Reduced emergency room and hospital utilization in persons with multiple chronic conditions and disability receiving home-based primary care.

BACKGROUND: Persons with multiple chronic conditions and disability face access barriers to office-based primary care and have very high rates of emergency department (ED) use and hospital admissions. Home-based primary care (HBPC) has been proposed as a way to improve disease management and prevent health crises. HYPOTHESIS: Enrollment of patients with disability and multiple chronic conditions in a HBPC program is associated with a subsequent decrease in ED visits and hospital admissions. METHODS: We abstracted electronic medical record (EMR) data among patients receiving HBPC and compared rates per 1000 patient days for ED visits, admissions, 30-day readmissions, and inpatient days for up to three years before and after enrollment. RESULTS: Of 250 patients receiving HBPC, 153 had admission data recorded in our EMR prior to enrollment. One year after HBPC enrollment, the rate of admissions dropped by 5.2 (95% confidence interval 4.3, 6.0), 30-day readmissions by 1.8 (1.3, 2.2) and inpatient days by 54.6 (52.3, 56.9) per 1000 patient-days. Three years post-enrollment, rates remained below baseline by 2.2 (1.3, 3.1) for admissions, 0.5 (0.04, 1.0) for 30-day readmissions and 32.2 (29.8, 34.7) for inpatient days. Among 91 patients with pre-enrollment ED data, the rate of ED visits also dropped at one and three years by 5.5 (4.6, 6.4) and 2.7 (1.7, 3.7), respectively. CONCLUSION: Provision of HBPC for persons with multiple chronic conditions and disability is associated with a persistent reduction in ED and hospital use.

Testing of a tethered personal health record framework for early end-of-life discussions.

OBJECTIVES: The process of planning for end-of life decisions, also known as advance care planning (ACP), is associated with numerous positive outcomes, including improved patient satisfaction with care and improved patient quality of life in terminal illness. In this study, we sought to test a novel personal health record (PHR)-delivered ACP framework through a small-scale randomized trial of usual care practices versus PHR-delivered ACP. STUDY DESIGN: Randomized controlled pilot intervention. METHODS: A novel PHR-ACP tool was tested using data and feedback collected in a randomized controlled pilot intervention (n = 50). Participants in the control group received standard care for ACP conversations while participants randomized to the intervention group received a novel ACP framework through the electronic health record. RESULTS: The pilot study testing the ACP framework found that its use resulted in improved ACP documentation rates (P = .001) and quality (P = .007) compared with usual care. CONCLUSIONS: Tethered PHR use as an initial ACP communication tool can improve outpatient documentation rates and quality. Future studies obtaining patient feedback on a revised framework and testing in a larger setting are needed to determine reproducibility of findings.

Development of a tethered personal health record framework for early end-of-life discussions.

OBJECTIVES: End-of-life planning, known as advance care planning (ACP), is associated with numerous positive outcomes, such as improved patient satisfaction with care and improved patient quality of life in terminal illness. However, patient-provider ACP conversations are rarely performed or documented due to a number of barriers, including time required, perceived lack of skill, and a limited number of resources. Use of tethered personal health records (PHRs) may help streamline ACP conversations and documentations for outpatient workflows. Our objective was to develop an ACP-PHR framework that would be for use in a primary care, outpatient setting. STUDY DESIGN: Qualitative content analysis of focus groups and cognitive interviews (participatory design). METHODS: A novel PHR-ACP tool was developed and tested using data and feedback collected from 4 patient focus groups (n = 13), 1 provider focus group (n = 4), and cognitive interviews (n = 22). RESULTS: Patient focus groups helped develop a focused, 4-question PHR communication tool. Cognitive interviews revealed that, while patients felt framework content and workflow were generally intuitive, minor changes to content and workflow would optimize the framework. CONCLUSIONS: A focused framework for electronic ACP communication using a patient portal tethered to the PHR was developed. This framework may provide an efficient way to have ACP conversations in busy outpatient settings.

Diffusion and Use of Tethered Personal Health Records in Primary Care.

BACKGROUND: Personal health records (PHRs) enable patients to access their healthcare information in a secure environment, increasing patient engagement in medical care. PHRs can be tethered to a patient's electronic health record (EHR). Tethered PHRs, also known as patient portals, allow patients to access relevant medical information from their provider. Despite recent policy efforts to promote the use of health information technology and increased availability of PHRs in the clinical setting, PHR adoption rates remain relatively low overall. This article examines physician characteristics of high vs. low PHR adopters. OBJECTIVE: The objectives of this study were to (1) examine PHR use patterns in the primary care setting, (2) identify physician characteristics affecting PHR adoption, and (3) explore physician perspectives encouraging and deterring use. METHODS: Information technology records provided data on primary care patient portal use at a large Midwestern academic medical center. Electronic surveys were administered to affiliated primary care physicians to measure their perceived use of patient portals. A focus group consisting of physician providers who completed the survey was used to further elucidate the trends and perceived utilization of the patient portal in the clinical setting. RESULTS: While they expended significant time communicating with patients using the portal, physicians generally overestimated the time spent per week on the system. Physicians who had been in practice longer estimated a higher average time spent on the system when compared to newer physicians. Patient portal activation rates and use decreased with increased years in practice. During the focus groups, physicians voiced motivation to use patient portals because they perceived improved patient communication and satisfaction with use. However, continued lack of reimbursement for time spent in portal communication was reported as a major barrier to providers' engagement with this technology. DISCUSSION: Physician endorsement and engagement is critical to achieve widespread adoption of PHRs. Such endorsement can be obtained through (1) providing rewards from health system employers for high use of PHRs, (2) providing financial reimbursement for time spent electronically communicating with patients via the PHR from federal initiatives incentivizing meaningful use of health information technology, (3) building robust support staff assistance for PHR communication into primary care workflows, and (4) integrating more PHR-specific education into providers' EHR training.