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

项目摘要：以高度承诺和信任为特征的患者-提供者关系是 对于改善高血压(HTN)相关结局提供高质量护理至关重要。不幸的是，健康 差异人群最不可能处于高水平的患者-提供者关系中 承诺和信任会导致负面的情感、行为和生理结果，包括 在互动过程中焦虑加剧，不坚持服药，血压控制不佳。 新冠肺炎不仅突显了这些社会不平等，还导致了我们的医疗体系的快速变化--从 主要是面对面的远程医疗访问。虽然远程医疗在改善临床治疗方面显示出了巨大的希望 对于HTN的管理，其对患者-提供者关系的影响尚不清楚。一些证据表明远程医疗 可以通过改善与护理团队的联系来加强这些关系，但其技术和 人际关系的缺陷可能会减少承诺和信任。为了解决这些差距，这项提案将利用 我们由NIMHD资助的R01建立的基础设施将支持该地区10家初级保健诊所 整合技术促进的团队护理(在此称为ALTA)，以提高服药依从性和BP 控制健康差距人群。Alta通过机会增强标准的面对面和远程医疗访问 让患者和提供者通过电子健康记录(EHR)和患者之间的安全消息进行交互 传送门。虽然ALTA的一个中心前提是它将建立提供公平、高质量医疗服务的诊所能力 对于健康差距人群，它并不是为了评估医疗技术对患者的影响- 提供商关系。在多层次NIMHD研究框架的指导下，拟议的研究将采用 连接四个数据源的混合方法研究设计，以严格评估阿尔塔的多层次影响 关于关系承诺(主要结果)、患者-提供者信任(次要结果)和患者健康 10个初级保健诊所和700名未得到控制的HTN患者的结果(第三级结果)(目标1 和2)。我们的评估策略将结合患者提供者的认知、情感和行为测量 关系和患者结果，以创建一个多方面的视图，了解个人对疾病的看法和行动 当Alta被引入时，合作伙伴就会改变。具体地说，有效的自我报告措施(例如，状态焦虑 库存)将通过对录制的互动进行自动文本分析并使用 自然语言处理技术，以及EHR提取的临床和家庭血压读数和 服药依从性(即药房记录)。目标3将探索潜在的背景因素(例如，权益；数字 识字；沟通方式)，影响阿尔塔与人与人之间的关系 使用自我报告和电子病历衍生措施的患者水平的结果。目标4将使用以人为中心的设计 系统收集临床利益相关者反馈的方法，以确定有效的最佳实践 技术促进的患者与提供者之间的关系。

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.