Design and Implementation of a Web-Based Patient Portal Linked to an Ambulatory Care Electronic Health Record: Patient Gateway for Diabetes Collaborative.

Design and Implementation of a Design and Implementation of a Web-Based Patient Portal Linked Web-Based Patient Portal Linked to an Ambulatory Care Electronic to an Ambulatory Care Electronic Health Record: Patient Gateway Health Record: Patient Gateway for Diabetes Collaborative Carefor Diabetes Collaborative Care

RICHARD W. GRANT, M.D., M.P.H., JONATHAN S. RICHARD W. GRANT, M.D., M.P.H., JONATHAN S. WALD, M.D., ERIC G. POON, M.D., M.P.H., JEFFREY WALD, M.D., ERIC G. POON, M.D., M.P.H., JEFFREY L. SCHNIPPER, M.D., M.P.H., TEJAL K. GANDHI, L. SCHNIPPER, M.D., M.P.H., TEJAL K. GANDHI, M.D., M.P.H., LYNN A. VOLK, M.H.S., and M.D., M.P.H., LYNN A. VOLK, M.H.S., and BLACKFORD MIDDLETON, M.D., M.P.H., M.Sc.BLACKFORD MIDDLETON, M.D., M.P.H., M.Sc.

DIABETES TECHNOLOGY & THERAPEUTICS 2006

OutlineOutline

IntroductionIntroduction Conceptual frameworkConceptual framework Key design elementsKey design elements Evaluation & ResultsEvaluation & Results CommentComment

IntroductionIntroduction Increasing patient's Increasing patient's knowledge about risk factor levknowledge about risk factor lev

elsels and facilitating and facilitating collaboration between patients acollaboration between patients and physiciansnd physicians have both been demonstrated to impr have both been demonstrated to improve clinical outcomes.ove clinical outcomes.

Personal health records (PHRs) represent one innovPersonal health records (PHRs) represent one innovative means to achieve these goals.ative means to achieve these goals.

But, there have been no large-scale studies of intervBut, there have been no large-scale studies of interventions that integrate PHRs directly with the electroentions that integrate PHRs directly with the electronic medical records(EMRs) used by patients' own prnic medical records(EMRs) used by patients' own primary care physicians (PCPs).imary care physicians (PCPs).

We hypothesized that enabled patients to both rWe hypothesized that enabled patients to both read (eg, laboratory results )and write (eg, medicead (eg, laboratory results )and write (eg, medication list) to the EMR was crucial to achieve meation list) to the EMR was crucial to achieve measurable changes in DM control.asurable changes in DM control.

Using the DM-specific PHR would result in imprUsing the DM-specific PHR would result in improved care by oved care by increasing patient knowledgeincreasing patient knowledge and and engagement in their own careengagement in their own care and by facilitatin and by facilitating patient-physician communication .g patient-physician communication .

Conceptual frameworkConceptual framework The key barriers to Diabetes Care:The key barriers to Diabetes Care:

lack of patient lack of patient engagement with therapeutic care engagement with therapeutic care plansplans..

lack of lack of medication adjustmentmedication adjustment by physicians by physicians during clinical encounters.during clinical encounters.

If properly prepared and engaged in care—patients If properly prepared and engaged in care—patients themselves may be themselves may be effective catalysts for changingeffective catalysts for changing clinical care processes.clinical care processes.

A patient web-portal designed to encourage patients A patient web-portal designed to encourage patients with with discuss corresponding medication initiation or discuss corresponding medication initiation or dose adjustmentdose adjustment would help reduce clinical inertia. would help reduce clinical inertia.

The patient’s viewThe patient’s view The key goals of the design for the patient The key goals of the design for the patient

interface wereinterface were to organize the clinical data in an to organize the clinical data in an

educational formateducational format.. to enable patients to author a detailed, to enable patients to author a detailed,

tailored Diabetes Care Plan to share with tailored Diabetes Care Plan to share with their PCP.their PCP.

