Leveraging Electronic Health Records to Measure and Reduce Harmful, Low-Value Care Among Older Adults

摘要 I（John N.我是加州大学洛杉矶分校的助理教授， 在兰德公司有个约会。我从事普通内科和追求健康服务的研究，重点是 识别和减少低价值护理-在特定临床情况下不提供净效益的患者护理， 也可能造成伤害。在哈佛大学接受卫生服务研究方面的出色培训后 并发表了一系列关于低价值护理的论文，我已经把研究的重点转向研究老年人， 因为他们不成比例地遭受低价值护理及其后果。的主要障碍 减少老年人的低价值护理缺乏有效的措施：目前的测量依赖于索赔数据 (e.g.,医生提交给医疗保险的账单索赔）缺乏足够的临床细节来正确地将护理分类为 “低价值”相比之下，电子健康记录（EHR）包含更丰富的临床数据，也是一种潜在的 减少低价值护理的工具。为了推进我的职业目标，改善对老年人的护理，我建议 开发基于EHR的低价值护理措施（“eMeasure”），然后设计和测试干预措施 包括一个行为经济学EHR临床决策支持工具（EHR CDS），以减少低价值护理， 老年人我的原型重点将解决低价值质子泵抑制剂（PPI）药物，这是相关的 有一些伤害。我的首要目标是改善美国老年人的健康和医疗保健， 一个领先的首席研究员利用EHR来衡量和减少老年人的低价值护理。 为了实现这一目标，我寻求NIA Beeson职业发展奖的支持。我得到了支持 包括主要导师Catherine Sarkisian博士（教授，NIA-R 01务实的PI）在内的杰出团队 试验），共同主要导师Cheryl Damberg博士（兰德/AHRQ U19中心的PI），导师罗恩海斯博士（质量 测量专家），Eric Cheng博士（首席医疗信息官），Noah Goldstein博士（经济学家），以及 合作者Folasade May博士（胃肠病学家），Sam Skootsky博士（首席医疗官）和Chi- 洪增（天文学家）。我将获得基于EHR的质量措施开发和利用的技能 （Damberg/Hays/Cheng），老年医学（Sarkisian），行为经济学和行为改变（Goldstein）， 务实的试验测试以用户为中心的EHR决策支持（Sarkisian/Damberg/Cheng）和领导力。 我提出了三个具体的职业发展目标：（1）开发和测试低价值PPI的eMeasure （2）设计和试点测试干预措施（行为经济学EHR CDS）， 减少老年人的低价值PPI处方，以确定可行性;（3）实施和评估 在加州大学洛杉矶分校卫生部进行的干预措施的延迟发作务实试验-通知NIA R 01提案， 多地点实用审判。我将把从培训中学到的知识应用于目标1 -3。Beeson奖 将为我提供成为国家领导人和独立临床医生所需的培训和技能 科学家利用EHR严格衡量和减少美国老年人中有害的低价值护理。

ABSTRACT I (John N. Mafi, MD, MPH) am an Assistant Professor at UCLA, with a secondary Natural Scientist appointment at RAND. I practice general internal medicine and pursue health services research focused on identifying and reducing low-value care—patient care that provides no net benefit in specific clinical scenarios, and can also cause harm. After receiving outstanding training in health services research at Harvard University and publishing a series of papers on low-value care, I have turned the focus of my research on studying older adults because they disproportionately suffer from low-value care and its consequences. A major barrier to reducing low-value care in older adults is a lack of valid measures: current measurement relies on claims data (e.g., billing claims physicians submit to Medicare) that lack enough clinical detail to correctly classify care as “low value.” In contrast, electronic health records (EHRs) contain richer clinical data and are also a potential tool for reducing low-value care. To advance my career goals and improve care for older adults, I propose to develop an EHR-based low-value care measure (“eMeasure”), and then design and test an intervention consisting of a behavioral economic EHR clinical decision support tool (EHR CDS) to reduce low-value care in older adults. My prototype focus will address low-value proton pump inhibitor (PPI) drugs, which are associated with some harm. My overarching goal is to improve the health and healthcare of older Americans by becoming a leading principal investigator utilizing the EHR to measure and reduce low-value care in older adults. To achieve this goal, I seek support from the NIA Beeson Career Development Award. I have the support of an outstanding group including primary mentor Dr. Catherine Sarkisian (Professor, PI of NIA-R01 pragmatic trial), co-primary mentor Dr. Cheryl Damberg (PI of RAND/AHRQ U19 Center), mentors Dr. Ron Hays (Quality Measure Expert), Dr. Eric Cheng (Chief Medical Informatics Officer), Dr. Noah Goldstein (Economist), and collaborators Dr. Folasade May (Gastroenterologist), Dr. Sam Skootsky (Chief Medical Officer), and Dr. Chi- Hong Tseng (Statistician). I will acquire skills in EHR-based quality measure development and utilization (Damberg/Hays/Cheng), geriatrics (Sarkisian), behavioral economics and behavior change (Goldstein), pragmatic trials testing user-centered EHR decision support (Sarkisian/Damberg/Cheng), and leadership. I propose 3 specific aims for my career development: (1) Develop and test an eMeasure of low-value PPI prescriptions among older adults, (2) Design and pilot test an intervention (behavioral economic EHR CDS) to reduce low-value PPI prescriptions in older adults to determine feasibility and (3) Implement and evaluate a delayed-onset pragmatic trial of the intervention at UCLA Health—informing an NIA R01 proposal for a multisite pragmatic trial. I will apply knowledge learned from my training to Aims #1-3. The Beeson Award would provide me with the training and skills needed to become a national leader and independent clinician scientist utilizing the EHR to rigorously measure and reduce harmful, low-value care among older Americans.