Do no digital harm? A multilevel evaluation of technology-facilitated team care on the patient-provider relationship in health disparity populations

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Project Summary: Patient-provider relationships characterized by high levels of commitment and trust are central to delivering high quality care for improved hypertension (HTN)-related outcomes. Unfortunately, health disparity populations are least likely to be in patient-provider relationships characterized by high levels of commitment and trust leading to negative affective, behavioral and physiological patient outcomes including heightened anxiety during the interaction, medication non-adherence, and poor blood pressure (BP) control. COVID-19 not only highlighted these social inequities but also led to a rapid change of our health system – from mainly in-person to telehealth visits. While telehealth has shown great promise in improving the clinical management of HTN, its impact on patient-provider relationships is unclear. Some evidence suggests telehealth could strengthen these relationships through improved access to the care team, but its technical and interpersonal drawbacks may reduce commitment and trust. To address these gaps, this proposal will leverage the infrastructure established by our NIMHD-funded R01, which will support 10 primary care clinics in the integration of technology-facilitated team care (herein called ALTA) to improve medication adherence and BP control in health disparity populations. ALTA enhances standard in-person and telehealth visits with opportunities for patients and providers to interact via secure messaging through the electronic health record (EHR) and patient portals. While a central premise of ALTA is that it will build clinic capacity to deliver equitable, high-quality care to health disparity populations, it was not designed to evaluate the impact of healthcare technologies on patient- provider relationships. Guided by the multilevel NIMHD research framework, the proposed study will employ a mixed methods study design that links four data sources to rigorously evaluate the multilevel impacts of ALTA on relationship commitment (primary outcome), patient-provider trust (secondary outcome) and patient health outcomes (tertiary outcomes) across 10 primary care clinics and 700 patients with uncontrolled HTN (Aims 1 and 2). Our evaluation strategy will combine cognitive, affective and behavioral measures of the patient-provider relationship and patient outcomes to create a multifaceted view of how individual perceptions and actions of the partners change when ALTA is introduced. Specifically, validated self-report measures (e.g., State Anxiety Inventory) will be augmented by automated text analysis of audiotaped interactions and secure messaging using natural language processing techniques, and EHR-extracted data on clinic and home BP readings and medication adherence (i.e., pharmacy records). Aim 3 will explore potential contextual factors (e.g., equity; digital literacy; communication modality) that influence the relationship between ALTA and the interpersonal and patient-level outcomes using self-report and EHR-derived measures. Aim 4 will use the human centered design approach to systematically gather feedback from clinic stakeholders to identify best practices for effective technology-facilitated patient-provider relationships.