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					  Building a Medical Home Through a
      Patient Wellness Portal and
               Health Risk Appraisal
               Zsolt Nagykaldi, PhD & Jim Mold, MD, MPH
University of Oklahoma HSC Department of Family & Preventive Medicine
  and the Oklahoma Physicians Resource/Research Network (OKPRN)

            Oklahoma Physicians Resource/Research Network
The Medical Home Concept (v2.3)


                                                                     Efficiency in
     Listening                        Building &                      delivering
     Understanding                    fostering                          value
     Responding                       relationships

                     Oklahoma Physicians Resource/Research Network
Foundations of the Medical Home
1.   Listening: ask, don’t assume! (e.g. frequent surveys and
     feedback from patients and office staff) Who is the architect
     of the Home? What’s going on in the Home? What do
     “inhabitants” want and need?
2.   Understanding: patients, clinicians, and staff / practice (e.g.
     regular staff meetings, case reviews)
3.   Responding: redesigned processes that meet specific
     needs >> evaluation >> adjustment >> testing (PDSA)
4.   Building relationships: multidirectional communication,
     going out to the community, “learning communities”
5.   Efficiency in delivering value: working smarter, not harder,
     accepting and implementing the wisdom of exemplars
6.   HIT: driver of fundamental change or an electronic version
     of the same?
                Oklahoma Physicians Resource/Research Network
The Issue of Prioritization
     “We are getting too good at testing…”

 • Even a healthy, non-smoker, 35 years old male
   could consider up to 50 preventive services and
   may be due for a dozen Grade A & B services.
   Exploding genetic testing options may easily
   double this number.
 • The “Seven Hours Problem” 1 and the “Ten Hours
   Problem” 2
 •   (1): Yarnall KS, Pollak KI, Ostbye I, et al. Primary care: is there enough time for prevention? Am J
           Public Health. Apr 2003;93(4):635-641.
 •   (2) Ostbye T, Yarnall KS, Krause KM, et al. Is there time for management of patients with chronic
          diseases in primary care? Ann Fam Med. May-Jun 2005;3(3):209-214.

                         Oklahoma Physicians Resource/Research Network
“But your EHR will prompt you…”

 “Finally, we had to turn off the reminders in our EHR…” (Dr. I)
              Oklahoma Physicians Resource/Research Network
So how did we….

 • listen
 • understand
 • respond
 • build and foster relationships
 • and design a system that
 • delivers value to patients and primary care
   practices in OKPRN?

           Oklahoma Physicians Resource/Research Network
The Wellness Portal Project

• Funded by an AHRQ Grant 1R18HS017188-01 “Impact of a
  Wellness Portal on the Delivery of Patient-Centered
  Prospective Care”
• PIs: Dr. James Mold, Dr. Ann Chou, and Dr. Zsolt Nagykaldi
• Project Period: 09/01/2007 – 08/31/2010

• Phases:
            - Development and pilot study (Year 1)
            - RCT (Year 2)
            - Dissemination (Year 3)

               Oklahoma Physicians Resource/Research Network
Listening, Understanding & Responding

Completed phases (multi / mixed methods):

• Multi-phase patient & clinician feedback (focus groups,
  interviews) >> What do you need? How do you need it?
• Prototype development and refinement (direct observation)
• Six-month pilot testing (60 patients in two OKPRN practices)

Ongoing (effectiveness testing):

• Two-arm exploratory RCT (480 patients in eight practices)

               Oklahoma Physicians Resource/Research Network
Wellness Portal Project - Aims

 1) To develop, field test, and refine an Internet-based patient
    Wellness Portal to facilitate patient-centered, prospective
    care in primary care practices;

 2) To determine the impact of the Wellness Portal on the
     process of patient-centered prospective care by
     examining the behavior and experiences of both patients
     and providers and the degree to which provided services
     are individualized; and

 3) To develop model Wellness Portal practices and
     disseminate the Wellness Portal technology and
     knowledge derived from Aims 1 and 2 findings.

