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8/12/2019 AHRQ HIT Findings and Lessons From Improving Management of Individuals With Complex Health Care Needs

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AHRQ Health Information Technology Ambulatory Safety and Quality | MCPi

AHRQ Health Information echnology

Ambulatory Safety and Quality

Findings and Lessons Fromthe Improving Managementof Individuals With ComplexHealth Care Needs ThroughHealth IT Grant Initiative

www.ahrq.gov HEALTH IT
http://healthit.ahrq.gov/


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AHRQ Health Information Technology Ambulatory Safety and Quality | MCPii

Tis document is in the public domain and maybe used and reprinted without permission, exceptthose copyrighted materials that are clearly noted in

the document. Further reproduction of those copy-righted materials is prohibited without the specificpermission of copyright holders.

Suggested Citation:Findings and Lessons From the Improving Man-agement of Individuals With Complex HealthCare Needs Trough Health I Grant Initiative.(Prepared by Westat Under Contract No. HHSA290200900023I.) AHRQ Publication No. 13-0058-EF. Rockville, MD: Agency for Healthcare Researchand Quality. September 2013.

Prepared for:Agency for Healthcare Research and QualityU.S. Department of Health and Human Services540 Gaither RoadRockville, MD 20850www.ahrq.gov

Contract No. HHSA 290200900023I

Prepared by:Westat

Russell Mardon, Ph.D., Project Director

AHRQ Publication No. 13-0058-EFSeptember 2013

Tis project was funded by the Agency for Healthcare Research

and Quality (AHRQ), U.S. Department of Health and HumanServices. Te opinions expressed in this document are those of

the authors and do not reflect the official position of AHRQ or

the U.S. Department of Health and Human Services.
http://www.ahrq.gov/http://www.ahrq.gov/


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AHRQ Health Information Technology Ambulatory Safety and Quality | MCPiii

Preface

Te Improving Management of Individuals WithComplex Healthcare Needs Trough Health I ini-

tiative is part of the Agency for Healthcare Researchand Qualitys (AHRQs) Ambulatory Safety andQuality (ASQ) program. Te purpose of the AHRQ

ASQ program is to improve the safety and qualityof ambulatory health care in the United States. Teprograms components, with the exception of therisk assessment grant initiative (FOA HS-07-003),emphasize the role of health information technology(I). Te ASQ program included the following grantinitiatives:

Enabling Quality Measurement Trough HealthI (FOA HS-07-002), which focused on strategiesfor the development of health I to assist clini-cians, practices, and systems to measure the qualityand safety of care in ambulatory care settings.

Ambulatory Care Patient Safety Proactive RiskAssessment (FOA HS-07-003), which supportedresearch in risk assessment and modeling to iden-tify preventable patient injuries and harms and toinform the development and deployment of inter-vention strategies to reduce threats to patient safety

in ambulatory care settings and during transitionsof care.

Improving Quality Trough Clinician Use ofHealth I (FOA HS-07-006), which supported

research related to the development, implemen-tation and use of health I to assist clinicians,practices, and systems in improving the quality andsafety of care delivery in ambulatory care settings.

Enabling Patient-Centered Care Trough HealthI (FOA HS-07-007), which was designed toinvestigate approaches to improve the patientexperience of care through the use of health I inambulatory care settings.

Improving Management of Individuals With Com-

plex Healthcare Needs Trough Health I (FOAHS-08-002), which was aimed at clinician andpatient and family use of health I in ambulatorysettings to improve outcomes through more effec-tive decision support or care delivery for patients

with complex health care needs.

Tis is one of a series of five reports highlightingfindings and lessons from the health I-focused ASQgrant initiatives. Tese reports summarize the projects ineach initiative and identify practical insights regardingthe use of health I to improve safety and quality in

ambulatory settings.


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AHRQ Health Information Technology Ambulatory Safety and Quality | MCPiv

Acknowledgments

Tis report was developed through a collaborativeprocess that would not have been possible without

the contributions of many individuals. Te projectdirector would especially like to thank the following keyparticipants who contributed to and guided the work:

Te Improving Management of Individuals WithComplex Healthcare Needs Trough Health I(MCP) grantees, whose work in advancing the useof health I to improve the quality and safety ofcare for patients with complex health care needsinspired and informed this report.

External reviewers Paul Johnson, Ph.D., and Ming

ai-Seale, Ph.D., for their valuable comments.

Vera Rosenthal, M.P.H., Program Manager, HealthI, and lead for the MCP initiative, whose feed-

back and guidance shaped the report.

Te Synthesis eam, a group of Westat senior staff,including Nathan Botts, Ph.D.; Brenda Leath,M.H.S.A.; Russell Mardon, Ph.D.; Lauren Mercin-cavage, M.H.S.; Eric Pan, M.D.; Jonathan Ratner,Ph.D.; Helga Rippen, M.D., Ph.D., M.P.H.,FACPM; and Larry Stepnick, M.B.A., of Te Sev-eryn Group; and the Westat project manager JulieBergmann, M.H.S.


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AHRQ Health Information Technology Ambulatory Safety and Quality | MCPv

Table of Contents

Executive Summary 1

Introduction 3

The Potential for Health IT To Improve Management of Patients

With Complex Health Care Needs 3

The Improving Management of Individuals With Complex Healthcare Needs

Through Health IT Initiative 4

Providing High-Quality, Appropriate Care

Through the Use of Health IT 6

Background 6

Highlights From the Projects 6

Integrating Patient Information Across Transitions in Care 9

Background 9


Supporting Clinical Workflow 12

Background 12


Strategies for Safe, Successful, and

Productive Adoption of Health IT 14

Background 14


Impact of Health IT on Outcomes Related to Patients With

Complex Health Care Needs in Ambulatory Settings and

Across High-Risk Transitions of Care 15

Process Outcomes 15

Intermediate Outcomes 16

Economic Outcomes 17

Conclusion 18

References 19

Appendix 21


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AHRQ Health Information Technology Ambulatory Safety and Quality | MCPvi

Figures

1 Grant Initiative Areas of Interest Addressed Across Projects 5

2 IOM Priority Areas Addressed Across Projects 5

Tables

1 Number of Projects by Type of Transition in Care Addressed 9


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AHRQ Health Information Technology Ambulatory Safety and Quality | MCP1

Findings and Lessons From the Improving Management of Individuals

With Complex Healthcare Needs Through Health IT Grant Initiative

Executive Summary

Tis report highlights key findings, lessons, andinsights from the experiences of 12 projects awardedin 2007 under the Agency for Healthcare Researchand Qualitys (AHRQs) Improving Managementof Individuals with Complex Healthcare NeedsTrough Health I initiative (Funding Opportunity

Announcement [FOA] HS-08-002 (http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.html)).Tis initiative was designed to investigate approachesfor using health information technology (I) toimprove the coordination and quality of services forpatients with complex health conditions, includ-

ing during transitions of care. It is part of AHRQsAmbulatory Safety and Quality (ASQ) program,which was designed to improve the safety and qualityof ambulatory health care in the United States.

Tis report summarizes the extent to which theprojects addressed the areas of interest laid out in theFOA, and identifies practical insights regarding theuse of health I to improve management of patients

with complex conditions in the ambulatory setting.It presents illustrative project findings in an effort to

inform research discussion and provide guidance toother entities implementing health I systems forthis purpose. As the researchers continue to dissemi-nate findings from these projects, additional lessonsand insights may become evident.

