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

摘要 我(约翰·N·马菲，医学博士，公共卫生硕士)是加州大学洛杉矶分校的助理教授，二级自然科学家 兰德的预约。我从事普通内科医学，从事健康服务研究，专注于 识别和减少低价值护理--在特定临床方案中不提供净效益的患者护理， 也可能造成伤害。在哈佛大学接受了出色的卫生服务研究培训后 发表了一系列关于低价值护理的论文，我将研究的重点转向了研究老年人 成年人，因为他们不成比例地遭受低价值护理及其后果。一个主要障碍是 减少老年人的低价值护理缺乏有效的措施：目前的衡量依赖于索赔数据 (例如，医生向联邦医疗保险提交的账单索赔)缺乏足够的临床细节以正确地将护理归类为 “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并改善对老年人的照顾，我提议 制定基于电子健康记录的低价值护理措施(“eMeasure”)，然后设计和测试干预措施 由行为经济学EHR临床决策支持工具(EHR CDS)组成，旨在减少 上了年纪的人。我的原型重点将涉及低价值的质子泵抑制剂(PPI)药物，这些药物与 但也带来了一些伤害。我的首要目标是通过成为 一位领先的首席研究员，利用电子健康记录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比森职业发展奖的支持。我得到了支持 一个杰出的团队，包括主要导师凯瑟琳·萨基西安博士(NIA-R01务实派教授 试验)，共同主要导师Cheryl Damberg博士(兰德/AHRQ U19中心的PI)，导师Ron Hays博士(质量 测量专家)、埃里克·程博士(首席医疗信息学官)、诺亚·戈尔茨坦博士(经济学家)以及 合作者Folasade May博士(胃肠病专家)、Sam Skootsky博士(首席医疗官)和Chii博士- 洪森(统计学家)。我将掌握基于eHR的质量测量开发和使用的技能 (Damberg/Hays/Cheng)，老年病学(Sarkisian)，行为经济学和行为改变(Goldstein)， 测试以用户为中心的EHR决策支持(Sarkisian/Damberg/Cheng)和领导力的实用试验。 我提出了我职业发展的三个具体目标：(1)开发和测试低价值PPI的电子测量 老年人的处方，(2)设计和试点测试干预措施(行为经济学EHR CDS)以 减少老年人的低价值PPI处方，以确定可行性和(3)实施和评估 加州大学洛杉矶分校健康干预的延迟性实用试验--告知NIA R01关于 多点务实试验。我将把从培训中学到的知识应用于目标1-3。比森奖 将为我提供成为国家领导者和独立临床医生所需的培训和技能 科学家利用电子健康记录严格测量和减少美国老年人中有害的、低价值的护理。

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.