               Oklahoma Physicians Resource/Research Network
RCT: Measuring Patient Centeredness
   Randomization: 8 clinicians from 6 practices; N=480 patients

  INTERVENTION                                                                                                   Post-test data coll.:
                                            Patients                    Patients visit
  Pre-test data collection:                 interact with               their primary                            + CAHPS survey
                                            the Wellness                care providers                           + Patient Activation
  + Chart, PSRS, and billing                Portal                                                                 survey
   data review                                                                                                   + Chart / PSRS /
  + CAHPS patient survey                                                                                           billing review
  + Patient Activation survey                                                                                    + Clinician survey
  + Clinician survey (modified                     Personalized preventive care based on clinical                + Clinician Interviews
    ACIC)                                           recommendations and Wellness Portal input                    + Patient focus groups

  Pre-test data collection:                                                                                      Post-test data coll.:

  + Chart, PSRS, and billing                                                                                     + CAHPS survey
    data review                                                                                                  + Patient Activation
                                                        Patients visit their primary care
  + CAHPS patient survey                                                                                           survey
  + Patient Activation survey                                                                                    + Chart / PSRS /
  + Clinician survey (modified                                                                                     billing review
    ACIC)                                                                                                        + Clinician survey
                                                 Preventive care based on clinical recommendations

                                   Study START                   Total of 12 months                  Study END

 PSRS: Preventive Services Reminder System; CAHPS-A: Consumer Assessment of Health Plan Surveys – Ambulatory version;
 ACIC: Assessment of Chronic Illness Care

                                 Oklahoma Physicians Resource/Research Network
Wellness Portal Conceptual Model

                                         Become informed, activated
         Patient                         patients:
                                         • Enhanced knowledge
                                         • Improved confidence
                                         • Better skills

                                                                                      Delivery of the
     Wellness Portal                       • More information                         right and value
                                                                        Patient-      added services
                                           • Better documentation
                                                                        Centered         to the right
           PSRS                            • Improved efficiency
                                                                          Care        patients at the
                                                                                      right time, and
                                         Transform into an active
                                         medical home:
                                         • Improved care processes
                                         • Wellness orientation
    OKPRN Practice                       • Personalized care

                                                Objective 2a1         Objective 2a2    Objective 2a3

    PSRS: Preventive Services Reminder System

                          Oklahoma Physicians Resource/Research Network
Building Medical Homes In OKPRN Since 2000
                                                  Evidence-based guidelines and
                                                       population statistics

        Risk Processor
             (HRA)                                                                                    Personal
                                                       Prioritized                                   attributes,
        Prioritizes available
         interventions from                       Recommendations Lists                                values,
        clinical guidelines by                                                                          goals,
                                                    Decision          Link to                       preferences,
        outcome and size of
                                                  Support Tool       Resources                       constraints

                         Wellness            Patient                             Clinician

                                                                                                    Lab results,
                             Wellness                         Plan                                  consults and
                              nurse                                                                   referrals

              Billing                                     Task Manager
             System,                 CCR               Registry, reminder, and
               EHR                                      recall system (PSRS)

        HRA: Health Risk Appraisal; EHR: Electronic Health Record; CCR: Continuity of Care Record
        PSRS: Preventive Services Reminder System

                      Oklahoma Physicians Resource/Research Network
 Practice Re-engineering: A Necessary Step
 Practice Information Flow After
 Portal & PSRS Implementation                                  Nurse Station
                                                                 Regular care              Waiting Room
                                                                                             Risk factors,
 PSRS: Preventive Services Reminder System
                                                                                            wellness history

                                              Report           Exam Room
                      Prevention Nurse
                                                            Review, negotiation,
                     Regular audits, patient
                                                           Scheduling & referral to    Existing
                  recalls and report generation
                                                             Prevention Station


                                     “Prevention” Workflow

                     Prevention Station                    Prevention Station                  Patient
                        Update Wellness                    Review, wellness plan,              Community
                           Database                         services/scheduling                and practice
                                                  Report                                       resources,
Labs, consults,                                                                                patient
and referrals                                                                                  education
between visits
                                                               Nurse empowerment

                              Oklahoma Physicians Resource/Research Network
Delivering Better Value Is Financially Feasible
                   2 -3 Year Olds                                                        Adults 50 - 74
   100%                                                                50%
    90%                                                                45%
    80%                                                                40%
    70%                                                                35%
    60%                                             03/05
                                                                       30%                                         03/05
    50%                                             01/06              25%                                         01/06
    40%                                             04/07              20%                                         04/07
    30%                                             07/07              15%                                         07/07
    20%                                                                10%
    10%                                                                 5%
     0%                                                                 0%
            HepB3         DTaP4         MMR1                                 Pneumo        CRC       Mammo