Te body of the report is organized around the fivemain areas of interest outlined in the FOA. Each isdescribed below:

Novel approaches to providing high-quality, appro-priate care through the use of health I, addressed in

12 projects, includes a variety of uses for health I,such as linking clinical health I systems to practicemanagement systems and using health I to engagepatients and their families to enhance self-care andcomanagement of chronic conditions.

Integrating patient information across transitions incare to improve quality, addressed in eight projects,by making sure that clinicians, patients, and familieshave access to relevant information during transi-tions between ambulatory care settings and othersettings such as hospitals, home care, assisted livingcenters, and nursing homes.

Shared decisionmaking and patient-clinician com-munication was addressed in four projects. Tisincluded the use of health I to support collabora-tion between patients and clinicians to arrive at

decisions about patient care that are informed andmutual. Tese projects also used health I to sup-port effective clinical interactions during office visitsas well as the delivery of clinical services throughsecure messaging or electronic visits.

Strategies for safe, successful, and productive adoptionof health I in ambulatory settings, addressed in threeprojects, includes managing the impact of health Iimplementation on team roles, team-based care, andworkflows within a practice and across settings.

Te impact of health I on outcomes related to

patients with complex health care needs in ambula-tory settings and across high-risk transitions of careincludes process, intermediate, health, and economicoutcomes. Seven projects reported a significantimpact on outcomes.

Te MCP projects were carried out in a variety ofambulatory care settings, including primary careand specialty care clinics. In addition, many projectsfocused on improving transitions across settings.Tey addressed a range of relevant care topics, includ-ing many of the priority areas for health care quality

improvement identified by the Institute of Medicine(IOM, 2003). Te names of the principal investi-gators, their institutions, and the project titles areshown in the Appendix, along with links to addi-tional information about the projects on the AHRQNational Resource Center for Health I Web site(http://healthit.ahrq.gov/portfolio).
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.htmlhttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.html


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Te projects funded under the initiative advancedunderstanding of the effective use of health I toimprove management of individuals with complex

health care needs in the ambulatory setting. Severalprojects showed a positive impact on clinician accep-tance and use of health I as well as improvementin the flow of information when patients transi-tion from one clinician to another. Other projectsdemonstrated high levels of patient engagement andactivation in self-care. Still others reported reductionsin hospital or emergency department (ED) use. Tefindings add to the evidence of the positive impacton health care-related outcomes of health I applica-tions designed to support management of patients

with complex health conditions.

Te studies also highlighted a number of barriersand facilitators to the use of health I. For example,several projects experienced difficulties integrating

health I interventions into existing clinical data sys-tems, while others achieved successes through carefulimplementation and staff training. Te continuinginterest in use of health I to improve health andhealth care delivery, and the positive impact of theseapproaches on a range of health care outcomes, makethe results of this body of research timely and rel-evant to ongoing efforts to improve management ofpatients with complex health care needs.


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Introduction

Tis report highlights key findings and lessons fromthe experiences of 12 projects awarded in 2008 underthe Agency for Healthcare Research and Qualitys(AHRQs) Improving Management of Individuals

With Complex Healthcare Needs Trough Health I(MCP) initiative (Funding Opportunity Announce-ment [FOA] HS-08-002 (http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.html)). Tisinitiative was designed to investigate approachesfor using health information technology (I) toimprove the coordination and quality of services forpatients with complex health conditions, including

during transitions across settings of care. It is partof AHRQs Ambulatory Safety and Quality (ASQ)program, which fostered research on the use of healthI to improve the safety and quality of ambulatoryhealth care in the United States.

Tis report summarizes the extent to which theprojects addressed the areas of interest laid out in theFOA and identifies practical insights regarding theuse of health I to improve management of complexpatients in the ambulatory setting. It presents illustra-

tive project findings in an effort to inform researchdiscussion and provide guidance to other entitiesimplementing health I systems for this purpose.Te report is organized around the five main areas ofinterest laid out in the FOA. Each section includesa brief background section on the topic, followed bya summary of how the projects addressed the topic,and specific descriptions of each relevant project. Inaddition, the report includes a synopsis of key find-ings from the projects that bear on several types ofoutcomes, including process outcomes, intermediateoutcomes, and economic outcomes.

Te names of the principal investigators, theirinstitutions, the project titles, and the MCP areas ofinterest addressed in each project are included in the

Appendix, along with links to additional informationabout the projects on the AHRQ National ResourceCenter for Health I Web site (http://healthit.ahrq.gov/portfolio).

The Potential for Health IT To ImproveManagement of Patients With ComplexHealth Care NeedsTe importance of providing treatment and sup-portive services for individuals with complex healthcare needs continues to increase. Approximately onein four Americans has multiple chronic conditions,including one in 15 children and as many as threeout of four persons age 65 and older (Anderson,2010). Yet care for these patients often remains frag-mented, occurring across multiple settings and clini-cians, with limited or no communication or coordi-

nation and no sense of overarching responsibility byany one member of the care team. Patients often donot seek services until a crisis occurs, a crisis that mayhave been avoidable had they sought care earlier orhad their care been better coordinated.

Currently, the management of patients with complexhealth care needs involves a web of relationships,

with information moving haphazardly among differ-ent clinicians, settings, and the patient. Te patientis rarely engaged directly in the management of his

or her care (Schoen et al., 2011; Wagner, 1998). Yetmultiple studies show that patients who are involvedwith their care decisions and management have betteoutcomes than those who are not (Wagner, Grothaus,et al., 2001; Wagner, Glasgow, et al., 2001; Green-field et al., 1985; Greenfield et al., 1988). Patientself-management, particularly for chronic conditions,has been shown to be associated with improvementsin health status and reductions in utilization ofservices (Lorig et al., 1999). Recognizing the centralrole of the patient can support information exchangeacross clinical encounters. Tis is not to imply thatthere is no role for clinician-to-clinician communica-tions, only that that communication can be mademore efficient by incorporating the patient either as aparticipant or conduit.

Research has demonstrated that health I can improvepatient safety and quality of care (Choudhry et al.,2006; Fitzmaurice et al., 2002), and the rate of health
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.htmlhttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-08-002.html


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I adoption in ambulatory settings is increasing. Datafrom the National Ambulatory Medical Care Sur-vey indicate that in 2011, 57 percent of office-based

physicians used electronic health records (EHRs), withuse by State ranging from 40 to 84 percent (Hsiaoet al., 2011), although adoption continues to lag fornonprimary care specialists, physicians age 55 andolder, and physicians in small (12 clinicians) andphysician-owned practices (Decker et al., 2012). Onceimplemented, health I has the potential to facilitatenew interventions and new models of care delivery forpatients with complex health care needs.

The Improving Management ofIndividuals With Complex Healthcare

Needs Through Health IT InitiativeTe MCP initiative was designed to identify andevaluate methods and strategies for both clinicianand patient and family use of health I in ambula-tory settings to improve outcomes through moreeffective decision support or care delivery for patients

with complex health care needs and across high-riskhealth care transitions. Te goal was to strengthenthe evidence demonstrating the value of health I inimproving the quality and safety of ambulatory carefor patients with complex health care needs, for use

by health care professionals, payers, policymakers,and the public.

As noted above, the FOA highlighted five areas ofinterest:

Novel approaches to providing high-quality, appro-priate care through the use of health I includes avariety of uses for health I, such as linking clini-cally oriented health I systems to practice man-agement systems and using health I to engagepatients and their families to enhance self-care and

comanagement of chronic conditions.

Integrating patient information across transitionsin care to improve quality by making sure thatclinicians, patients, and families have access torelevant information during transitions betweenambulatory care settings and other settings suchas hospitals, home care, assisted living centers, andnursing homes.

