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Reports
& Studies:
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SPNS
Information Technology Initiative |
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TABLE
OF CONTENTS |
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SPNS
Initiative Evaluates Application of Information Technology to HIV
Care |
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The
SPNS IT Initiative |
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References |
Contact
Information |
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SPNS
INITIATIVE EVALUATES APPLICATION OF INFORMATION TECHNOLOGY TO HIV
CARE |
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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A
POWERFUL TOOL FOR HEALTH CARE DELIVERY |
Information technology (IT) is a powerful new tool in health care
delivery. Applications of electronic technology are improving care
from the systems level to the point of care. Because HIV treatment
has grown increasingly complex, and reaching underserved people living
with HIV is difficult, HIV providers are challenged to provide comprehensive,
coordinated care. IT is providing solutions that address this challenge,
especially in primary health care settings.
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
CONFIRMS THAT IT IMPROVES CARE |
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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MORE
RESEARCH IS NEEDED |
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
SPNS IT INITIATIVES |
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
INTERVENTIONS |
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.
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Table
One describes the interventions in detail.Click image
to enlarge. |
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THE
EVALUATIONS |
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:
- Health care
delivery
- Quality
of health care
- Cost-effectiveness
of IT interventions
Table
Two describes the evaluations in more detail. Click image
to enlarge. |
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INFORMATION
DISSEMINATION |
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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REFERENCES |
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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CONTACT INFORMATION |
SPNS
Grantees
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