            Established Patient Visits                                            Financial Data
     1400                                                              $400,000
     1200                                                              $350,000
     1000                                                              $300,000
                                               01/05-06/05             $250,000
      800                                                                                                         01/05-06/05
      600                                      07/05-12/05             $200,000
                                               07/06-12/06             $150,000
      400                                                                                                         07/06-12/06
               1      2     3       4    5
                                                                                  Income Expense Net Profit
                      Level of Visit           “Having a prevention nurse has made the entire office more prevention focused and
                                                 everyone is working harder to identify patients who need preventive care.” (Dr. B)

                                Oklahoma Physicians Resource/Research Network
 Wellness Portal Website  

                               Home Page            Portal Web Ad

                                Wellness Kiosk

Ad (Flyer)

                             Home Page

             Oklahoma Physicians Resource/Research Network
Wellness Portal Website - Account
                         Portal Registration

                                                    Family Wellness Account

           Oklahoma Physicians Resource/Research Network
 Wellness Portal Website - Options

            Oklahoma Physicians Resource/Research Network
Wellness Portal Website – Prevention

                                                      13 vaccine types
                                                    > 30 vaccine doses

       24 preventive
        - primary
        - secondary
        - tertiary

              Oklahoma Physicians Resource/Research Network
Wellness Portal Website – Risk Engine

                                   43 risk factors and
                                   personal preferences

           Oklahoma Physicians Resource/Research Network
Wellness Portal Website – Wellness Plan
                                            Personalized wellness plan
                                            (for current visit)

        Personalized wellness plan
        (for the next 3 years)

              Oklahoma Physicians Resource/Research Network
Wellness Portal Website – Vitals, Labs
                                        Tracking of vitals
                                        and labs:
                                         - Weight (also in SI)
                                         - Height (also in SI)
                                         - BP (sys)
                                         - BP (dia)
                                         - Fasting blood glucose
                                         - HbA1c
                                         - Lipid panel

                                                                   Charting trends

Create &

            Oklahoma Physicians Resource/Research Network
Wellness Portal Website – Symptom Diary
                                           Interactive calendar
                                           for quick data entry

                                               Symptom log

                                               Visual analog severity chart

           Oklahoma Physicians Resource/Research Network
Wellness Portal Website – Tracking
                                                    Medical encounter tracking
                                                    (patient’s perspective)

   Medication tracking

                 Oklahoma Physicians Resource/Research Network
Wellness Portal Website – Secure Messaging
Messaging signup interface                    Signup process:
                                               - practice offers secure messaging
                                               - patient responds with request
                                               - practice approves with one click
                                               - patient is notified about approval

                                                                      Secure inbox & outbox

     Messaging process:
      - recipient receives notification
        via his/her regular e-mail account
      - clicks on secure link and logs in
        to the Portal to read messages
        and respond securely

                      Oklahoma Physicians Resource/Research Network
Wellness Portal Website – Ownership
                                       Official shot record
                                       signed by the clinician

                                                 Complete wellness record in CCR* format
                                                     *CCR: Continuity of Care Record (an interoperable
                                                     snapshot of the person’s medical history)

 CCR elements:
  - Demographics
  - Health alerts / risk factors
  - Social history
  - Providers and actors
  - Vital signs
  - Symptoms (“problems”)
  - Immunizations
  - Encounters
  - Lab results
  - Plan of Care / Wellness Plan

                   Oklahoma Physicians Resource/Research Network
Pilot Study Patient & Practice Feedback
  Patient Satisfaction Survey (N=38):
  • 14 domains of acceptability, feasibility, utilization, and usefulness
  • Level of satisfaction: 85% (across domains)
                           98% (improves interaction with practice)
                           93% (presented information is important)
                           88% (helps improve health and wellness)
  Qualitative Inquiry:
  • A wealth of actionable information was obtained through open-ended
    feedback:             web survey
                          unstructured interviews
                          direct participant observation / immersion
                          Wellness Portal contact/support e-mail
“Since beginning to use the Wellness Portal, my health has greatly improved. I've lost weight, my blood
 pressure has dropped, I've increased my activity level--and I feel and look so much better. Perhaps these
 positive attributes come simply from being more conscious of my health, but nevertheless, I'm thrilled.“
                                                                            (72 years old Afr. Am. woman)
                        Oklahoma Physicians Resource/Research Network
Next: Prioritization of Preventive Services