Shared decisionmaking and patient-clinician com-munication through the use of health I to sup-port collaboration between patients and clinicians

to arrive at decisions about patient care that areinformed and mutual. Patient-clinician commu-nication includes the use of health I to supporteffective clinical interactions during office visitsas well as the delivery of clinical services throughsecure messaging or electronic visits.

Strategies for safe, successful adoption of healthI in ambulatory settings includes managing theimpact of health I implementation on teamroles, team-based care, and collaborative workflows

within a practice and across settings.

Te impact of health I on outcomes related topatients with complex health care needs in ambu-latory settings and across high-risk transitions ofcare, includes process, intermediate, health, andeconomic outcomes.

Some of the projects addressed more than one area ofinterest. As shown in Figure 1, the most commonlyaddressed areas were approaches to providing high-quality care, addressed in all 12 projects, and the inte-gration of patient information across care transitions,

addressed in 8 projects. Seven projects demonstrateda significant impact on outcomes, while four proj-ects worked on supporting shared decisionmaking orpatient-clinician communication, and three identifiedstrategies for successful adoption of health I.

Te projects developed and implemented a rangeof health I applications, including EHRs, diseasemanagement systems, health information exchange(HIE) applications, secure messaging, interactivevoice response (IVR) systems, personal health records(PHRs), and clinical decision support tools. Te proj-

ects took place in both primary care and specialty careambulatory settings. Furthermore, eight of the proj-ects involved transitions to ambulatory settings fromacute care, skilled nursing, or home health care. Teclinical specialties of participating clinicians includedprimary care (defined here to include geriatrics, aninternal medicine subspecialty, and adolescent medi-cine, a pediatrics subspecialty) and psychiatry.


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FIG.

1

Grant Initiative Areas

of Interest Addressed

Across Projects*

16

14

12

10

8

6

4

2

0

Impacts onOutcomes

7

SharedDecision-making andPatient-ClinicianCommuni-cation

4

ProvidingHigh-QualityCare

12

Health ITAdoption inAmbulatorySettings

3

NumberofProjects

Integrationof PatientInformationAcrossTransitionsof Care

8

Areas of Interest

* Many projects addressed multiple MCP areas of interests.

As shown in Figure 2, the projects also addressed arange of relevant care topics, including 12 of the pri-ority areas for health care quality improvement identi-

fied by the Institute of Medicine (IOM, 2003). Tetwo most common priority areas addressed involvecare processes (care coordination and medicationmanagement), while many of the remaining priorityareas addressed in the MCP projects concern specificdiseases or patient populations. Each project addressedat least one Institute of Medicine priority area.

FIG.

2

IOM Priority Areas

Addressed Across Projects*

9

8

7

6

5

4

3

2

1

0

NumberofProjects

IOM Priorit Areas

2

Diabetes

2

Self-

Manage-

ment/Health

Literacy

1

Cancer

Screening

2

Frailty

Associated

With Old Age

1

Asthma

4

Medication

Manage-

ment

3

Ischemic

Heart

Diseease

3

Severe and

Persistent

Mental

Illness

2

Hyper-

tension

2

Major

Depres-

sion

1

Children

with

Special

Health

Care Needs

8

Care

Coor-

dination

* Many projects addressed multiple priority areas.


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Providing High-Quality, Appropriate CareThrough the Use of Health IT

BackgroundPatients who have complex health care needs suchas frail elders, patients with multiple chronic condi-tions, or those with comorbid mental and physicalillnesses typically require both medical care and socialservices and support from a wide variety of profes-sionals and caregivers. Novel approaches to the useof health I may help patients, caregivers, clinicians,and social service providers communicate and coordi-nate to improve the delivery of needed services. Tiscommunication may take place between health careprofessionals and patients and their families, withinteams of health and social service professionals, andacross care teams, particularly when patients transferbetween care settings (Rich et al., 2012). Specifi-cally, health I tools and systems may be used for (1)maintaining, updating, and tracking care plans; (2)initiating referrals and returning results from lab andradiologic tests, specialty consultations, and homehealth care, community-based services; (3) real-timemonitoring of critical events such as hospital admis-sions, ED visits, or patient-reported warning signsthat trigger a need for followup; (4) prompts and

reminders to patients regarding visits and preventivecare; (5) clinician decision-support tools such as clini-cal care paths and guidelines; (6) delivering patienteducational and self-management support; and (7)maintaining lists of available community resourcesand support services.

Highlights From the ProjectsTe MCP projects used a variety of novel approachesto provide high-quality, appropriate care using healthI. Tese included enhancing EHR systems withdecision support to ensure timely diagnosis andimproved medication reconciliation, designing HIEsystems and secure messaging to ensure that informa-tion is shared across clinicians to improve the coordi-nation of care, using IVR to followup with patientsafter a hospital discharge, and using PHRs to educateand enable patients to improve self-care and helpthem prepare for visits with clinicians. Tese projectsare described in more detail below.

Wende Baker, M.Ed.(R18 HS 17838) implementedand evaluated a regional HIE designed to servepatients living in rural areas who are being treatedfor mental illness in urban settings, due to the lackof clinicians in the local community, by exchangingclinical information within the region. Te systemprovides timely access to patient information betweenand among clinicians serving the patient, includ-ing behavioral health care clinicians, primary carepractitioners, hospitals in rural areas, and emergencybehavioral health systems. Te researchers evaluatedthe impact of the HIE on length of stay, patient func-tioning, and readmissions for patients with majordepression, schizophrenia, or bipolar disorder bycomparing patients for whom clinical information

was available in the HIE system with patients forwhom it was not.

Elizabeth L. Ciemins, Ph.D.(R18 HS 17864)developed and implemented a system that facilitatesthe exchange of information between the hospitaland ambulatory care providers after a patient in arural area is discharged home from the hospital.

Te program initially focused on adults with at leasttwo chronic conditions, but was later expanded toall patients, with the goal of increasing ambulatoryfollowup visits and reducing hospital readmissionsand ED visits compared to the baseline period. Tesystem prompts clinicians in rural areas to accessmore complete medical information through the hos-pital EHR. An enhanced medication reconciliationcomponent at the time of admission was also addedto the intervention 2 years after its launch.

David Dorr, M.D.(R18 HS 17832) assessed a

health I-enabled approach to care coordination andcare management in primary care. Tis approach usesfinancial incentives, specially trained care managers,and tracking software to help clinics better care forpatients with complex chronic illness such as frailelders, those with multiple comorbidities, or patients

with previous high utilization. Te approach helpsthe clinical team prioritize health care needs and


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develop a care plan based on structured protocols,and it provides tools to assist patients and caregiv-ers to self-manage chronic diseases, with the goal of

reducing hospitalizations and ED visits while increas-ing patient satisfaction.

A mental health PHR developed by BenjaminDruss, M.D.(R18 HS 17829) was designed toimprove and coordinate care for patients with seriousmental illness and one or more comorbid conditions.Te PHR includes information on the care team,patient, diagnoses, goals and action steps, healthindicators, medications and allergies, medical history,hospital visits, immunizations, and patient and fam-ily health history. Te researchers tailored the PHR to

the needs of patients with mental health conditionsthrough a series of patient and clinician focus groups,and used clinical care specialists to teach patients howto use the PHR. Te researchers evaluated the impactof the PHR on a set of standard quality indicators forhypertension, diabetes, asthma, and other chronicconditions, as well as schizophrenia and bipolar dis-order by comparing randomly assigned patients whohad the opportunity to use the PHR with a usual-care group.

