The Special Projects of National Significance (SPNS) Information Technology Initiative evaluates the impact of interventions using information technology (IT) on the delivery and quality of primary care for underserved people living with HIV. Six grantees have been funded in the four-year initiative, which began in October 2002 and will continue through September 2006. Both the Special Projects of National Significance (SPNS) and the AIDS Education and Training Centers (AETC) in the Health Resources Services Administration (HRSA) HIV/AIDS Bureau (HAB) are involved in the initiative.

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Electronic medical records

The electronic medical record (EMR) stands at the core of clinical information management systems. Various patient databases can be linked so that users have integrated access to medical, laboratory, service utilization, and billing information from different sources. The EMR can contain a wide range of documentation, including multimedia elements such as heart and lung sounds and digitized photographs. The data can be manipulated to create information such as summaries and graphs of test results over time.

Clinicians can enter medical information as well as order prescriptions, treatments, referrals and tests electronically (Computerized Physician Order Entry: CPOE). Records can be accessed from multiple sites within networked systems, or geographically remote users can enter patient information into their local machines and send the data securely via the internet to a centralized server, where the patient file is maintained (Jerant, 2000).

With internet technologies, the EMR allows patient data to be securely shared (i.e. without breach of confidentiality) by providers in multiple agencies and by patients and families, creating the potential for new collaborative partnerships by supporting communication, consultation and cooperation (Safran and Goldberg, 2000).
Decision support and CQI

Individual patient databases can be linked with knowledge databases such as standards of care, which opens up another array of possibilities. As patient treatment data is monitored against treatment guidelines or standards of care, electronic messages can be sent to treating clinicians regarding differences that are noted. Electronic messages can notify the clinician of standard treatments, including medications, doses, and potential adverse effects of treatment. Clinicians can be sent reminders when treatments or tests are recommended at standard intervals (Lobach, 1997). On a systems level, a clinic's patient databases can be tracked to monitor for continuous quality improvement (CQI) purposes, using selected standards against which patient care is assessed. (Ornstein, 1997). For example, intervals between Pap smears or PPD tests might be measured.

Even without being linked to EMRs, interactive applications can be used to provide clinicians with decision support using up to date guidelines and standards of care. Some applications enable clinicians to key in patient treatment information and receive instant feedback regarding implications of potential treatment decisions, such as possible drug interactions. Personal data assistants (PDAs) enable clinicians to download from the internet and thus access up-to-the-minute information in a hand-held repository immediately available at the point of care. Decision support is an invaluable tool for clinicians prescribing complex and rapidly evolving antiretroviral therapy for HIV.

Interactive health communication (IHC)

Patient-oriented IT tools can be used to facilitate patient learning, decisionmaking and behavior change as well as self-care and social support. Internet websites provide patients with information and support that include electronic communication with other patients and with experts. Computer-based interactive health surveys can promote patient adherence to treatment and encourage healthy behaviors. With computer-assisted survey information (CASI), with audio assist for those with low literacy (ACASI), patients can complete a touch-screen questionnaire that screens multiple behaviors, prioritizes areas for interventions, initiates interventions, and provides synthesized information to the clinician for reinforcement. This also enables health providers to assess and intervene regarding multiple patient behaviors with few demands on staff time (Prochaska, 2000).

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Research studies document that IT applications such as these can improve health care delivery. In a comparison study, EMRs were more likely than paper based records to be fully understandable, fully legible, have at least one diagnosis recorded, to record services provided, referrals made, drug dosage of treatment prescribed (Hippisley-Cox 2003). Electronic reminders and alerts have been shown to improve clinician adherence to specific practice guidelines (Safran, 1995; Lobach 1997). Studies have documented that CPOE can improve physician prescribing practices, improve physician compliance with guidelines, shorten length of hospital stay, decrease medical errors, and decrease costs (Teich, 2000; Kuperman, 2003).

Research also confirms that IT can improve patient involvement in and adherence with care. Studies document that patients disclose information about health-related behaviors more readily responding privately to surveys than speaking with interviewers (Turner, 1998; Weidle, 1999). Providers armed with information from ACASI applications are better able to engage their patients in adopting healthier behaviors and adhering to treatment regimens. Web-based interactive patient support systems have also been proven useful in providing support to patients. The Comprehensive Health Enhancement Support System (CHESS) is a consumer health information system that provides patients with HIV with information, decision support, and connections to experts and other patients. In a randomized controlled trial, use of CHESS improved quality of life, decreased time during outpatient visits, reduced hospitalizations and physician phone calls for users compared to nonusers (Gustafson, 1999).