• AHRQ K08 Award to “Use Health Risk Appraisal to
  Prioritize Primary Care Interventions” (09/2008 –
• Develop (Y01), pilot test & improve (Y02), and study
  (Y03-Y05) a comprehensive, web-based HRA in
  primary care settings
• Patient HRA input >> Risk Engine >> calculation of
  health impact (length & quality of life) >> Life
  Expectancy estimates (clinician) and RealAge or
  wellness score estimates (patient)

             Oklahoma Physicians Resource/Research Network
Goals of the HRA Project

• Ultimate goal: individualized & prioritized 3-year
  Wellness Plan integrated into a new preventive care
  delivery system.
• Change in Life Expectancy estimate, RealAge and
  wellness score as risk factors are adjusted via the
• Longitudinal patient assistance and follow-up through
  the connected patient Wellness Portal (developed)
  and the clinician portal (Preventive Services Reminder

             Oklahoma Physicians Resource/Research Network
     HRA Risk Engine – Under the Hood

Step 1.
                      Baseline total risk calculated from
                      appropriate population life tables

Step 2.                                      Breaking down total risk into components

  Log [Personal risk] = a x risk(1) + b x risk(2) + .... + z x risk(n)
   (log relative hazard)

  Risk adjustment coefficients (tailoring)   Cause-specific baseline risk components

Step 3.                                      Summing up individual risk components

  Total personal risk              final probability of dying in each year

Step 4.                                      Calculating personal life table values

          Life table conversion into Life Expectancy in each year
Risk Adjustment – Personalization Example
 1) 35 yo white male >> lambda values calculated from baseline life table
 2) 2nd BMI quartile (24) and and <65 yo ->> 0.77 RR for CVD; 1.07 RR for cancer
 3) Non-married < 55 yo, non-poor urban living ->> 1.03 RR for all-cause mortality
 4) Father (only) had prostate cancer ->> 1.59 RR for prostate cancer (5% of all cancer
    risk: 1.03 RR)
 5) Has DM2 ->> 2.6 RR for CVD; 2.0 RR for stroke; 2.4 RR for pneumonia & influenza
 6) Smoker <15 per day ->> 3.0 RR for COPD; 1.8 for ischemic HD (68% of all CVD
     risk); 8.1 RR for lung cancer (28% of all cancer risk)
 7) ETOH - 1 drink a day ->> 1.2 RR for chronic liver; 1.4 RR for ETOH-related cancers
     (2.2%); 0.7 RR for CVD; 0.7 RR for stroke
 8) Has > 11 yrs education ->> 0.905 RR for all-cause mortality
 9) Lives in suburban OKC metro area ->> 0.74 RR of homicide
 10) Drives ~14,000 miles yearly ->> lambda of motor vehicle mortality (42% al all) is
     -    ln(1-14,000 * 3.2x10^-8 * 1.4) (1.4 - age factor)
 11) Always uses seatbelt and has airbag in car ->> 0.18 (combined) RR for motor
     vehicle accidents (42% of all accident risk)
 12) Occasional physical exercise (about once a week 30 min cardio) ->> 0.76 RR for
     all-cause mortality
 13) Works in the retail industry ->> 1.3 RR for non motor vehicle accidents (58% of all
    accident risk)
 14) Eats 2 servings a day of dairy and grain and 1 serving of fruits or vegetables
    (Dietary Diversity Score: 3) ->> 1.1 RR for all-cause mortality
Presentation of Estimates - LE
    Age          Baseline Life Expectancy   Adjusted Life Expectancy                                        Difference of
                    (35 yo white male)        (w/ risk adjustments)                               adjusted – baseline (years of LE)

   33-34                  76.50                             72.64                                                  -3.86
   34-35                  76.57                             72.67                                                  -3.89
   35-36                  76.63                             72.70                                                  -3.92
   36-37                  76.70                             72.75                                                  -3.94
   37-38                  76.77                             72.80                                                  -3.97
    (…)                                                                                  Life-Years Lost Compared to Baseline

Baseline Life Expectancy:         76.6 years
                                                    Life Expectancy at Age X
                                                                                           Baseline (white male)
LE adjusted with personal risk factors,
health habits & preferences: 72.0 years                                        80

Average years of life lost compared to                                         70
                                                                                                                        Personalized LE estimate
“average” person in group: 4 years                                             65
                                                                                     0     20         40           60         80        100        120
                                                                                                            Age (years)
Presentation of Estimates - RealAge
    “RealAge” is a hypothetical age that the person would be at
    compared to the same probability of death in the baseline
    population (or by “converting” health status into age).
Prioritization of Personalized Services

   • Based on estimated health impact: initially
     length of life, patient preferences, values, and
     constraints are considered (top 3-5 services
     with “most bang for the buck”)

   • Later, we will also include in quality of life
     through preservation of functions (e.g. ability
     to see, hear, walk, think, etc.)

