Practical Patient Report Measures for Primary Care Progress

Practical, Patient Report Measures for Primary Care: Progress on the My Own Health Report (MOHR) Project to Date Bijal Balasubramanian Maria Fernandez Russ Glasgow Beth Glenn Marcia Ory Catherine Rohweder for the MOHR Research Group

Topics to be Covered Overview • Context and Design: Russ • Pragmatic Research Features: Marcia • Group Discussion of Above: All Results • Early Results: Reach: Maria • Early Results: Health Behaviors(baseline): Beth • Group Discussion of Above: All Lessons Learned Thus Far: Catherine • General Discussion and Future Directions

Vision for “Big Data”—A Comprehensive Big Database to be Maximally Useful Should Contain: • Diagnostic and health care utilization data • Genomic and biomarker data • Patient-reported information, preferences, and patient-centered goals- this is MOHR contribution • Geospatial and social/physical/environmental data on fundamental determinants of health

EHR Measures for Primary Care • Advent of patient-centered medical home, CMS annual wellness exams, “meaningful use” of EHRs • In the billions of dollars spent on EHRs in last several years, one thing is missing: Patient. Reported Measures • Impossible to provide patient-centered care if no patient measures, goals, preferences, concerns collected • With recent advances in measurement, meaningful use incentives, time is right Estabrooks PA, et al. Harmonized patient-reported data elements… J Am Med Inform Assoc 2012 Jul-Aug; 19(4): 575 -82.

Evidence Integration Triangle (EIT)— A Patient-Centered Care Example Intervention Program/Policy ba ed Primary care (PC) staff, patients and consumer groups; health care system decision makers; groups involved in meaningful use of EHRs ck Stakeholders: ba US Preventive Services Task Force recommendations for health behavior change counseling; goal setting & shared decision making ed Fe Evidence: Fe ck Evidence-based decision aids to provide feedback to both patients and health care teams for action planning and health behavior counseling Practical Progress Measures Participatory Implementation Process Iterative, wiki activities to engage stakeholder community, measurement experts and diverse perspectives Feedback Multi-Level Context Brief, tested, standard patientreported data items on health behaviors & psychosocial issues—actionable and administered longitudinally to assess progress • Dramatic increase in use of EHR • CMS funding for annual wellness exams • Primary Care Medical Home • Meaningful use of EHR requirements Glasgow RE, et al. An evidence integration triangle…Am J Prev Med

Measures for Adult Primary Care Domain 1. Overall Health Status 2. Eating Patterns Final Measure (Source) 1 item: BRFSS Questionnaire 3 items: Modified from Starting the Conversation (STC) [Adapted from Paxton AE et al. Am J Prev Med 2011; 40(1): 67 -71] 3. Physical Activity 2 items: The Exercise Vital Sign [Sallis R. Br J Sports Med 2011; 45(6): 473 -474] 4. Stress 1 item: Distress Thermometer [Roth AJ, et al. Cancer 1998; 15(82): 1904 -1908] 5. Anxiety and 4 items: Patient Health Questionnaire—Depression & Anxiety (PHQ-4) Depression [Kroenke K, et al. Psychosomatics 2009; 50(6): 613 -621] 6. Sleep 2 items: a. Adapted from BRFSS b. Neuro-QOL [Item PQSLP 04] 7. Smoking/Tobacco Use 2 items: Tobacco Use Screener [Adapted from YRBSS Questionnaire] 8. Risky Drinking 1 item: Alcohol Use Screener [Smith et al. J Gen Int Med 2009; 24(7): 783 -788] 9. Substance Abuse 1 item: NIDA Quick Screen [Smith PC et al. Arch Int Med 2010; 170(13): 1155 -1160] 10. Demographics 9 items: Sex, date of birth, race, ethnicity, English fluency, occupation, household income, marital status, education, address, insurance status, veteran’s status. Multiple sources including: Census Bureau, IOM, and National Health Interview Survey (NHIS)

My Own Health Report (MOHR) Automated Assessment Tool ‣ Summary display and printout for patient • Patient Fills Out Tool ‣ Database of text messages and triggers ‣ Action Plan printout ‣ Summary display and printout for health care team ‣ Report data stored in database ‣ Research analysis Krist A, et al. Designing a valid pragmatic primary care implementation trial…Implement Sci , 2013, 8: 73

www. My. Own. Health. Report. org

Basic patient and clinician goal advice (electronic) and goal setting (paper)

MOHR Project—Key Points ‣ Cluster randomized trial of 9 clinic pairs, staggered early and late intervention ‣ Approximately half of clinics community health centers; others AHRQ type PBRN clinics ‣ Diverse sample of clinics and patients—e. g. , varying levels of clinic integration of EHRs; urban, rural, suburban; large and small clinics; ‣ Study goal = Sustainable, routine use of intervention VT OR CA VA NC TX www. myownhealthreport. org

MOHR Key Outcomes • Primary Outcome = Percent and representativeness of patients who have a personalized action plan set • Secondary Outcomes = Percent who receive follow-up contacts; improvement on health behaviors and mental health issues; costs and resources required

Other Important Data Collected in MOHR • Cost § Collected 2 x in early intervention sites • Clinic Context § Collected 3 x pre-, mid-, post-intervention, qualitative template • Project Context § Collected once, end of project, open-ended survey of key project stakeholders (e. g. , researchers, funders) • Post-Implementation Interview § Group interview, clinic staff