Penny Feldman, Ph.D.(R18 HS 17837) developedtwo interventions designed to facilitate patient-clini-cian communication when they move to home healthcare from an acute care setting, with a particularfocus on avoiding serious medication problems. Tefirst uses an algorithm to provide alerts, reminders,and point-of-care decision support to home healthnurses visiting patients at risk of a potentially seriousmedication problem after discharge from an acutecare setting. Te second intervention provides infor-mation about their medications to the patients athome, using electronic, CD, and hard-copy formats.

Terry S. Field, D.Sc.(R18 HS 17817) created anelectronic medical record-based medication reconcili-ation system to enhance medication monitoring andfollowup care for elderly patients with complex medi-cal conditions transitioning from a skilled nursingfacility to home. Most of the patients were in skillednursing following a hospital stay. Te system providesalerts and key medication information to ambula-

tory care clinicians and to nurses making home visitswith the aim of increasing appropriate monitoringfor high-risk medications and reducing adverse drugevents, hospital readmissions, and ED visits com-pared to the baseline period.

Robert Friedman, M.D.(R18 HS 17855) modifiedan existing IVR system to serve patients with com-plex care needs, such as those with multiple chronicconditions and who have increased health careutilization. Te system uses conversational computer-ized telephone calls to monitor patients with complexneeds after discharge from an acute care setting andbetween ambulatory visits to identify important clinical problems such as an exacerbation in a disease orinadequate patient self-care behaviors. Te research-ers are studying its effect on reducing unnecessary

hospital and ED use, improving disease-specificmetrics, increasing patient satisfaction, and reducingnet payer costs through a randomized controlled trialcompared to usual care.

James Kahn, M.D.(R18 HS 17784) created a securePHR that provides information, Web-based supporttools, and reminders to HIV/AIDS patients. Tegoal of the project was to increase the connectionbetween clinicians and patients by promoting self-management and decision support and by providingpatients with access to the medical record and linksto clinicians and other patients through an onlineforum. Te PHR includes support for tobacco cessa-tion, depression abatement, anxiety reduction, andmedication adherence improvement. Te researchersstudied its impact on improved outcomes includingimpact on patient behaviors, patient-clinician trust,clinical outcomes, medication safety, and utilizationthrough a randomized controlled trial compared tousual care.

On February 24, 2010, AHRQ hosted a national

Web conference on transitions in care featuring

Dr. Field. Information about this national Web coference can be found at:

http://healthit.ahrq.gov/transitionsincareteleconf

ence
http://healthit.ahrq.gov/transitionsincareteleconferencehttp://healthit.ahrq.gov/transitionsincareteleconferencehttp://healthit.ahrq.gov/transitionsincareteleconference


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David Lobach, M.D., Ph.D., and Eric Eisenstein,D.B.A.(R18 HS 17795) created a regional HIEnetwork to connect providers serving 42,000 Med-

icaid beneficiaries in rural and urban settings in asix-county region in central and northern NorthCarolina. Te project enhanced an existing HIEand decision support tool so as to detect transitionsin care and provide patient-specific information topatients, primary are clinicians, and members of themultidisciplinary care management team. By facilitat-ing information sharing about diagnoses, procedures,the identities of clinicians on the care team, sched-uled appointments, and specialist notes, the HIE wasintended to increase followup of recommended care,

while reducing hospitalizations, ED visits, and costs.

Ann Mertens, Ph.D.(R18 HS 17831) created aPHR for pediatric cancer survivors that provides evi-dence-based recommendations and other educationalmaterials to primary care and specialty clinicians whoare treating adults who had cancer as children. Tesystem is intended to improve both clinician andpatient knowledge and awareness of cancer survivor-ship issues and risks as well as increase the receipt ofrecommended screenings and other followup services.

Christine Ritchie, M.D., M.S.P.H.(R18 HS 17786)developed an alternative to the traditional approachof having a nurse conduct home visits and telephonefollowup after discharge from the hospital. Te

project team developed an IVR system that helpscoach primarily patients in rural areas after they aredischarged from the hospital to the home. Te IVR

system calls patients during specified intervals afterdischarge and stores the patient responses regard-ing symptoms, signs, behaviors, or other issues in asecure database that is monitored by a care transitionnurse. Te nurse follows up on potential warningsigns by telephone with the goal of reducing hospitalreadmissions. Dr. Ritchie evaluated the impact of thesystem on reducing rehospitalizations in a random-ized controlled trial of patients.

Hardeep Singh, M.D.(R18 HS 17820) created asystem to identify patients who experience delays

during the cancer diagnosis and treatment processand then facilitate their progression through thediagnosis and treatment process through informationsharing with relevant clinicians. Te system includesthree types of cancer where early detection andtreatment may improve survivalcolon, lung, andprostate. It uses trigger-based data mining of an EHRrepository to identify patients experiencing delays,combined with targeted electronic communicationand surveillance techniques to facilitate care designedto reduce the time intervals between several key steps

in the optimal pathway of cancer diagnosis and treat-ment. Dr. Singh evaluated the impact of the systemon reducing delays in diagnosis in a randomizedcontrolled trial of clinicians.


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Integrating Patient InformationAcross Transitions in Care

BackgroundSafe and effective transitions across care settings orproviders of care are critically important for patients

with complex health care needs, as there is increasedrisk of adverse events (e.g., medication interactions,new or worsening symptoms, transfer to a higherintensity care setting, or death) during transitionsbetween ambulatory care settings and other settingssuch as hospitals, home care, and nursing homes.Health I can play an important role in ensuringeffective transitions by integrating or transferringpatient information across settings. Key issues for

research include what information is needed fromthe various participants in care delivery (e.g., primarycare practices, home health care, skilled nursing facil-ities, patients themselves) to enable effective ambula-tory care and improve patient outcomes; how theintegration of information from all clinicians (e.g.,physicians, nurses, and other clinicians) and settingscan improve the quality and safety of care, includingeffectiveness, patient-centeredness, efficiency, andequity; and how health I can alleviate miscommu-nication at the time of patient hand-offs and transi-

tions in institutional and community settings.

Highlights From the ProjectsEight of the projects focused on the quality of carebefore, during, or after transitions. Tese projectsall focused on patients who were transitioning to orfrom an ambulatory setting and included strategiesfor transferring or integrating information acrosssettings of care. Te investigators used a variety oftechnologies for this purpose, including regionalHIEs, PHRs linked with EHRs, and automated tele-phone systems, although not all were able to achieveelectronic integration of information across cliniciansand settings of care. Tese technologies supported

a range of approaches for delivering high-qualitycare across transitions, such as enhanced hospitaldischarge management, improved patient monitor-ing following transitions, and improved medicationreconciliation and management. Figure 3 illustratesthe type of transitions studied across the MCP proj-ects. Ambulatory care settings included both primarycare and specialty care. Tese projects are described inmore detail below.

Te HIE designed and implemented by Ms. Baker

was intended to support patients in rural areasbeing treated for mental illness and transitioning

TABLE

1 Number of Projects by Type of Transition in Care Addressed*

Transition To Setting of Care

Transition From

Setting of Care Ambulatory Home Health Hospital

Ambulatory 3

1

Hospital 5 1

Skilled Nursing 1

* Some projects addressed multiple types of transitions.


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between behavioral health clinicians, primary carepractitioners, hospitals in rural areas, or emergencybehavioral health systems. Te system integrates

and makes available a standardized informationset that is accessible by clinicians across settings ofcare, including diagnoses, medications, involve-ment with other clinicians, and treatment plans.It also provides information on available supportsystems in place for the patient, which may avoidthe need for placement in emergency protectivecustody or an inpatient admission during a crisis.