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Application of IT to health care services has the potential to streamline service delivery systems, improve the quality of care, and make care more cost effective (Hippisley-Cox, 2003). So far, however, most studies of IT applications in health care have evaluated the impact on provider or patient behaviors. While EMRs have been shown to improve some surrogate outpatient outcomes in outpatient settings, rigorous research is still needed on how IT impacts morbidity and mortality and cost-effectiveness of care, particularly primary care (Safran, 1995; Jerant, 2000; Mitchell, 2001). In addition, more attention must focus on introducing the applications to clinicians and training them in their use, as physicians may find them inaccessible or time-consuming to use (Kuperman, 2003; Bodenheimer, 2003).

Studies of IT patient education and support programs are also needed, to assess their effectiveness on clinically important outcomes, to assess their effectiveness on increasing access to care, and to identify and overcome barriers to implementation, especially for patients of lower socioeconomic status and those patients with lower computer and English literacy skills.

Moreover, while promising, IT has not been sufficiently evaluated in the HIV clinical setting. The benefits of IT applications must be documented so that health care providers and payers are encouraged to adopt and use the technology.

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The four-year initiative began in October 2002 and the first meeting of grantees was held in April 2003. The purpose of the initiative is to test and evaluate existing IT tools and interventions, not to develop or apply new technologies. Each grantee has crafted a team that includes a program or programs providing services to people with HIV, contractors with relevant IT expertise, and researchers with evaluation expertise.

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The intervention of each grantee is an IT application that is being implemented in an outpatient or community-based HIV primary care or ancillary services setting. The target populations to whom the grantees provide care are all underserved people with HIV.

Two of the IT interventions involve IHC for consumers intended to enhance patient/provider communication. The other four interventions involve decision support for providers through use of electronic medical records and interactive internet information databases.

Table One describes the interventions in detail.Click image to enlarge.

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Each grantee has developed an evaluation plan tailored to examine identified outcomes resulting from its intervention. Because the initiative has just begun, many of the outcomes are still under development, but more information will be available as the initiative progresses. The initiative focuses on three areas of evaluation:

1. Health care delivery
2. Quality of health care
   
3. Cost-effectiveness of IT interventions

Table Two describes the evaluations in more detail. Click image to enlarge.

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The goal of SPNS is to identify innovative tools that can be used improve care to underserved people living with HIV. Therefore an important component of the initiative is to disseminate the findings to HIV care providers. Each grantee has a plan to actively bring its findings to program planners and policymakers through publications and presentations at HIV-related conferences and meetings. Although the project ends in 2006, preliminary results are being communicated through multiple information channels available to the target audiences.

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Bodenheimer T, Grumbach K. Electronic technology: a spark to revitalize primary care? JAMA. 2003;290:259-64.

Gustafson DH, Hawkins R, Boberg E, Pingree S, Serlin RE, Graziano F, Chan CL. Impact of a patient-centered, computer-based health information/support system. Am J Prev Med. 1999;16(1):1-9.

Hippisley-Cox J, Pringle M, Cater R, Wynn A, Hammersley V, Couplan d C, Hapgood R, Horsfield P, Teasdale S, Johnson C. The electronic patient record in primary care--regression or progression? A cross sectional study. BMJ. 2003;326(7404):1439-43.

Jerant AF and Hill DB. Does the use of electronic medical records improve surrogate patient outcomes in outpatient settings? J Fam Practice. 2000;49:349-57.

Kaushal R, Shojania KG, and Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety. Arch Intern Med. 2003;163:1409-1416.

Kuperman, GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003;139(1):31-9.

Lobach DF, Hammond WE. Computerized decision support based on a clinical practice guideline improves compliance with care standards. Am J Med. 1997;102(1)89-98.

Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-1997. BMJ. 2001;322:279-82.

Ornstein, SM, Jenkins RG, Lee FW, Sack JL, LaKier EI, Roskin SD, Wulfman JS, Wriston GA. The computer-based patient record as a CQI tool in a family medicine center. Jt Comm J Qual Improv. 1997;23(7):347-61.

Prochaska, JJ, Zabinskim MF, Calfas, KJ, Sallis, JF and Patrick, K. PACE+ Interactive communication technology for behavior change in clinical settings. Am J Prev Med. 2000;19:127-131.

Safran C, Rind DM, Davis RB, et al. Guidelines for management of HIV infection with computer-based patient's record. Lancet. 1995;346:341-6.

Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr CD, and Bates DW. Effects of computerized physician ordered entry on prescribing practices. Arch Intern Med. 2000; 160:2741-2747.

Turner CF, Ku L, Rogers SM, Lindberg LD, Pleck JH, Sonenstein FL. Adolescent sexual behavior, drug use, and violence: increased reporting with computer survey technology. Science. 1998;280:867-73.

Weidle PJ, Ganera CE, Irwin KL, McGowan JP, Ernst JA, Olivo N et al. Adherence to antiretroviral medications in an inner-city population. J Acquir Immune Defic Syndr. 1999;22:498-502.

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SPNS Grantees

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