Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results

BACKGROUND: Patient-physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient-physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters. OBJECTIVE: In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient-physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters. METHODS: We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit patient important issue questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient-staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes. RESULTS: The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient-clinician communication, particularly during the COVID-19 pandemic. CONCLUSIONS: EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians\u27 work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians. TRIAL REGISTRATION: ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30431

Using CollaboRATE, a brief patient‐reported measure of shared decision making: Results from three clinical settings in the United States

Abstract Introduction: CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real‐time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations. Method All adult patients at three United States primary care practices were eligible to complete CollaboRATE post‐visit. To inform key learnings, we aggregated all mentions of unanticipated decisions, problems and administration errors from field notes and email communications. Mixed‐effects logistic regression evaluated the impact of site, clinician, patient age and patient gender on the CollaboRATE score. Results: While CollaboRATE score increased only slightly with increasing patient age (OR 1.018, 95% CI 1.014‐1.021), female patient gender was associated with significantly higher CollaboRATE scores (OR 1.224, 95% CI 1.073‐1.397). Clinician also predicts CollaboRATE score (random effect variance 0.146). Site‐specific factors such as clinical workflow and checkout procedures play a key role in successful in‐clinic implementation and are significantly related to CollaboRATE scores, with Site 3 scoring significantly higher than Site 1 (OR 1.759, 95% CI 1.216 to 2.545) or Site 2 (z=−2.71, 95% CI −1.114 to −0.178). Discussion This study demonstrates that CollaboRATE can be used in diverse primary care settings. A clinic's workflow plays a crucial role in implementation. Patient experience measurement risks becoming a burden to both patients and administrators. Episodic use of short measurement tools could reduce this burden

Patient Experiences in Selecting a Medicare Part D Prescription Drug Plan

Background/Aims: To obtain publicly subsidized prescription drug insurance, Medicare beneficiaries must enroll in one of the 28–39 private plans offered by their state. We sought to understand the experiences of individuals selecting a Part D plan, specifically what resources and which factors were of greatest importance to them. Methods: Participants were patients of a large multispecialty group practice in northern California. Potential participants were recruited through flyers, several events for seniors and an article in the group practice’s newsletter. Four focus groups were conducted from June through October 2014 until thematic saturation was reached. The 17 participants were all in a Medicare Part D plan, with ages ranging from 65 to 91 years (average of 74), primarily wealthy, retired and Caucasian. Focus groups were transcribed and qualitatively analyzed for main emergent themes. Results: Most found the process of selecting a plan to be a “nightmare” to “extremely difficult” and “confusing” due to “too many options.” Participants expressed that the characteristic of most importance to them in choosing a plan was the lowest cost, mainly through lower copays for medicines. Another important feature was the reputation of the company providing the plan to learn if “they make mistakes often,” “handle claims satisfactorily,” and “can you reach somebody if you need to.” The main resources used in the decision-making process were other people (e.g. spouse, friend, family), books, brokers, AARP, the Health Insurance Counseling and Advocacy Program –– a volunteer-supported program run by the California Department of Aging that provides unbiased information to help Medicare beneficiaries make the best choices for their individual health care needs –– and the Internet, specifically the Medicare.gov website. Conclusion: While low cost was a top priority for some, other participants reported that other characteristics like reputation of the company was so important to them that they were willing to pay a higher cost. More help from individuals and clearer information are necessary to assist Medicare beneficiaries in selecting a Medicare Part D prescription drug plan. Given that highly educated and affluent Medicare beneficiaries are finding the Part D plan selection process so difficult and complex, this poses a greater challenge for those with fewer resources

Estimating the Human Resource Costs of Developing and Implementing Shared Medical Appointments in Primary Care

Background/Aims: Shared medical appointments (SMAs) or group visits have been shown to improve access, but there is no research to date on the costs of developing and implementing SMAs. We estimate the human resource costs of developing and implementing an administrative program to support SMAs and an additional SMA on cancer survivorship. Methods: Activity-based costing was used to analyze the human resource costs for completed tasks, personnel involved and time to complete tasks. The study occurred in one division of a nonprofit, multispecialty group practice in northern California that serves 126,000 patients. We conducted in-depth, key-informant interviews with stakeholders involved in SMAs –– clinicians, coordinator, and operations manager –– from different levels of the organization. National median wages were calculated from the 2013 Bureau of Labor Statistics. Results: We estimate that the human resource cost to develop and implement a program to support SMAs was $62,874. The employee who spent the most time (1,255 hours) was the SMA coordinator and the activity that required the most time (1,211 hours,$52,945) was for research tasks including establishing workflow and logistics of a SMA program. Once the SMA program was established, the cancer survivorship SMA cost $7,271 to develop and implement. The physician who ran the cancer survivorship SMA spent the most time and provided the most expensive labor (72.5 hours,$6,513) and the most time-consuming and costly activity was the development of materials (44 hours, $3,768). Discussion: Developing and implementing a program to support SMAs took the SMA coordinator about 8 months. Introducing new providers or a new type of SMA may require a relatively modest incremental commitment of organizational resources and provider time (less than 6% of the time and less than 14% of the finances required to start the initial SMA). It is possible that the total time and cost could be further decreased by leveraging relevant materials from existing SMAs