Dr. Cieminsstudied a care transition informa-tion transfer system that facilitates the exchangeof information after a patient in a rural area is

discharged home from the hospital. Building off anexisting EHR at a large community health system,the care transition information system provideselectronically generated discharge instructions,including a patient-friendly medication list, to thepatient at discharge, and sends by fax the sameinformation to the patients outpatient clinic. Tesystem prompts clinicians in rural areas to accessmore complete medical information through thehospital EHR.

Dr. Feldmanfocused on facilitating patient-clini-

cian communication after patients transitioned tohome health care from an acute care setting. Teintervention was based on improving informationflow during these transitions, using an algorithmto provide a risk assessment, alerts, reminders, andpoint-of-care decision support to home healthnurses visiting patients at risk of a potentially seri-ous medication problem. Along with educationalinformation for the patients, the system aimed tofacilitate better communication between the homehealth nurse and patient.

Te EHR-based medication reconciliation systemdesigned by Dr. Fieldsupported elderly patients

with complex medical conditions transitioningfrom a skilled nursing facility to ambulatory care.Te system provides alerts to ambulatory cliniciansand to nurses making home visits. Because of chal-lenges automating the production and transmis-sion of the alerts, the researchers relied on manualfaxes to transmit them. Te alerts provided key

information, such as changes in clinical status andnew medications and monitoring needs to improvemedication monitoring and followup care duringthis high-risk transition.

Te automated telephone followup system devel-oped by Dr. Friedmanfor patients with complexhealth care needs after discharge from an acute caresetting initiated 7- to 20-minute virtual visitsthrough the phone, collecting information thatallows for the identification of important clini-cal problems (e.g., an exacerbation in a disease,inadequate patient self-care behaviors). Te systemorganizes the alerts for a nurses review and action.Te system is linked with the EHR system thatis used by the patients physician so the nurse can

create and send a clinical note about the patientsclinical problem and what action she took (if any).

Drs. Lobachand Eisensteinenhanced an existingHIE and decision support tool so as to detect tran-sitions in care and deliver timely, patient-specificinformation about these transitions to patients,primary are clinicians, and members of the mul-tidisciplinary care management team by fax orEmail. Te system focuses on three specific tran-sitionsthe transition back to the primary careprovider (PCP) after an inpatient stay, ED encoun-

ter, or specialty clinic evaluation. Te informationcommunicated includes diagnoses, procedures,clinicians on the care team, and scheduled appointments. In addition, the primary care clinician isgiven access to encounter notes from the specialistevaluation, ED encounter, and hospitalization.Te system also provides patients with educationalmaterials related to the primary diagnosis for theencounter.

On August 18, 2011, AHRQ hosted a national W

conference on utilizing health IT to improve med

cation management for the care of elderly patienfeaturing Dr. Field. Information about this nation

Web conference can be found at:

http://healthit.ahrq.gov/medicationmanagement

forelderlyteleconference
http://healthit.ahrq.gov/medicationmanagementforelderlyteleconferencehttp://healthit.ahrq.gov/medicationmanagementforelderlyteleconferencehttp://healthit.ahrq.gov/medicationmanagementforelderlyteleconference


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Dr. Mertensfocused on pediatric cancer survivorsmaking the transition from cancer treatment byan oncologist to ongoing care by other clinicians;

transitions in care clinicians due to relocation, jobchange, or insurance change; and the transitionfrom pediatric to adult care at ages 18 to 21. Tesystem enabled patients to give clinicians access toinformation on the patients cancer treatment, riskprofile, other chronic conditions, and late effectsexperienced by the patient following cancer treat-ment. Clinicians may view or download this infor-mation in document form.

Te IVR system developed by Dr. Ritchiewasdesigned to coach primarily patients in rural areas

after they are discharged from the hospital to thehome. Te IVR system calls patients during speci-fied intervals after discharge to gather informationon symptoms, signs, behaviors, or other issues using

questions tailored to each patients medicationlist, problem list, and discharge instructions. Tepatient-reported information is stored in a secure

database that is monitored by a care transitionsnurse who intervenes by telephone as necessary.Patients may also grant access to the database totheir primary care physician so the physician canreview the patient-entered data.

On April 8, 2010, AHRQ hosted a national Web

conference on patient empowerment featuring

Dr. Ritchie. Information about this national Web

conference can be found at:

http://healthit.ahrq.gov/patientempowermenttel

econference
http://healthit.ahrq.gov/patientempowermentteleconferencehttp://healthit.ahrq.gov/patientempowermentteleconferencehttp://healthit.ahrq.gov/patientempowermentteleconference


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Supporting Clinical Workflow

BackgroundShared decisionmaking is a process in which boththe patient and physician contribute to the medicaldecisionmaking process to arrive at informed, mutualchoices. Clinicians explain treatment alternatives topatients, along with information on risks and ben-efits, so that patients can choose the option that mostclosely aligns with their values and priorities. Patientparticipation can lead to greater self-efficacy, which,in turn, can lead to better health outcomes (Heisleret al., 2002). Furthermore, when a patient more fullyparticipates in the decisionmaking process, self-man-agement behaviors improve (Hibbard et al., 2007).

Shared decisionmaking depends upon successfulpatient-clinician communication. In addition, severalMCP projects focused on other aspects of improvingpatient-clinician communication by using health Ifor either synchronous or asynchronous secure mes-saging or electronic visits as a substitute or supple-ment for in-person clinical visits or to support effec-tive clinical interactions during office visits by helpingpatients and clinicians better prepare for the visit.

Electronic communications can enhance and extendthe personal connections patients have with their doc-tors and other clinicians, offering patients the oppor-tunity for sustained collaboration and more involve-ment in their own care. Such communications areemerging as a key component in patient-centered careand patient-centered relationships (Francis, 2012).

Highlights From the ProjectsFour projects focused on shared decisionmaking ormethods to enhance the ability of patients, families,and caregivers to share information with clinicians

to improve care and facilitate timely interventionswhen warranted. More detailed explanations of howthese researchers used health I to enhance shareddecisionmaking or patient-clinician communicationfollow:

Dr. Drussadapted an existing PHR to meet theneeds of individuals with serious mental illnessand one or more comorbid medical conditions.

Each patient works with a clinical care special-ist to develop a shared care plan within the PHRand may use secure Email communications withthe clinical care specialist and other cliniciansthat the patient authorizes through the PHR. TePHR thus facilitates patient-clinician communica-tion and shared decisionmaking, with the goal ofimproving the quality of care.

Dr. Friedmanfocused on patients who frequentlytransition between the hospital or ED and ambula-tory care clinicians, with particular attention to thetransition back home after an acute episode andthe period between ambulatory visits. Te auto-mated telephone followup system automaticallyalerts clinicians about patient-reported problemssuch as an exacerbation in a disease or inadequatepatient self-care behaviors based on patient reportsof symptoms, behaviors, and vital signs. Except inurgent or emergent situations, alerts go to nursesfor triage rather than to physicians. Te systemorganizes the alerts for the nurses review, action,documentation, and communication to the PCPand other clinicians for appropriate followup.

Te enhanced PHR created by Dr. Kahnhelps

patients with HIV/AIDS understand their medicalrecord and connect them to resources to supportshared decisionmaking and communication suchas medication information (e.g., photographs ofmedications with generic and trade names of themedications), problem lists, and guides to inter-preting laboratory values. Te tool also helps themaccess support services, including help in quittingsmoking, managing depression, reducing anxiety,and adhering to medication regimens.

