Volume 16, Issue 4
Fall 2004
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Feature Article
By Katie Saunders
Information technology (IT) has been hailed as a way to improve the
quality, safety, and efficiency of health care. But can IT deliver on its
promise? The informatics research program at Group Health Center for Health Studies (CHS) seeks to find the answer while advancing
the field and helping Group Health patients benefit from innovation.
Jump-started by the hiring of informatics investigator James Ralston, MD,
MPH, one year ago, the program now has six IT-related projects
underway.
CHS’ focus on health-IT research reflects intense interest at the
national level. For example, in a joint editorial appearing in The
Washington Post in August 2004, Senators Hillary Clinton and Bill
Frist touted IT as a potential solution to some of the problems plaguing
health care in the United States. Citing findings from a study by The RAND
Corporation that U.S. adults with medical insurance receive recommended
care only 55 percent of the time, the senators argued that by using
advances in IT, we can put "the right information in the hands of
doctors and patients at the right time," and thus "improve care,
lower costs, improve quality, and empower consumers."
These high hopes pinned on IT can be traced to studies showing that
advanced electronic medical records (EMRs) increase patient safety,
improve quality of care, and save money, according to Ralston. Advanced
EMRs include some or all of the following features that can potentially
enhance the quality of care: computerized provider ordering of
medications, lab tests, etc; automated reminders and alerts for
appropriate care; real-time documentation of visits; and online
communication between providers. "There have been some successes with
advanced electronic medical records, particularly in inpatient academic
settings," Ralston explains. "This has fueled a drive to broadly
implement advanced EMRs in ambulatory and hospital-based
environments."
Group Health is no exception. While the Cooperative’s providers have
long been able to access information such as patients’ pharmacy, lab,
and allergy records online, the paper medical record has historically been
the official repository of a patient's medical history. But this paper
record is headed for obsolescence in the face of the Co-op’s shift to
EpicCare, an advanced EMR and Clinical Information System being phased in
between 2003 and 2005.
The EpicCare package also includes "My Group Health," the
patient Web portal that allows enrollees to send secure e-mail messages to
their providers, view their medical record online, and access health
promotion information relevant to their specific medical conditions.
Patients must register and verify their identification to qualify for
these enhanced Web services. Ralston emphasizes that Group Health
considers this "patient" side of EpicCare to be as important as
the "provider" side, in contrast to many other organizations
that consider patient portals to be mere "add-ons" to the EMRs
used by providers at the point-of-care.
The ultimate goal of this integrated system linking patients with
providers, and providers with other providers, is to improve the health of
patients. Offering patients more "continuous access" to
providers via secure messaging has the potential to change the paradigm of
health care delivery from predominantly acute-care, in-person visits to a
model involving more continuous care and connection. This type of system
redesign could have important implications for patients with chronic
conditions, in that it could enhance the monitoring, follow-up, and
self-management support that are so critical to the successful care of
these patients. Indeed, early data indicate that people with chronic
conditions are twice as likely to use secure messaging than are patients
without any of these conditions.
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"MyBP" will test the Web’s usefulness in blood pressure
control
While Web-based health care delivery has been heralded for its
"impressive convenience, speed, reach, information breadth and depth,
and cost efficacy benefits,1" its
possibilities are largely unexplored. Group Health, with its largely
integrated delivery system, is an ideal real-world setting to test
Web-based interventions, according to Ralston.
Robert S. "Tom" Thompson, MD, and Beverly Green, MD, MPH, are
taking advantage of this setting in their current randomized trial of a
Web-based intervention to improve care for hypertension, "MyBP."
One-quarter of adult Americans have diagnosed hypertension, and less than
half of them have blood pressure that’s under control (< 140/90). It’s
not that health care providers lack information about how to treat this
major risk factor for heart attack and stroke; physician guidelines
reflect the state-of-the-art knowledge regarding blood pressure control,
including recommendations for first-and second-line antihypertensive
medications. However, due to patient, provider, technology, and system
factors, these evidence-based recommendations are often not followed. As a
result, blood pressure control is a major public health challenge.
