Daniel R. Longo

Engaging Primary Care Patients to Use a Patient-Centered Personal Health Record

PURPOSE Health care leaders encourage clinicians to offer portals that enable patients to access personal health records, but implementation has been a challenge. Although large integrated health systems have promoted use through costly advertising campaigns, other implementation methods are needed for small to medium-sized practices where most patients receive their care. METHODS We conducted a mixed methods assessment of a proactive implementation strategy for a patient portal (an interactive preventive health record [IPHR]) offered by 8 primary care practices. The practices implemented a series of learning collaboratives with practice champions and redesigned workflow to integrate portal use into care. Practice implementation strategies, portal use, and factors influencing use were assessed prospectively. RESULTS A proactive and customized implementation strategy designed by practices resulted in 25.6% of patients using the IPHR, with the rate increasing 1.0% per month over 31 months. Fully 23.5% of IPHR users signed up within 1 day of their office visit. Older patients and patients with comorbidities were more likely to use the IPHR, but blacks and Hispanics were less likely. Older age diminished as a factor after adjusting for comorbidities. Implementation by practice varied considerably (from 22.1% to 27.9%, P <.001) based on clinician characteristics and workflow innovations adopted by practices to enhance uptake. CONCLUSIONS By directly engaging patients to use a portal and supporting practices to integrate use into care, primary care practices can match or potentially surpass the usage rates achieved by large health systems.

Baby BEEP: A randomized controlled trial of nurses' individualized social support for poor rural pregnant smokers.

Objectives We tested the effect of nurse-delivered telephone individualized social support (“Baby BEEP”) and eight mailed prenatal smoking cessation booklets singly and in combination (2 × 2 factorial design) on smoking cessation in low-income rural pregnant women (N = 695; 75% participation). Methods Participants randomized to Baby BEEP groups (n = 345) received weekly calls throughout pregnancy plus 24-7 beeper access. Saliva cotinine samples were collected monthly from all groups by other nurses at home visits up to 6 weeks post-delivery. Primary outcomes were point prevalence abstinence (cotinine < 30 ng/ml) in late pregnancy and post-delivery. Results Only 47 women were lost to follow-up. Intent-to-treat analyses showed no difference across intervention groups (17–22%, late pregnancy; 11–13.5%, postpartum), and no difference from the controls (17%, late pregnancy; 13%, postpartum). Post hoc analyses of study completers suggested a four percentage-point advantage for the intervention groups over controls in producing early and mid-pregnancy continuous abstainers. Partner smoking had no effect on late pregnancy abstinence (OR = 1.7, 95% CI = 0.95, 3.2), but post-delivery, the effect was pronounced (OR = 3.2, 95% CI = 1.8, 5.9). Conclusions High abstinence rates in the controls indicate the power of biologic monitoring and home visits to assess stress, support, depression, and intimate partner violence; these elements plus booklets were as effective as more intensive interventions. Targeting partners who smoke is needed.

How patients want to engage with their personal health record: a qualitative study

Objective To assess factors related to use and non-use of a sophisticated interactive preventive health record (IPHR) designed to promote uptake of 18 recommended clinical preventive services; little is known about how patients want to use or be engaged by such advanced information tools. Design Descriptive and interpretive qualitative analysis of transcripts and field notes from focus groups of the IPHR users and of patients who were invited but did not use the IPHR (non-users). Grounded theory techniques were then applied via an editing approach for key emergent themes. Setting Primary care patients in eight practices of the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participants Three focus groups involved a total of 14 IPHR users and two groups of non-users totalled 14 participants. Outcomes/results For themes identified (relevance, trust and functionality) participants indicated that endorsement and use of the IPHR by their personal clinician was vital. In particular, participants’ comments linked the IPHR use to: (1) integrating the IPHR into current care, (2) promoting effective patient–clinician encounters and communication and (3) their confidence in the accuracy, security and privacy of the information. Conclusions In addition to patients’ stated desires for advanced functionality and information accuracy and privacy, successful adoption of the IPHRs by primary care patients depends on such technologys relevance, and on its promotion via integration with primary care practices’ processes and the patient–clinician relationship. Accordingly, models of technological success and adoption, when applied to primary care, may need to include the patient–clinician relationship and practice workflow. These findings are important for healthcare providers, the information technology industry and policymakers who share an interest in encouraging patients to use personal health records. Trial Registration Clinicaltrials.gov identifier: NCT00589173