On February 27, 2013, AHRQ hosted a national

Web conference on enhancing behavioral health

care featuring Dr. Druss and Ms. Baker. Informatiabout this national Web conference can be found

http://healthit.ahrq.gov/enhancingbehavioralhea

careteleconference
http://healthit.ahrq.gov/enhancingbehavioralhealthcareteleconferencehttp://healthit.ahrq.gov/enhancingbehavioralhealthcareteleconferencehttp://healthit.ahrq.gov/enhancingbehavioralhealthcareteleconference


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Te PHR developed and assessed by Dr. Mertensprovided educational materials for clinicians toimprove awareness of issues and best practices

related to care of pediatric cancer survivors oncethey reach adulthood. Te patient can share infor-

mation about their medical condition or care planwith any clinicians involved in their care so as toimprove communication and provide individual-

ized data to support shared clinical decisions.


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Strategies for Safe, Successful, andProductive Adoption of Health IT

BackgroundHealth I cannot be fully effective in improving themanagement of patients with complex health careneeds unless clinicians and patients use it. Yet clini-cian and patient acceptance and use of health I iscontingent on overcoming both organizational andtechnical barriers at different stages of the implemen-tation process. Barriers and facilitators to adoptionin clinical settings can occur at the strategic, opera-tional, and frontline levels (Avger et al., 2012) as theimplementation of health I systems affects culturaland organizational factors at all of these levels. Inaddition to meeting clinician needs and preferences,consumer or patient needs and preferences must alsobe taken into account in the design and implemen-tation of health I systems that depend upon theiruse and adoption. Te MCP initiative focused onimproving understanding of the essential strategiesfor safe, successful, and productive adoption of healthI for the delivery of patient-centered care to patients

with complex health care needs. Tese strategiesmay include changes in team roles and collaborative

workflows within and across settings of care, organi-

zational and cultural factors associated with successfuladoption, payment and financing models to sustainthe use of health I, and ways to react to unantici-pated consequences of health I implementation.

Highlights From the ProjectsTree projects focused on developing an improvedunderstanding of the strategies, benefits, and barriers tothe adoption of health I by ambulatory care clinicians:

Ms. Bakerevaluated acceptance and adoptionof the regional HIE in behavioral health settings

through interviews and surveys of behavioral healthcare clinicians to assess their perceived importanceof benefits and barriers to electronically exchangingclinical information. Tree themes emerged from theinterviews regarding attitudes towards quality of care,privacy, and delivery of services. Beliefs about thequality benefits of electronic data sharing contributedto generally positive views of these technologies, but

patient privacy concerns, and cost and increasedstaff time were frequently mentioned as significantbarriers to adopting HIEs. Cost-saving approaches,such as shared computing services, may be neededto make health I financially viable for behavioralhealth providers, many of whom operate in smallpractices.

Dr. Feldmanexamined the adoption of the deci-sion support system that facilitated patient transi-tions from an acute care setting to home health careby monitoring the ways in which home health care

nurses used the tool as well as the overall level of itsadoption. Te intervention was designed based onstrategies that had proven successful in other contextssuch as ensuring that decision support informationis computer-generated, provided as part of clinician

workflow, offers recommendations in addition toassessments, and is delivered at the time a place ofdecisionmaking. During the project, the researcherslearned that adoption of the system was limited bythe lack of opportunity to orient and train staff aboutthe clinical importance of the intervention supportedby the decision support system as well as by the rela-tively short time that most post-acute patients wereexposed to the intervention prior to being dischargedfrom home care.

As part of the implementation of the adoption of theHIE-based tool for delivering timely, patient-specificinformation about selected transitions in care toprimary care clinicians, Drs. Lobach andEisensteinperformed workflow analyses for each study site tobetter understand how to integrate this new informa-tion into existing workflows. Te researchers dis-

covered that the inability to electronically exchangerelevant clinical information regarding patient transi-tions and the need to rely on Email and fax to trans-mit this information instead limited the availabilityof the information at the time a patient visited his orher medical home provider when it would have beenof most use. Te integration of this new informationflow into existing workflows remained a problem fora significant number of study sites.


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Impact of Health IT on Outcomes Related to PatientsWith Complex Health Care Needs in AmbulatorySettings and Across High-Risk Transitions of Care

Tis section summarizes the impact of the projectson several types of outcomes related to patients withcomplex health care needs in ambulatory settings andacross high-risk transitions of care, including processoutcomes,1intermediate outcomes,2and economicoutcomes,3where the effects were statistically signifi-cant. Several projects showed an impact on processoutcomes related to clinician use of health I or thecompletion of ambulatory followup visits. In addi-tion, several projects showed an impact on inter-mediate outcomes, including patient engagement.Other projects demonstrated an impact on economicoutcomes such as hospitalizations or ED visits. Noneof the projects demonstrated a significant impact onhealth outcomes. Tese results are highlighted below.

o facilitate evaluation across projects, AHRQencouraged the MCP researchers to report on par-ticular outcome measures where applicable, includingadoption and use of health I; the delivery of appro-priate care for prevention, treatment, and medicationtherapy; the percent of patients who have access tothe personal health information; patient and clinician

access to and use of quality measurement reports,and patient experience of care, especially as assessedthrough the Consumer Assessment of HealthcareProviders and Systems (CAHPS) Clinician & GroupSurvey. Studies that addressed these measures arenoted below. Several of the MCP researchers arefinalizing their analyses and may report additionalsignificant findings when their studies are complete.

Process Outcomes

Clinician Use of Health IT

AHRQ encouraged the researchers to assess the adop-tion and use of health I in the MCP projects. Oneproject reported findings regarding clinician use ofhealth I.

In Dr. Feldmansstudy of medication managemenclinical decision support for home health nurses,80 percent of the nurses randomly assigned tothe intervention arm of the study documented amedication management action in the patient-carerecord system. Te most commonly documentedactions were patient education and updating themedication list. Nurses who were older, more expe-rienced, and who had a larger number of patients

were more likely to use the system.

Another evaluation area of interest to AHRQ was

patient and clinician access to and utilization ofquality measurement reports, especially if accessedthrough an HIE. Several of the projects includedquality measurement reports in the intervention, butnone reported on access to or utilization of them.

Ambulatory Processes of Care

AHRQ also asked that the MCP researchers assessthe delivery of appropriate care for prevention, treat-ment, and medication therapy. Tree projects dem-onstrated an impact on the frequency of followup

visits where such care may be delivered, and otherprocess measures.

Patients who received the care transition interven-tion implemented by Dr. Cieminsthat facilitatesthe exchange of information after a patient in arural area is discharged home from the hospital weresignificantly more likely to visit a PCP within thefirst 14 and 30 days following discharge comparedto the baseline period. For example, 49 percent ofpatients with medically complex conditions saw theirPCP within the first 30 days after discharge, while

75 percent saw any clinician. Both rates were signifi-cantly above the baseline period (40 and 64 percent,respectively).

1 Process outcomes include actions taken by members of a clinical team or by patients in the course of care delivery or self-management.

2 Intermediate outcomes are indicators that are impacted by processes and that may precede or lead to health outcomes. Health outcomes aresymptoms and conditions that patients can feel or experience.

3 Economic outcomes include costs, and measures of utilization that drive costs, such as hospitalizations and emergency department visits.


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In Dr. Dorrsevaluation of the primary care inter-vention for enhanced care coordination and qualityimprovement through financial incentives, and the

use of care managers and health I, the researchersfound that at clinics that were randomly assignedto receive incentive payments for care coordina-tion, more care coordination activities (e.g., assess-ments, education, communication) took place. Incontrast, at clinics that were randomly assigned toreceive incentive payments for improving qualitymeasures, greater improvements in measures suchas screening and monitoring were observed.