   • Finally, prioritized recommendations will be
     further adjusted through negotiation and dialog
     with the patient (e.g. with wellness nurse)
    Real Life Example 1
•    A 75-year-old white, non-Hispanic woman with diabetes (for 5 years), hypertension
     (for 10 years), elevated cholesterol, and painful osteoarthritis
•    Has no recognized microvascular or macrovascular disease and no symptoms
     related to hyperglycemia.
•    She has attended diabetic education classes and modified her diet and activity.
•    Her medications include glyburide, atorvastatin, hydrochlorothiazide,
     acetaminophen, and aspirin.
•    She has a family history of diabetes and cardiovascular disease.
•    She has never smoked or used alcohol to excess. The review of her systems is
     unremarkable except for one recent fall, which occurred when she tripped on a
     throw rug in the bathroom. She was not injured.
•    She is a retired teacher and widow, lives in her own home, values her
     independence, and has little interest in therapies that would increase her medical
     costs or change her daily routine. The arthritis limits her ability to exercise.
     However, she enjoys reading, sewing, sports on TV, and a little flower gardening.
•    Her body mass index is 29 (5 ft 4 inches; 169 lbs.); her systolic blood pressure is
     154/76 mm Hg supine but 132/70 mm Hg while standing without lightheadedness.
     Her hemoglobin A1c is 8.4%, fasting glucose level is 150 mg/dL, total cholesterol
     200 mg/dL, low-density lipoprotein cholesterol 110 mg/dL, high-density lipoprotein
     cholesterol 55 mg/dL, triglycerides 180 mg/dL, serum creatinine 1.2 mg/dL, and
     urine microalbumin < 20 mg/dL.
Real Life Example 1 - Estimates

 Estimated Life Expectancy:          81. 3 years
 RealAge Estimate:                   82 years
 Probable Causes of Death:           1) CVD (RRI*: 7.73)
                                     2) Stroke (RRI*: 1.84)

*RRI:   relative risk increase compared to standard (average)
        population of her age, gender, and race / ethnicity
Putting It All Together

Lessons Learned:
•   Patients are excited about the Portal -driven medical home
    intervention that empowers them to improve their well-being
•   Pilot study feedback indicates a high level of satisfaction with
    the Portal and the way it was implemented in practices
•   Advisors and users provided rich and meaningful feedback
    about their experiences and facilitated Portal development
•   We learned a lot about how patients interact with web-based
    tools and the best ways a Portal should be implemented
•   The ongoing RCT will determine the impact of the
    intervention on patient centeredness and appropriateness /
    tailoring of prospective care in “medical home” practices

                Oklahoma Physicians Resource/Research Network
 Funding Sources:
  Concept and PDA Prototype Development               AHRQ (Grant)
  PDA Prototype Testing                               Medicaid (Contract)
  Web-based Version                                   Medicaid (Contract)
  Testing in Medicaid Population                      Medicaid (Contract)
  TRIP Prevention Project                             AHRQ (Grant)
  Prevention Nurse Model                              OCAST (Grant)
  Medicaid Implementation                             Medicaid (Contract)
  Wellness Portal                                     AHRQ (Grant)

Key Contributors:
   James Mold, MD, MPH (PI)            Katy D Smith, MS (Practice Facilitator)
   Zsolt Nagykaldi, PhD (Co-PI)        Crystal Turner, MPH (Practice Facilitator)
   Cheryl Aspy, PhD (Co-PI)            Cara Vaught, MPH (Practice Facilitator)
   Ann Chou, PhD (Co-PI)               Eileen Merchen, MS (Practice Facilitator)
   Robert Salinas, MD (consultant)     OKPRN community clinicians and patients
   John H Wasson, MD (consultant)      Portal Advisory Committee Members

                 Oklahoma Physicians Resource/Research Network

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