MyBP is a three-arm randomized trial conducted among patients with
poorly controlled hypertension. Patients will be randomly assigned to
receive: 1) usual care; 2) home blood-pressure monitors and instructions
in Web communication; or 3) all of the above plus proactive and
interactive medication management and self-management support provided
over the Web by clinical pharmacists. Patients in the intervention arm of
the study will e-mail their BP readings to the pharmacist, who, if
necessary, will provide support for better medication adherence or will
adjust the type, dose, or number of medications. The pharmacist will also
help patients with lifestyle goals, such as weight loss or tobacco
cessation. The main study outcomes to be measured are changes in blood
pressure and the percent of patients with adequately controlled blood
pressure.
In addition to Thompson and Green, My BP investigators include Ralston,
Sheryl Catz, PhD, Paul Fishman, PhD, and Carolyn Rutter, PhD, from CHS;
James Carlson, PharmD, Assistant Director of Pharmacy Administration at
Group Health; and Harold Goldberg, MD, from the University of Washington (UW) Department of Medicine.
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Web tools may help with diabetes management
Diabetes would appear to be another logical candidate for a Web-based
care management program. Because the successful management of diabetes
depends mainly on what the patient does at home and work—diet, exercise,
medication adherence—a Web-based disease management program that is
integrated into a patient’s daily life may be just the vehicle to
instigate positive lifestyle changes.
Ralston and colleagues at the UW pilot-tested a Web-based diabetes
management program among nine patients at the UW. Participants
communicated via e-mail with a case manager (a nurse practitioner) who
encouraged all patients to review their online medical records, upload
blood glucose readings weekly, and send secure messages as needed. Among
other things, participants could graphically view their blood glucose
levels at home and could engage in interactive feedback with the case
manager about their nutrition, medications, and exercise based on entries
in a Web-based self-management tool, "My Diabetes Daily Diary."
Researchers interviewed the nine pilot subjects both before and after they
used the program.
According to Ralston, the take-home message from the pilot study, which
was published in the British Medical Journal earlier this year, was
that Web-based support can fill an important gap in some populations of
patients with diabetes. On the other hand, a few patients became very
frustrated when they experienced either technological breakdowns or
breakdowns in communication with the nurse practitioner. Based on this
feedback, the researchers revised the intervention and the Web site to
clarify expectations. Ralston and Goldberg are now collaborating on three
randomized trials of Web-based diabetes management programs, one of which
involves an underserved African-American population. To make the trial
feasible, the study provided all participants with computers and training—a
step that addresses a major challenge for informatics researchers: how to
bridge the "digital divide."
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Internet access: Disparities in access present a thorny issue
Factors such as socioeconomic status, physical disability, health
literacy, technical literacy, and race/ethnicity can result in disparities
in who has online access to health information and health care. This
digital divide presents a thorny issue for researchers—to wit, the MyBP
trial had to be restricted to those patients with Web access. Although
rates of Internet access are on the rise—Seattle’s rate of 88 percent
is among the highest in the country—Ralston does not see the problem
going away anytime soon. "I think the digital divide in health care
will help force us as a society to decide how egalitarian we want our
health care to be," he says. For example, should health care Web
sites be heard as well as seen, so as to reach the visually impaired, he
asks. "I'd really like to see our health informatics program be able
to address these issues in a meaningful way so we can inform a
conversation on a national, and hopefully, international level."
A first step in tackling the issue of the digital divide is getting a
handle on who is using secure messaging and who isn't, says Ralston. That
is one of the goals of an observational study he is conducting with CHS
investigators Greg Simon, MD, MPH, and Carolyn Rutter, PhD. The
researchers will study the characteristics of users and non-users of
secure messaging among four groups of Group Health enrollees—patients
with diabetes, depression, congestive heart failure, and a group of
patients with no chronic conditions. The grant will examine the users’
age, gender, and socioeconomic status, as well as provider characteristics
such as age, tenure at Group Health, rates of secure messaging use, and
response times. A second aim of the study is to evaluate the impact of
secure messaging on the safety and effectiveness of diabetes care. The
researchers will compare quality of care indicators, such as rates of foot
exams and Hemoglobin A1c testing, for diabetes patients who use secure
messaging with their provider vs. those who have Advanced Web access but
have not yet sent a secure message to their physician.
