和患者自我管理(3)。为了帮助患者自我管理，人们对将个人健康记录(PHR)与提供者的电子病历(EMR)集成在一起的兴趣越来越大，但很少有研究对此进行评估。(4)匹兹堡大学医疗中心健康系统(UPMC-HS)在许多初级保健地点部署了集成的PHR，允许患者查看部分EMR，包括问题清单、药物、过敏、健康提醒和测试结果，并向初级保健医生(PCP)办公室发送安全电子消息。 该项目旨在通过促进患者自我管理来改善复杂的心血管疾病患者或罹患心血管疾病的高风险患者的医疗保健结果。这将通过以下3个目标在4个不同的大型初级保健实践中实现：(1)开发针对患者的、针对复杂疾病患者的现有电子PHR的主动组成部分，旨在降低心血管疾病风险；(2)对被动和主动PHR在门诊环境中改善复杂患者的依从性和临床结果的有效性进行随机对照试验；以及(3)列举在门诊环境中提供者和患者实施和使用PHR的障碍和促进者。为了实现目标1，将组建一个用户小组，以确定“主动PHR”的哪些潜在功能对他们来说最可接受和最有用。为了实现第二个目标， 1,000名患有导致心血管风险增加的复杂慢性疾病(即心血管疾病或HTN、DM或高脂血症的4种情况中的2种需要至少一种药物来控制)的患者将在当前安装和使用PHR的4个地点随机分为被动PHR(n=500)和主动PHR(n=500)。要评估的结果包括风险因素(例如血压)控制的改善、遵守测试指南的频率(例如糖尿病患者的年度扩大视网膜检查)和临床结果(例如心肌梗死、住院)。目标3将通过调查所有使用PHR的参与者以及研究地点的护士和医生，并通过对PHR参与者、护士和医生进行焦点小组来确定PHR最有用的特征以及使用的障碍和促进者来实现。

DESCRIPTION (provided by applicant): The medical complexity of patients presenting to clinicians is increasing, and that complexity has made preventive care and disease management more complicated (1). This complexity is illustrated in cardiovascular disease (CVD), the leading cause of mortality in the US. (2) Patients with CVD or with CVD risk factors, such as hypertension (HTN), elevated cholesterol, and diabetes (DM), are medically complex, requiring lifestyle modification, medications, periodic testing for complications of disease, and monitoring of medications. The Chronic Care Model provides an approach to medically complex patients that emphasizes the use of health information technology and patient self-management (3). To assist with patient self management, there is growing interest in personal health records (PHRs) integrated with providers' electronic medical records (EMRs), but there have been few studies to evaluate this. (4) The University of Pittsburgh Medical Center health system (UPMC-HS) has deployed an integrated PHR at many primary care sites, which allows patients to view portions of their EMR including the problem list, medications, allergies, health reminders, and test results and to send secure electronic messages to the primary care physician's (PCP) office. This project seeks to improve health care outcomes in complex patients with CVD or who are at high risk for developing CVD by promoting patient self-management. This will be accomplished in 4 diverse, large primary care practices through the following 3 aims: (1) develop a patient-specific, active component to an existing electronic PHR directed towards patients with complex illnesses that is designed to reduce the risk of cardiovascular disease, (2) conduct a randomized controlled trial of the effectiveness of passive and active PHRs for improving adherence and clinical outcomes of complex patients in an ambulatory environment, and (3) enumerate the barriers and facilitators to implementation and use of an PHR among providers and patients in an ambulatory setting. To accomplish the aim 1, a users group will be assembled to determine which potential features of an 'active PHR' would be most acceptable and useful to them. To accomplish the 2nd aim, 1,000 patients with complex chronic disease leading to increased cardiovascular risk (i.e., CVD or 2 of the 4 conditions of HTN, DM, or hyperlipidemia requiring at least one medication for control) will be randomized to a passive PHR (n=500), or an active PHR (n=500) at 4 sites where the PHR currently is installed and in use. Outcomes to be assessed include improvement in control of risk factors (e.g., blood pressure), frequency of compliance with testing guidelines (e.g., annual dilated retinal exams in DM), and clinical outcomes (e.g., myocardial infarction, hospitalizations). Aim 3 will be accomplished by surveying all participants using the PHR, along with nurses and physicians at the study sites, and by conducting focus groups of PHR participants, nurses, and physicians to determine the most useful features of the PHR and to barriers and facilitators of use.