Drs. Lobach andEisensteinfound that patientsrandomly assigned to the intervention group (e.g.,patients whose primary care providers and care

managers received notifications of specific caretransition events) had significantly more frequentcontact with their care manager than did thosereceiving usual care, with most of the increasedcontact coming by telephone.

On May 14, 2013, AHRQ hosted a national Web

conference on using health IT to enable care coor-dination featuring Dr. Dorr. Information about this

national Web conference can be found at:

http://healthit.ahrq.gov/greatercarecoordination-

teleconference

Intermediate Outcomes

Patient Engagement

AHRQ was interested in evaluations of the percentof eligible patients who have access to their personalhealth information. wo projects showed improvement

in patient engagement, and use of personal healthinformation as described in the following findings:

Patients who received the care transition interven-tion implemented by Dr. Cieminsthat facilitatesthe exchange of information after a patient in arural area is discharged home from the hospital were

more likely to report receiving education on theirmedications by phone after their hospitalization.

In Dr. Ritchiesstudy of a system for automated tele-

phone followup for patients in rural areas after a hos-pital discharge, over 90 percent of patient answeredone or more calls, and almost one-third answered allseven calls in the first week, a response rate consideredoptimal by the researchers. Nearly two-thirds had atleast one red flag during the first call indicating theneed for a followup call by a coach.

Patient Experience and Patient-ClinicianCommunication

AHRQ encouraged use of the CAHPS Clinician &

Group Survey to assess patients perception of andexperience of care, especially in the areas of access,clinician communication, and shared decisionmak-ing. Four researchers used CAHPS, although onlyone demonstrated a significant impact:

Dr. Dorrfound that patient satisfaction did notchange significantly except for a 9-percent increasein appointment ease at clinics that were randomlyassigned to receive incentives for care coordina-tion; these clinics had an unusually low baseline inthis area at the beginning of the study, which may

explain this increase.

Clinician Perceptions of Health IT and HealthCare Processes

wo of the researchers reported findings regardingclinician perceptions of health I systems and theirimpact on care processes.

Ms. Bakeridentified perceived benefits and bar-riers of using HIE through interviews with 32community behavioral health clinicians. Benefitsto the quality of care, such as improved continuity

and coordination, and more complete medicationinformation, were mentioned by all of the clini-cians. In contrast, more than half expressed con-cern about the possibility of miscommunicationsbetween clinicians. Most respondents (81 percent)expressed overall positive views toward electronicdata sharing.
http://healthit.ahrq.gov/greatercarecoordinationteleconferencehttp://healthit.ahrq.gov/greatercarecoordinationteleconferencehttp://healthit.ahrq.gov/greatercarecoordinationteleconference


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Clinicians in counties that were included in thecare transition intervention implemented by Dr.Cieminsthat facilitates the exchange of informa-

tion after a patient in a rural area is dischargedhome from the hospital were significantly morelikely to report that the care transition process wasefficient and reliable (63 versus 38 percent), andbelieved that their patients were more likely to getadequate information about their medications atthe time of discharge.

Medication Management

One project assessed the impact of the interventionon a measure of medication complexity.

In Dr. Feldmans study of medication manage-ment clinical decision support for home healthnurses, patients whose nurse used the system

were more likely to move below the threshold formedication complexity than patients whose nursehad the opportunity to use the system, but did not,indicating that their medication regimens had beensimplified (8.1 versus 4.5 percent).

Economic OutcomesFour studies reported an impact on an economicoutcome:

Dr. Dorrfound a significant decrease in hospitalbed days in the 6 months following the imple-mentation of the primary care intervention forenhanced care coordination and quality improve-ment through financial incentive, care managers,and health I.

In Dr. Feldmansstudy of medication managemenclinical decision support for home health nurses,patients whose nurse used the system were signifi-cantly less likely to be hospitalized (17.9 versus21.3 percent).

In Dr. Fieldsstudy of medication monitoring andfollowup care for complex elderly patients transi-tioning from a skilled nursing facility to ambula-tory care, ED visits within 30 days discharge weresignificantly lower in the intervention group (17versus 7 percent) compared to the baseline period.

In Dr. Ritchiesstudy of a system for automatedtelephone followup for patients in rural areas aftera hospital discharge, patients randomly assigned tothe intervention had significantly fewer days out

of the community due to a readmission or deathin the first 30 days after discharge (0.5 versus 1.6)compared to the control group.


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Conclusion

Te projects funded under the Improving Manage-ment of Individuals With Complex Healthcare NeedsTrough Health I Initiative demonstrated progresstoward understanding the effective use of healthI to better deliver care to patients with complexhealth care needs in the ambulatory setting. Teydeveloped and tested a range of health I-enabledapproaches to better serve these patients, with a focuson approaches to providing high-quality, appropri-ate care, especially during transitions to ambulatorysettings. Several projects showed a positive impact onoutcomes related to clinician acceptance and use of

health I as well as improving the flow of informa-tion when patients transition from one clinician toanother. Other projects demonstrated high levels ofpatient engagement in self-care, while several of themshowed an impact on reducing hospital or ED use.

Tese projects demonstrated the potential of EHRsand PHRs to effectively move evidence-based infor-mation to the point of care, including the transfer ofstructured information between clinical data systems.Te researchers also studied ways to increase the

participation of clinicians, patients, and families inHIE. Te studies highlighted a number of barriersand facilitators to the use of health I to improve themanagement of individuals with complex health careneeds. For example, the researchers encountered andin some cases adapted to challenges integrating newhealth I systems or components into establishedclinical information systems and workflows.

Te findings, lessons, and insights from this initiativecan inform researchers and implementers interestedin using health I to support better management of

individuals with complex health care needs, includingduring patient transitions across care settings. Giventhe continuing interest in the use of health I toimprove health care delivery and health and the posi-tive impact of these approaches on a range of healthcare outcomes, the results of this body of research aretimely and relevant to efforts to better serve patients

with complex health care needs.


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Greenfield S, Kaplan SH, Ware JE, et al. Patients

participation in medical care: effects on blood sugarcontrol and quality of life in diabetes. J Gen InternMed 1988 Sep-Oct; 3(5):448-57.

Heisler M, Bouknight RR, Hayward RA, et al. Terelative importance of physician communication,

participatory decision making, and patientunderstanding in diabetes self-management. J GenIntern Med 2002 Apr;17(4):24352.

Hibbard JH, Mahoney ER, Stock R, et al. Doincreases in patient activation result in improvedself-management behaviors? Health Serv Res 2007Aug;42(4):144363.

Hsiao CJ, Hing E, Socey C, et al. Electronic healthrecord systems and intent to apply for meaningfuluse incentives among office-based physician practices:United States, 20012011. NCHS data brief, no 79.

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Institute of Medicine. Priority areas for nationalaction: transforming health care quality. Washington,DC: Te National Academies Press; 2003.

Lorig KR, Sobel DS, Stewart AL, et al. Evidencesuggesting that a chronic disease self-managementprogram can improve health status while reducinghospitalization: a randomized trial. Med Care 1999Jan;37(1):5-14.

Rich E, Lipson D, Libersky J, et al. Coordinating carefor adults with complex care needs in the patient-centered medical home: challenges and solutions.White Paper (Prepared by Mathematica PolicyResearch under Contract No. HHSA290200900019I/HHSA29032005). AHRQ Publication No. 12-0010-EF. Rockville, MD: Agency for HealthcareResearch and Quality. January 2012.

