Patient Portal to Support Treatment Adherence

描述(由申请人提供)：开发和实施卫生信息技术(HIT)以改善医疗保健是国家的优先事项。基于Web的共享患者和提供者对电子病历(EMR)的访问有可能打破传统通信和患者护理的界限，成为疾病管理的重要工具。由于这一成功是相对较新的，人们对电子病历门户网站用于个人疾病管理的使用或应用知之甚少。疾病管理对任何慢性病都很重要，尤其是在艾滋病毒方面，其中20%-50%的患者对延长生命的抗逆转录病毒疗法(ART)没有足够的坚持。信息-动机-行为技能(IMB)模型表明，艾滋病病毒携带者对ART的遵守受到消息灵通、动机良好和拥有有效行动技能的程度的影响。使用为患者提供医疗信息访问的网络门户以及与提供者直接沟通的安全方式，可能会提供独特的机会来增加与依从性相关的信息、动机和行为技能。我们正在寻求表征HIV+患者使用EMR患者网络门户的特征，并设计和现场测试使用这种HIT并以IMB理论为指导的个人行为干预。我们的团队处于独特的地位，可以在已经将这项新技术应用到临床护理中的两个大型附属医疗系统(加州北部的团体健康合作社和Kaiser Permanente)进行这项研究。该项目将在五年内分三个相关阶段进行。第一阶段是一项观察性研究，使用HIV+患者中的自动化数据来描述EMR门户网站随时间的使用模式以及频繁、不频繁和非门户用户的特征。第二阶段是一项随机试点，有30名艾滋病毒携带者参加，以审查可接受性/可行性问题并改进程序和措施。在第二阶段，将试行计划在第三阶段通过EMR患者门户网站(n=20)和注意控制臂(患者门户网站登记和信息联系人；n=10)提供的护士促进的个人依从性干预程序。阶段3是护士通过EMR患者门户网站(N=150)与注意力控制臂(N=150)进行的基于IMB的个人干预的随机对照试验。主要结果是在干预后、3个月和9个月的随访中，通过自动药房记录和自我报告来衡量ART的依从性。假想的依从性相关的IMB干预改变过程变量(依从性相关的信息、动机和行为技能)将随着时间的推移进行评估，并测试其对ART依从性的中介作用。次要结果还包括12个月的EMR患者Web门户利用率和面对面服务利用率。这项工作将加强我们对患者如何使用EMR患者门户网站的理解，并强调通过该系统提供护理所涉及的复杂性。它将使我们能够评估使用HIT作为干预提供工具来改善患者治疗结果的有效性，这一点具有超越艾滋病毒疾病管理的意义。 公共卫生相关性基于Web的共享患者和提供者访问电子病历(EMR)有可能打破传统通信和患者护理的界限，并成为慢性病管理的重要工具。这个项目将加强我们对HIV+患者如何使用网络访问EMR的理解，并测试这种系统作为干预交付工具的有效性，以改善患者的结果，如服药依从性。这项研究的发现将不仅与艾滋病毒护理有关，还将与许多其他慢性病的管理有关。

DESCRIPTION (provided by applicant): Development and implementation of health information technology (HIT) to improve healthcare is a national priority. Web-based shared patient and provider access to electronic medical records (EMR) has the potential of pushing the boundaries of traditional communication and patient care and becoming an essential tool in disease management. Due to the relative newness of this HIT, little is known about the use or application of EMR web portals for individual disease management. Disease management is important in any chronic illness but particularly in HIV, where 20-50% of patients have inadequate adherence to life prolonging antiretroviral therapy (ART). The Information-Motivation-Behavioral Skills (IMB) model suggests that ART adherence is influenced by the extent to which HIV+ patients are well-informed, motivated, and possess skills to act effectively. Use of a web portal that provides patients access to their medical information and a secure way to directly communicate with providers may provide unique opportunities to increase adherence-related information, motivation and behavioral skills. We are seeking to characterize the use of an EMR patient web portal by HIV+ patients, and to design and field test an individual behavioral intervention using this HIT and guided by IMB theory. Our team is in a unique position to conduct this research in two large affiliated health systems (Group Health Cooperative and Kaiser Permanente, Northern California) who have already adopted this new technology into clinical care. The project will be conducted in three related stages over five years. Stage 1 is an observational study using automated data among HIV+ patients to describe EMR web portal use patterns over time and the characteristics of frequent, infrequent and non-users of the web portal. Stage 2 is a randomized pilot with 30 HIV+ persons to examine acceptability/ feasibility issues and refine procedures and measures. In Stage 2, procedures for the nurse-facilitated individual adherence intervention delivered via EMR patient web portal (n=20) and the attention control arm (patient web portal enrollment and informational contacts; n=10) planned for Stage 3 will be piloted. Stage 3 is an RCT of an IMB-based individual intervention delivered by nurses via EMR patient web portal (N=150) as compared to an attention control arm (N=150). Primary outcomes will be ART adherence as measured by automated pharmacy records and self report at post-intervention, 3- and 9-month follow-up. Hypothesized adherence-related IMB intervention change process variables (adherence-related information, motivation, and behavioral skills) will be assessed over time and tested for mediating effects on ART adherence. Secondary outcomes also include 12-month EMR patient web portal utilization and in-person service utilization. This work will enhance our understanding of how patients use EMR patient web portals and highlight the complexities involved in delivering care via this system. It will allow us to evaluate the effectiveness of using HIT as an intervention delivery vehicle to improve patient treatment outcomes, which has relevance beyond HIV disease management. PUBLIC HEALTH RELEVANCE Web-based shared patient and provider access to electronic medical records (EMR) has the potential of pushing the boundaries of traditional communication and patient care and becoming an essential tool in chronic disease management. This project will enhance our understanding of how HIV+ patients use web access to an EMR, and test the effectiveness of such a system as an intervention delivery tool to improve patient outcomes such as medication adherence. Findings from this research will have relevance beyond HIV care to the management of many other chronic diseases.