Key design elementsKey design elements

Medication Module to allow patients to view their Medication Module to allow patients to view their EHR medication list(EHR medication list(藥物單藥物單 ).).

Diabetes-specific medication library used tDiabetes-specific medication library used to treat each of three conditions.o treat each of three conditions.

Increase the detection and handling of discrepancIncrease the detection and handling of discrepancies and adverse drug events (ADEs).ies and adverse drug events (ADEs).

The physician’s viewThe physician’s view

The system was designed with the following The system was designed with the following workflow workflow Only one diabetes module at a time can be Only one diabetes module at a time can be

open per patient.open per patient. A Diabetes Care Plan can only be submitted A Diabetes Care Plan can only be submitted if if

the visit still appears in the scheduling systemthe visit still appears in the scheduling system.. Once submitted, a Diabetes Care Plan link Once submitted, a Diabetes Care Plan link

appears near the patient's name on the appears near the patient's name on the provider schedule.provider schedule.

Patient submissions auto close after 21 days of Patient submissions auto close after 21 days of inactivity.inactivity.

Avoiding physicians receive multiple care plans Avoiding physicians receive multiple care plans from a single patient, or care plans submitted from a single patient, or care plans submitted without an appointment.without an appointment.

Clinical Data Repository

Evaluation & ResultsEvaluation & Results This study was conducted in 11 primary care practices This study was conducted in 11 primary care practices

within the Partners HealthCare system (Boston, MA).within the Partners HealthCare system (Boston, MA).

Patients were unaware of their PHR assignment Patients were unaware of their PHR assignment ((interventionintervention, control) when consenting to enroll in t, control) when consenting to enroll in the study.he study.

Control practicesControl practices who were invited to use an online fa who were invited to use an online family history and health maintenance PHR (mily history and health maintenance PHR (non–DM-snon–DM-specific PHRpecific PHR))

The primary distinction between the 2 study arms was The primary distinction between the 2 study arms was the content of the PHR modules.the content of the PHR modules.

No significant differences between No significant differences between intervention and control.intervention and control.

Patients who submitted DM PHR Care Plans were more Patients who submitted DM PHR Care Plans were more likely to have a medication initiation or dosage adjustment.likely to have a medication initiation or dosage adjustment.

There were too few patients for meaningful There were too few patients for meaningful comparisons by risk factor within the “on comparisons by risk factor within the “on treatment” subset.treatment” subset.

Patients with medication changes had Patients with medication changes had clinically and statistically clinically and statistically significant significant subsequent decreases in HbAsubsequent decreases in HbA1c1c level level and and LDL-C levelLDL-C level..

CommentComment Users of the DM-specific PHR were markedly more likUsers of the DM-specific PHR were markedly more lik

ely to have their medical regimens changed at their nely to have their medical regimens changed at their next clinic visit.ext clinic visit.

Specific patient portals linked directly to physicians’ Specific patient portals linked directly to physicians’ EMRs can have an important impact on reducing cliniEMRs can have an important impact on reducing clinical inertia.cal inertia.

The lack of an impact on DM-related risk factor levelsThe lack of an impact on DM-related risk factor levels Only a Only a small proportionsmall proportion of potentially eligible patie of potentially eligible patie

nts signed up for access to the Web portal.nts signed up for access to the Web portal. Patients with poor metabolic control were less likelPatients with poor metabolic control were less likel

y to enroll in the Prepare for Care study.y to enroll in the Prepare for Care study.

Study population consist of younger and more aStudy population consist of younger and more affluent patients and thus may not be immediateffluent patients and thus may not be immediately generalizable to other patient groups.ly generalizable to other patient groups.

limitations of the studylimitations of the study DDid not seek to significantly change the ways id not seek to significantly change the ways

in which PCPs currently practicedin which PCPs currently practiced.. DDid not collect patient measuresid not collect patient measures such as such as DM DM

knowledge, level of engagement in care, or conknowledge, level of engagement in care, or confidence with patient-physician communication.fidence with patient-physician communication.

Thanks for your Thanks for your attention.attention.