Anthony E Brown, MD, MPH J Travis Gossey , MD, MS, MPH Susan G Nash, PhD

1. Using the Electronic Health Record to Improve Transfer of Medical Information after a Primary Care Office Visit Anthony E Brown, MD, MPH J Travis Gossey, MD, MS, MPH Susan G Nash, PhD Adriana Linares, MD, DrPH ValoryPavlik, PhD

2. Disclosure InformationAHRQ Conference, September 18-21, 2011Anthony Brown MD MPH • Disclosure of Relevant Financial Relationships: • I have no financial relationships to disclose. • Disclosure of Off-Label and/or Investigative Uses: • I will not discuss off label use and/or investigational use in my presentation.

3. Task Order #17: Using Health Information Technology to Improve Healthcare Quality in Primary Care Practices and in Transitions between Care Settings • Sponsor: Agency for Healthcare Research and Quality (AHRQ) • Contract: University of New Mexico (UNM), Robert Williams, MD, MPH (PRIME-Net) • Subcontract: Baylor College of Medicine • PBRN: PRIME-Net/SPUR-Net

4. Relevance • Up to 50% of the information relayed to patients during a visit is forgotten by the time they leave • The after-visit summary (AVS) is built from information in the electronic health record (EHR) • (AVS) may improve patient retention of that information • After the project began Centers for Medicare and Medicaid Services (CMS) released Meaningful Use (MU) AVS guidelines • Limited evidence exists to inform the design of the AVS

5. Goals and AHRQ Priority Population Focus • To determine the optimal format and content for the AVS in primary care settings serving economically and ethnically diverse patients • Three phase study consisting of qualitative data from physicians and patients, development of three different AVS, evaluation of AVS versions in comparison to a fourth group consisting of the usual care AVS at the clinic site • Data collection is ongoing and we are presenting initial findings

6. Patient Centered Care: Patient Response Summary • Many reported satisfaction with current AVS • Visual appearance of the form was not a concern for most • Some requested additional information yielding a list similar to CMS “Meaningful Use” requirements • Medication lists were not always current • Reinforced education potential of the AVS through explanations of diagnoses and medications, and inclusion of diet/exercise plans and personalized health goals • Along with easier to read summaries, many patients requested more details and directions in the AVS, particularly in regard to medications

7. Spanish Speaking Patients • Those with little or no English fluency wished to receive information in Spanish • Often share the AVS with their families • The free text box can be used for Spanish information • Concerns for the monolingual Spanish speaking patient: • More detailed instructions for medications • Inclusion of prevention topics such as diet and exercise and ways to stay healthy • Understanding tests ordered • Confidentiality of the AVS

8. CMS Meaningful Use (MU) AVS Guidelines • Patient name • Provider's office contact information • Date and location of visit • Medication list • Vitals • Reason for visit • Symptoms • Instructions based on clinical discussions that took place during office visit • Problem list • Immunizations or medications administered • Summary of topics covered • Future appointment and test information • Recommended patient decision aids • Test/laboratory results (if received before 24 hours after visit) https://questions.cms.hhs.gov/app/answers/detail/a_id/10558/~/%5Behr-incentive-program%5D-what-information-must-an-eligible-professional-provide

9. Programming Constraints • Problem list is generated from ICD-9 codes without the ability to translate to Spanish or into “everyday” language • For the Spanish speakers the best we could do would be to translate the headings • Medication auto generated by EHR prescribed list • AVS given at time of visit so only in office same day lab results available for the AVS • Patient instructions free text box • Required by health system to be on every AVS • Used by physicians for personalized instructions and for education materials • Information added here at times extends the length of the AVS by several pages

10. Prototype AVS Forms

11. AVS 1

12. AVS 2

13. AVS 3

14. Translatability • A program code was developed for each test version • The health systems’ programming team inserted the code into the EHR environment • The design of the three experimental AVS versions was constrained by the existing Epic EHR environment in our research settings • Program code can be disseminated to other healthcare settings utilizing the Epic EHR • 56514 - AVS: Current Meds” The line to execute this command should be: • d CtAcMeds^LARHCR62("Current Medications / MedicamentosActuales","","",2,"", 3,"","","","","","","","", 1,"",1,1,1,"Facility-Administered Medications",1,"","","","")

15. Evaluation of AVS • We are testing the three different AVS versions in a randomized design • A fourth group received the existing AVS format in each clinic • Primary outcome • Amount of information recalled by patients at the follow up time points • Recall test consists of two parts • Part 1: recall of the general categories of information contained on the AVS. • Part 2: ask the patient to generate the list of medications prescribed and instructions given. • The total test score is the percent of items correctly recalled • Secondary Outcomes • Patient Satisfaction with the AVS • Adherence to Treatment • Other Study Variables • Health Literacy - Short Test of Functional Health Literacy in Adults (S-TOFHLA) • Demographic and Health

16. Conclusions • Physicians prefer a brief but accurate AVS, whereas patients focus more on inclusiveness and accessibility of the information • This is a work in progress; we have recruited 174 of a planned 272 patients to the randomized experiment • Our experiment will indicate whether variation in content affects recall, adherence, use of information, or patient satisfaction • More details available at our poster on display at this conference • Contact: Anthony Brown, MD MPH: anthonyb@bcm.edu

17. Acknowledgements • Research Coordinators: Lillian Carreon, Roshanda Chenier, Abdul Syed, Lizette Rangel, and Ashela Bean • Physician and patient participants