Schoen C, Osborn R, Squires D, et al. New 2011survey of patients with complex care needs in elevencountries finds that care is often poorly coordinated.Health Aff (Millwood) 2011 Dec;30(12):2437-48.
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Appendix: Improving Management of Individuals WithComplex Healthcare Needs Through Health IT Projects

PrincipalInvestigator (PI) Institution Project Title*

MCP Initiative Areas of InterestAddressed

Baker, Wende Southeast Nebraska

Behavioral Health

Information Network

Chronic Mental Health: Improving

Outcomes Through Ambulatory Care

Coordination

Improving Quality, Transitions in Care,

Adoption of Health IT, Impact on

Outcomes

Ciemins, Elizabeth Billings Clinic

Foundation

Evaluation of Effectiveness of an Health

Information Technology-based Care

Transition Information Transfer System


Impact on Outcomes

Dorr, David Oregon Health and

Science University

Enhancing Complex Care Through an

Integrated Care Coordination Informa-

tion System

Improving Quality, Impact on Outcomes

Druss, Benjamin Emory University An Electronic Personal Health Record for

Mental Health Consumers

Improving Quality, Communication/

Shared Decisionmaking

Feldman, Penny Visit ing Nurse Service

of New York

Improving Medication Management

Practices and Care Transitions Through

Technology


Adoption of Health IT, Impact onOutcomes

Field, Terry University of

Massachusetts

Medical School -

Worcester

Using Health Information Technology to

Improve Transitions of Complex Elderly

Patients from Skilled Nursing Facilities

(SNF) to Home


Impact on Outcomes

Friedman, Robert Boston Medical Center A Longitudinal Telephone and Mul-

tiple Disease Management System To

Improve Ambulatory Care


Communication/Shared Decisionmaking

Kahn, James University of California

San Francisco

Randomized Control Trial Embedded in

an Electronic Health Record

Improving Quality, Communication/

Shared Decisionmaking

Lobach, David and

Eisenstein, Eric

Duke University Improving Care Transitions for Complex

Patients through Decision Support


Adoption of Health IT, Impact onOutcomes

Mertens, Ann Emory University Improving Pediatric Cancer Survivorship

Care Through SurvivorLink


Communication/Shared Decisionmaking

Ritchie, Christine University of Alabama

at Birmingham

E-Coaching: IVR-Enhanced Care Transi-

tion Support for Complex Patients


Impact on Outcomes

Singh, Hardeep Baylor College of

Medicine

Using Electronic Data To Improve Care

of Patients With Known or Suspected

Cancer

Improving Quality

* To access descriptions of each project, please select the respective project title.
http://healthit.ahrq.gov/ahrq-funded-projects/chronic-mental-health-improving-outcomes-through-ambulatory-care-coordinationhttp://healthit.ahrq.gov/ahrq-funded-projects/chronic-mental-health-improving-outcomes-through-ambulatory-care-coordinationhttp://healthit.ahrq.gov/ahrq-funded-projects/chronic-mental-health-improving-outcomes-through-ambulatory-care-coordinationhttp://healthit.ahrq.gov/ahrq-funded-projects/evaluation-effectiveness-health-information-technology-based-care-transitionhttp://healthit.ahrq.gov/ahrq-funded-projects/evaluation-effectiveness-health-information-technology-based-care-transitionhttp://healthit.ahrq.gov/ahrq-funded-projects/evaluation-effectiveness-health-information-technology-based-care-transitionhttp://healthit.ahrq.gov/ahrq-funded-projects/enhancing-complex-care-through-integrated-care-coordination-information-systemhttp://healthit.ahrq.gov/ahrq-funded-projects/enhancing-complex-care-through-integrated-care-coordination-information-systemhttp://healthit.ahrq.gov/ahrq-funded-projects/enhancing-complex-care-through-integrated-care-coordination-information-systemhttp://healthit.ahrq.gov/ahrq-funded-projects/electronic-personal-health-record-mental-health-consumershttp://healthit.ahrq.gov/ahrq-funded-projects/electronic-personal-health-record-mental-health-consumershttp://healthit.ahrq.gov/ahrq-funded-projects/improving-medication-management-practices-and-care-transitions-throughhttp://healthit.ahrq.gov/ahrq-funded-projects/improving-medication-management-practices-and-care-transitions-throughhttp://healthit.ahrq.gov/ahrq-funded-projects/improving-medication-management-practices-and-care-transitions-throughhttp://healthit.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-transitions-complex-elderlyhttp://healthit.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-transitions-complex-elderlyhttp://healthit.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-transitions-complex-elderlyhttp://healthit.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-transitions-complex-elderlyhttp://healthit.ahrq.gov/ahrq-funded-projects/longitudinal-telephone-and-multiple-disease-management-system-improvehttp://healthit.ahrq.gov/ahrq-funded-projects/longitudinal-telephone-and-multiple-disease-management-system-improvehttp://healthit.ahrq.gov/ahrq-funded-projects/longitudinal-telephone-and-multiple-disease-management-system-improvehttp://healthit.ahrq.gov/ahrq-funded-projects/randomized-controlled-trial-embedded-electronic-health-recordhttp://healthit.ahrq.gov/ahrq-funded-projects/randomized-controlled-trial-embedded-electronic-health-recordhttp://healthit.ahrq.gov/ahrq-funded-projects/improving-care-transitions-complex-patients-through-decision-supporthttp://healthit.ahrq.gov/ahrq-funded-projects/improving-care-transitions-complex-patients-through-decision-supporthttp://healthit.ahrq.gov/ahrq-funded-projects/improving-pediatric-cancer-survivorship-care-through-survivorlinkhttp://healthit.ahrq.gov/ahrq-funded-projects/improving-pediatric-cancer-survivorship-care-through-survivorlinkhttp://healthit.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-ivr-enhanced-care-transition-supporthttp://healthit.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-ivr-enhanced-care-transition-supporthttp://healthit.ahrq.gov/ahrq-funded-projects/using-electronic-data-improve-care-patients-known-or-suspected-cancerhttp://healthit.ahrq.gov/ahrq-funded-projects/using-electronic-data-improve-care-patients-known-or-suspected-cancerhttp://healthit.ahrq.gov/ahrq-funded-projects/using-electronic-data-improve-care-patients-known-or-suspected-cancerhttp://healthit.ahrq.gov/ahrq-funded-projects/using-electronic-data-improve-care-patients-known-or-suspected-cancerhttp://healthit.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-ivr-enhanced-care-transition-supporthttp://healthit.ahrq.gov/ahrq-funded-projects/improving-pediatric-cancer-survivorship-care-through-survivorlinkhttp://healthit.ahrq.gov/ahrq-funded-projects/improving-care-transitions-complex-patients-through-decision-supporthttp://healthit.ahrq.gov/ahrq-funded-projects/randomized-controlled-trial-embedded-electronic-health-recordhttp://healthit.ahrq.gov/ahrq-funded-projects/longitudinal-telephone-and-multiple-disease-management-system-improvehttp://healthit.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-transitions-complex-elderlyhttp://healthit.ahrq.gov/ahrq-funded-projects/improving-medication-management-practices-and-care-transitions-throughhttp://healthit.ahrq.gov/ahrq-funded-projects/electronic-personal-health-record-mental-health-consumershttp://healthit.ahrq.gov/ahrq-funded-projects/enhancing-complex-care-through-integrated-care-coordination-information-systemhttp://healthit.ahrq.gov/ahrq-funded-projects/evaluation-effectiveness-health-information-technology-based-care-transitionhttp://healthit.ahrq.gov/ahrq-funded-projects/chronic-mental-health-improving-outcomes-through-ambulatory-care-coordination

ahrq hit findings and lessons from improving management of individuals with complex health care...

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