The advantages and challenges of unannounced standardized patient methodology to assess healthcare communication

OBJECTIVE This paper provides an overview of the implementation of using unannounced standardized patients (USPs) to conduct health communication research in clinical settings. METHODS Certain types of health communication situations are difficult to capture because of their rarity or unpredictable nature. In primary care the real reasons for a visit are frequently unknown until the consultation is well under way. Therefore, it is logistically difficult for communication studies to capture many real-time communications between patients and their physicians. Although the USP methodology is ideal for capturing these communication behaviors, challenges to using this method include developing collaborative relationships with clinical practices, logistical issues such as safeguarding the identity of the USP, training USPs and creating their identities, maintaining fidelity to the role, and analyzing the resultant data. RESULTS This paper discusses the challenges and solutions to USP implementation. We provide an example of how to implement a USP study using an on-going study being conducted in primary care practices. CONCLUSION This paper explores the advantages and challenges as well as strategies to overcome obstacles to implementing a USP study. PRACTICE IMPLICATIONS Despite the challenges, USP methodology can contribute much to our understanding of health communication and practice.

Rethinking the Information Priorities of Patients

There is growing interest in offering patients better information to guide their health care decisions, from choosing a clinician or hospital to deciding which surgical procedure to consider.1 The availability and use of such information may be a powerful vehicle to help consumers understand their options and make informed decisions about their care.2 This movement is motivated in part by a commitment to patient engagement and activation and the importance of shared decision making for preference-sensitive decisions. For 2 decades, this movement has held that patients benefit from evidence-based materials that provide the key facts they need to make more informed choices about which options are best for them and that help them to balance the pros, cons, and scientific uncertainties surrounding available options.3 Comparative effectiveness research is thought to provide useful data to help patients weigh their options.4

Internet Use for Prediagnosis Symptom Appraisal by Colorectal Cancer Patients

Background. This study explored the characteristics of colorectal cancer (CRC) patients who accessed Internet-based health information as part of their symptom appraisal process prior to consulting a health care provider. Method. Newly diagnosed CRC patients who experienced symptoms prior to diagnosis were interviewed. Brief COPE was used to measure patient coping. Logistic and linear regressions were used to assess Internet use and appraisal delay. Results. Twenty-five percent of the sample (61/242) consulted the Internet prior to visiting a health care provider. Internet use was associated with having private health insurance (odds ratio [OR] = 2.55; 95% confidence interval [CI] = 1.20-5.43) and experiencing elimination symptoms (OR = 1.43; 95% CI = 1.14-1.80) and was marginally associated with age (OR = 0.96; 95% CI = 0.93-0.99). Internet use was not related to delayed medical care seeking. Conclusion. Internet use did not influence decisions to seek medical care. The Internet provided a preliminary information resource for individuals who experienced embarrassing CRC symptoms, had private health insurance, and were younger.

MyPreventiveCare: implementation and dissemination of an interactive preventive health record in three practice-based research networks serving disadvantaged patients—a randomized cluster trial