Engaging Patients as Stakeholders to Foster More Open Communication With Primary Care Providers

Background/Aims: The philosophy of the Patient Centered Outcomes Research Institute (PCORI) is to “do research differently” by involving patients throughout the research process. By leveraging an existing resource of a senior “aging in place” community, we recruited patients to be stakeholders and help develop an intervention to create more open communication between primary care providers and patients. This was one of our initial forays into engaging patients as stakeholders. We wish to share our experience on the patient engagement journey. Methods: A reflexive, qualitative summary of our observations on the process of engaging patient stakeholders during all phases of a research study. Results: Five patient stakeholders, all older retired individuals, participated through all stages of the research process, attending regular stakeholder meetings and events and responding to impromptu requests by email or phone. Our patient stakeholders were an important part of the construction of the study materials, a visit companion booklet and a postvisit survey, and we featured their pictures and comments on the back of these tools so that study participants could better relate to their experience. One stakeholder was a former marketing professional who was instrumental in helping us formulate and sharpen the language and delivery of the intervention. When we encountered study recruitment problems, we held a patient stakeholder meeting to seek their advice. They provided us with suggestions that we incorporated into our workflow. Discussion: Expanding the relationship between patients and researchers was easier than expected and yielded a great improvement on the design and conduct of this research study. Engaging patient stakeholders was not only invaluable for the researchers but also created a reciprocal relationship. The researchers were asked by patient stakeholders for guidance in their own projects, e.g. in one case a patient asked the research team to help her plan an advance care planning workshop at a senior center. Our older retired patient stakeholders are not representative of all patients, but their availability allowed them to share their cumulative wisdom and insights –– not only as patients, but also as resourceful professionals –– with the research team

Patient Experiences in Selecting a Medicare Part D Prescription Drug Plan

Introduction: Medicare beneficiaries often report that the process of choosing a prescription drug plan is frustrating and confusing and many do not enroll in the plan that covers their drugs at the lowest cost. Methods: We conducted 4 focus groups to understand beneficiaries’ experiences in selecting a drug plan to identify what resources and factors were most important to them. Participants were patients served by a multispecialty delivery system and were primarily affluent and Caucasian. Results: While low cost was essential to many, other characteristics like having the same plan as a partner, company reputation, convenience, and anticipation of possible future health problems were sometimes more important. Although some used resources including insurance brokers, counselors, and websites beyond Medicare.gov , many expressed a desire for greater assistance with and greater simplicity in the choice process. Conclusion: Although older adults would likely benefit from greater assistance in choosing Medicare Part D prescription drug plans, more research is necessary to understand how to help with decision-making in this context

Comparative Usability Study of a Newly Created Patient-Centered Tool and Medicare.gov Plan Finder to Help Medicare Beneficiaries Choose Prescription Drug Plans.

IntroductionIn response to reported difficulties in selecting a Medicare Part D prescription drug plan, we designed a patient-centered online Part D plan selection tool (CHOICE1.0) to simplify the selection process and to provide personalized, expert recommendations.MethodsThis ethnographic comparative usability study observed 44 patients using the first version of the tool during Medicare 2016 Open Enrollment. Participants were observed as they chose their drug plan using Medicare.gov and 1 of 3 versions of CHOICE1.0 that varied in amount of expert guidance. Descriptive statistics were used to analyze exit survey data. The observations were video-recorded, and field notes were analyzed thematically.ResultsParticipants were significantly more satisfied with CHOICE1.0 for choosing a plan, understanding information, and ease of use compared to Medicare.gov. Those using expert versions of CHOICE1.0 were more likely to indicate their intention to switch plans than those using Medicare.gov, though they wanted to know the source and content.ConclusionThe more patient-centered prescription drug choice tool improved user experience and enabled users to choose plans more consistent with expert recommendations