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Study will examine how Web tools improve patient access
Some of these same issues will be examined in a broader context under a
new UW/CHS grant evaluating the impact of Group Health's "Access
Initiative." This access work, begun by Group Health management and
medical staff in 2000, reflects the Cooperative’s commitment to removing
system barriers to patient care. As part of the initiative, the
Cooperative instituted: 1) "open access," which increases the
number of same-day appointments to primary care physicians; 2)
"direct access," which allows patients to self-refer to most
specialists; and 3) "Web access," which enables patients to send
secure messages, access their medical record online, and tap into
electronic health promotion specific to their medical conditions.
Funded by a $656,000 grant to UW from the Robert Wood Johnson
Foundation, the UW/CHS team will determine the impact of the initiative on
patient access and other variables—such as continuity of care, quality
of care, costs, and patient and provider satisfaction. Investigators David
Grembowski, PhD, Douglas Conrad, PhD, and Diane Martin PhD, of the UW
Department of Public Health and Community Medicine, along with CHS
collaborators Eric Larson, MD, MPH, Ralston, and Paul Fishman, PhD, will
compare measures such as utilization, quality, and costs both before and
after implementation of the Access Initiative. For example, while it’s
hypothesized that the total number of health care encounters—in-person,
telephone, and e-mail—might be rising with the advent of the Access
Initiative, the mix may also be changing so as to lessen the relative
contribution of in-person visits, and thus, lower costs. Ralston speaks in
broad-scale terms when discussing the relevance of IT to this evaluation
project: "I think the project tries to answer the question: ‘How
does the technology side deliver—or not deliver—on the Cooperative’s
larger emphasis on improving access for patients and promoting
patient-centered care?"
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New project will establish a shared informatics platform among several
health plans
Technology is also at the heart of the new Coordinated Clinical Studies
Network (CCSN), a $3.5 million contract recently awarded to CHS by the
National Institutes of Health (NIH). Part of NIH’s initiative to re-engineer
the clinical research process, this contract seeks to develop
interoperable information systems that will enhance the productivity and
efficiency of clinical research in the United States. Led by CHS Director
Eric Larson, MD, MPH, the network will establish a powerful, shared
informatics platform, supporting clinical research into a defined
population of 13 million people (4 percent of the U.S. population)
enrolled in 13 health plans of the HMO Research Network. The goal of the
CCSN will be to conduct "translational research"—i.e.,
answering questions about the way health care innovations work in real
practice among large populations. "As the principal investigator of
this project, I feel fortunate that Group Health has been on the forefront
in developing its own clinical information system. I’m also grateful for
the strong support we’ve had from (Group Health Medical Director) Hugh
Straley, (President and CEO) Cheryl Scott, and other leaders in the
delivery system and the rest of the HMO Research Network as we submitted
this work to NIH," Larson says.
James Ralston, too, is grateful for the close working relationship he’s
enjoying with the Group Health delivery system and IT leaders. This
mutually beneficial relationship is illustrated by a recently-funded
project led by Ralston that will evaluate Group Health’s use of the
Clinical Decision Support (CDS) tool in EpicCare. CDS automatically
integrates clinical evidence with real-time patient-provider
decision-making at the point of care. For example, beginning in the fall
of 2004, Group Health providers are alerted if a patient with diabetes or
coronary artery disease has not received an appropriate prescription for
ACE inhibitors or HMG-CoA reductase inhibitors. While Group Health is
excited about CDS’ potential role in improving the quality and safety of
health care, the Informatics Department recognizes the need for systematic
evaluation, and to this end, sought the collaboration of CHS. Ralston’s
project proposes to develop an infrastructure that will facilitate ongoing
evaluations of CDS at the Cooperative.
Ralston also sits on Group Health Permanente’s Clinical Information
Systems Oversight Committee, a group of six physicians who work "on
the nuts and bolts of how EpicCare can best be used by doctors to help
patients." And that’s the bottom line for Ralston—helping
patients. "When I hear of a patient who isn’t getting the best we
can provide, that motivates me to say, ‘What are we doing wrong and how
can we do better?’ I think information technology has the potential to
help make things better," he says.
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1Berry LL, Seiders K, Wilder SS. Innovations in access to
care: a patient-centered approach. Ann Intern Med 2003;
139(7):568-74.
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