BackgroundEvidence-based preventive services for early detection of cancer and other health conditions offer profound health benefits, yet Americans receive only half of indicated services. Policy initiatives promote the adoption of information technologies to engage patients in care. We developed a theory-driven interactive preventive health record (IPHR) to engage patients in health promotion. The model defines five levels of functionality: (1) collecting patient information, (2) integrating with electronic health records (EHRs), (3) translating information into lay language, (4) providing individualized, guideline-based clinical recommendations, and (5) facilitating patient action. It is hypothesized that personal health records (PHRs) with these higher levels of functionality will inform and activate patients in ways that simpler PHRs cannot. However, realizing this vision requires both technological advances and effective implementation based upon clinician and practice engagement.Methods/designWe are starting a two-phase, mixed-method trial to evaluate whether the IPHR is scalable across a large number of practices and how its uptake differs for minority and disadvantaged patients. In phase 1, 40 practices from three practice-based research networks will be randomized to add IPHR functionality to their PHR versus continue to use their existing PHR. Throughout the study, we will engage intervention practices to locally tailor IPHR content and learn how to integrate new functions into their practice workflow. In phase 2, the IPHR to all nonintervention practices to observe whether the IPHR can be implemented more broadly (Scalability). Phase 1 will feature an implementation assessment in intervention practices, based on the RE-AIM model, to measure Reach (creation of IPHR accounts by patients), Adoption (practice decision to use the IPHR), Implementation (consistency, fidelity, barriers, and facilitators of use), and Maintenance (sustained use). The incremental effect of the IPHR on receipt of cancer screening tests and shared decision-making compared to traditional PHRs will assess Effectiveness. In phase 2, we will assess similar outcomes as phase 1 except for effectiveness.DiscussionThis study will yield information about the effectiveness of new health information technologies designed to actively engage patients in their care as well as information about how to effectively implement and disseminate PHRs by engaging clinicians.Trial registrationClinicalTrials.gov: NCT02138448

Are Researcher Development Interventions, Alone or in Any Combination, Effective in Improving Researcher Behavior? A Systematic Review:

Academic institutions funded by the Clinical and Translational Science Awards (CTSA) Program of the National Institutes of Health were challenged recently by the Institute of Medicine to expand traditional mentoring of graduate and postdoctoral scholars to include training and continuing education for faculty, professional staff, and community partners. A systematic review was conducted to determine whether researcher development interventions, alone or in any combination, are effective in improving researcher behavior. PubMed, CINAHL, and Education Research Complete databases and select journals were searched for relevant articles published from January 2000 through October 2012. A total of 3,459 papers were identified, and 114 papers were retrieved for in-depth analysis. None included randomization. Twenty-two papers reported subjects with professional degrees, interventions, and outcomes. Interventions were meetings, outreach visits, colleague mediation, audit and feedback, and multifaceted interventions. Most studies reported multifaceted interventions (68.2%), often involving mentored learning experiences, and meetings. All studies reported a change in performance, including numbers of publications or grant applications. Nine studies reported changes in competence, including writing, presentation, or analytic skills, and performance in research practice (40.9%). Even as, the quality of evidence was weak to establish causal linkages between researcher development and improved researcher behavior, nearly all the projects (81.8%) received funding from governmental agencies, professional societies, or other organizations. Those who design researcher development activities and those who evaluate the programs are challenged to develop tools and conduct studies that measure the effectiveness, costs, and sustainability of researcher development in the CTSA Program.

Education and patient preferences for treating type 2 diabetes: a stratified discrete-choice experiment

Purpose Diabetes is a chronic condition that is more prevalent among people with lower educational attainment. This study assessed the treatment preferences of patients with type 2 diabetes by educational attainment. Methods Patients with type 2 diabetes were recruited from a national online panel in the US. Treatment preferences were assessed using a discrete-choice experiment. Participants completed 16 choice tasks in which they compared pairs of treatment profiles composed of six attributes: A1c decrease, stable blood glucose, low blood glucose, nausea, treatment burden, and out-of-pocket cost. Choice models and willingness-to-pay (WTP) estimates were estimated using a conditional logit model and were stratified by educational status. Results A total of 231 participants with a high school diploma or less education, 156 participants with some college education, and 165 participants with a college degree or more completed the survey. Participants with a college degree or more education were willing to pay more for A1c decreases (

Engaging Patients in Decisions About Cancer Screening: Exploring the Decision Journey Through the Use of a Patient Portal

58.84, standard error [SE]: 10.6) than participants who had completed some college (