Promoting Use of an Integrated Personal Health Record for Prevention

描述（由申请人提供）：个人健康记录（PHRs）与电子医疗记录（emr）集成是促进以患者为中心的护理并最终改善健康结果的重要工具。尽管集成phrr的采用和使用正在增加，但它通常发生在具有支持其使用的业务模型的大型集成医疗保健系统中。这些系统是否能在典型的初级保健实践中得到广泛采用仍然未知。在以前由ahrq资助的R18中，我们创建了一个用于预防的PHR，它与临床医生的EMR集成在一起，我们称之为“交互式预防性医疗记录”（IPHR）。IPHR还将临床决策支持软件、提醒系统、量身定制的教育材料和决策辅助工具整合到一个可操作的包中，供患者和临床医生使用。在一项测试ipr可行性和效果的研究中，ipr加强了临床与患者的沟通，促进了推荐的预防服务的提供。尽管这些发现令人鼓舞，但研究设计只允许研究实践患者的一小部分被纳入，并且患者仅通过低强度的邀请函被介绍到IPHR。下一个合乎逻辑的步骤是进行可行性试验，以评估在通常的实践条件下，实践是否能够可持续地和更深入地将IPHR纳入医疗保健。我们建议在参与第一项研究的弗吉尼亚门诊护理结果研究网络（ACORN）的八个实践中测试这个问题。所有接受治疗的成年患者都被认为有资格使用IPHR。在组织变革理论的指导下，我们将参与实践，通过实践冠军、学习协作和以患者为中心的沟通策略，就如何将IPHR整合到医疗服务中创建一个共同的愿景。从IPHR和EMR数据库中，我们将应用RE-AIM模型来衡量Reach、有效性、实施和维护。我们将“达到”定义为在诊所就诊的患者中建立了IPHR账户并接受预防建议的比例和特征；“有效性”是指患者使用IPHR后预防性服务提供的改变；“实施”是指临床医生对ipr确定的患者需求的反应；“实践水平维持”是指诊所在最初的PHR实施后6至12个月维持“达到”的能力。患者水平维持，即患者在6个月后是否继续使用IPHR。我们将比较Reach在实践中采用综合方法向患者推广IPHR与低强度邀请信的历史控制率；8个研究点将提供80%的功率，使用单侧0.05水平检验检测10%的增量增加。我们将进行关键信息提供者访谈，并记录和分析学习协作，以了解实践如何将知识产权与调解员和版主结合使用。本研究的结果将有助于设计未来的实践水平随机对照试验，并为实践、政策制定者和付款人提供有关如何将PHR纳入典型初级保健实践的信息。以患者为中心的卫生信息技术系统，如综合个人健康记录，通过提供集中的医疗信息、患者教育和激活、增强患者和临床医生的沟通、决策支持和提醒系统，具有提高护理质量的巨大潜力。然而，如果患者和临床医生不使用这些系统，它们就无法改善健康。我们试图了解初级保健实践是否可以通过将其整合到常规护理中来鼓励患者使用这种系统，并确定干预措施如何影响医疗保健服务

DESCRIPTION (provided by the applicant): Personal health records (PHRs) integrated with electronic medical records (EMRs) are an essential tool to promote patient-centered care and ultimately improve health outcomes. Although adoption and use of integrated PHRs is increasing, it typically occurs within large integrated healthcare systems that have business models supporting their use. Whether such systems can have broad uptake in typical primary care practices remains unknown. In a previous AHRQ-funded R18, we created a PHR for prevention that is integrated with a clinician's EMR, which we term an "interactive preventive healthcare record" (IPHR). The IPHR also incorporates clinical decision support software, a reminder system, tailored educational materials, and decision aids into one actionable package for both patients and clinicians. In a study that tested IPHR feasibility and effect, the IPHR enhanced clinician-patient communication and promoted the delivery of recommended preventive services. Although these findings are encouraging, the study design permitted only small subsets of the study practices' patients to be included and patients were introduced to the IPHR with only a low- intensity invitational letter. The next logical step is to conduct a feasibility trial to assess whether practices can, under usual practice conditions, sustainably and more intensively integrate the IPHR into care. We propose to test the question in eight practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) that participated in the first study. All adult patients presenting for care will be considered eligible for IPHR use. Guided by organizational change theory, we will engage practices to create a shared vision on how to integrate the IPHR into care delivery using practice champions, learning collaboratives, and a patient-centered communications strategy. From the IPHR and EMR databases, we will apply the RE-AIM model to measure Reach, Effectiveness, Implementation, and Maintenance. We define Reach as the proportion and characteristics of patients seen for an office visit who establish an IPHR account and receive prevention recommendations, Effectiveness as change in documented preventive service delivery after patients use the IPHR, Implementation as clinician response to IPHR-identified patient needs, practice-level Maintenance as the practice's ability to sustain Reach 6 to 12 months after initial PHR fielding, and patient-level Maintenance as whether patients continue to use the IPHR after 6 months. We will compare the Reach in practices promoting the IPHR to patients using the integrated approach to the historical control rate of the less intensive invitational letter; the eight study sites will provide 80% power, using a one-sided 0.05-level test to detect a 10% incremental increase. We will conduct key informant interviews and record and analyze learning collaboratives to understand how practices integrated the IPHR and mediators and moderators to use. Findings from this study will assist in the design of a future practice-level randomized controlled trial, and inform practices, policymakers, and payers about how to integrate a PHR in typical primary care practices. Patient-centered health information technology systems, such as integrated personal health records, have great potential to improve the quality of care by providing centralized medical information, patient education and activation, enhanced patient and clinician communication, decision support, and reminder systems. However, these systems cannot improve health if they are not used by patients and clinicians. We seek to learn whether primary care practices can encourage patients to use such a system by integrating it into routine care and to determine how the intervention influences healthcare delivery