Applying Health Information Technology to Enhance Patient Outcomes: A Study on Electronic Personal Health Records in the Management of Coronary Artery Disease in Northeast Indiana

About the Parkview Heart Institute and Catheterization Laboratory

Parkview Health is a major health system serving a population of over 800,000 in five counties in northeast Indiana. Parkview Heart Institute (PHI), located at the Parkview Regional Medical Center in Fort Wayne, maintains a state-of-the-art cardiac catheterization laboratory with five procedure rooms, including one electrophysiology hybrid room, one coronary/peripheral vascular hybrid room with surgical capabilities, one dual coronary electrophysiology room and two dual coronary-vascular cath labs. The prep/recovery area has the capacity of caring for 28 patients at any given time. The staff of the PHI cath lab currently includes four invasive cardiologists, four electrophysiology cardiologists, 10 interventional physicians, 15 registered nurses, and five radiologic technologists who conduct almost 5000 procedures every year.  

The Parkview Health cath lab staff performs coronary percutaneous interventions as well as peripheral interventions. Additionally, the cath lab has reduced door-to-balloon time using advanced technology that allows the emergency medical system providers to electronically send 12-lead EKGs to the emergency department prior to patient arrival at the hospital. In the future, the cath lab will also be performing trans-aortic valve replacements (TAVR) in the vascular hybrid room. 

Post-revascularization, patients receive care for chronic disease management in an ambulatory setting at Parkview Physicians Group-Cardiology (PPG-Cardiology). PPG-Cardiology, the physician practice component of PHI, has about 70,000 office visits and consultations each year. In addition, they perform about 73,000 tests and procedures annually. To reduce readmission rates and the reoccurrence of cardiac events, the practice continually investigates ways to help patients achieve management goals for coronary artery disease (CAD) such as exercise, weight loss, smoking cessation, and adherence to prescribed medications. Successful management of chronic diseases has been linked to patients’ levels of engagement in their health care facilitated by electronic tools.¹ Electronic personal health records (ePHR)s are a form of health information technology (HIT) that can assist patients in achieving these healthcare goals. 

Electronic personal health records 

With advances in technology, storage of health information has migrated from paper-based records to electronic formats. Further development of electronic storage systems includes interfacing with other electronic information.² According to the Markle Foundation, which provided a Common Framework for the advancement of health information technology, the ePHR is an “Internet-based set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it”.³ Using these tools, patients may aggregate and manage their medical information, as well as allow for electronic storage of patient-generated data. An ePHR provides the patient with more responsibility, control, and support in their healthcare.⁴ Over half of the population in the United States reports using the internet to search for information regarding a health concern or problem, and the number of people who have an ePHR, currently about 7%, has more than doubled within the past 5 years.⁵ Kaiser Permanente, one of the largest integrated healthcare organizations in the United States, created an ePHR (My Health Manager) and reported that the use of an electronic record leads to less office visits and phone contacts, and secure messaging between patient and physician facilitates care for patients with chronic illness (diabetes, cholesterol, hypertension).⁶  

An important aspect of ePHR technology is interoperability, defined as “the ability of two or more systems to exchange information and use the information that has been exchanged.”⁷ In 2006, Parkview started providing patients of PPG-Cardiology and PHI with the option to adopt an interoperable electronic personal health record powered by NoMoreClipboard.com. With advanced functionalities to support electronic fax and storage of information (laboratory, summary of care documents), registering for appointments, and monitoring of key health indicators like blood pressure, this interoperable system enables information exchange between patients and providers.  

Study: ePHR-COPE

In January 2011, the Office of the National Coordinator for Health Information Technology (ONC) initiated a Challenge Grant program to enhance consumer-mediated health information exchange. Grant recipients NoMoreClipboard.com and Indiana Health Information Technology, Inc. collaborated with Parkview Health’s Research Department. They sought to explore the impact of interoperable electronic personal health records (ePHRs) on patient engagement and health outcomes in a pilot study, Deployment of Electronic Personal Health Records Post-Coronary Intervention: Analysis of Outcomes and Patient Engagement (ePHR-COPE), which launched in March 2012 at PPG-Cardiology. The study, expected to conclude in August 2013, is designed to assess acceptance and attitudes about the use of ePHRs among a population of patients with CAD currently under the care of physicians, nurses and staff at Parkview Physicians Group (PPG-Cardiology). For the purposes of this study, evidence of severe CAD was defined by a positive history of previous coronary artery bypass graft surgery and/or percutaneous coronary intervention with stent procedures.  

Of the 200 enrolled patients, more than 50% had undergone a stent(s) procedure in the past, while 26.5% had undergone coronary artery bypass surgery, and approximately 18% had received both types of procedures in their medical history. Upon enrollment, patients received ePHRs powered by NoMoreClipboard, pre-populated with the patients’ health information from PPG-Cardiology’s electronic medical record (EMR) system. The enrollment process involved training on how to log-in, manually update personal information, and use specialized functions of the ePHR, such as sending blood pressure recordings to a cardiologist and retrieving information from physicians. The ePHR met interoperability standards, meaning that readable and useful information is exchanged electronically between patient and provider.  Additionally, PPG-Cardiology identified key educational materials for this patient population, including information on low-density lipoprotein, hypertension, and weight management, and made this information accessible through the ePHR portal system.  

During the enrollment process, patients completed a baseline survey that assessed computer and internet self-efficacy, acceptance of the ePHR technology, and level of patient engagement through the Patient Activation Measure (PAM). The PAM, developed by Judith Hibbard (2005), provides insight into patient confidence and skill level in regard to knowledge, understanding, treatment, and maintenance of their chronic disease and health care.  As patients progress toward a higher confidence and skill level, this allows them to shift toward self-actualized behaviors.⁸ Patient engagement encompasses actions, beliefs, and intrinsic motivators that lead to receiving the greatest benefit from healthcare providers and resources. Studies have shown that an increase in patient engagement leads to improved health outcomes.⁹ For patients managing CAD, taking prescribed medications and practicing healthy lifestyle behaviors are important factors for positive outcomes.^10,11 To assess whether the ePHR helps patients engage in their healthcare and improve their health regimen, health indicators including blood pressure and body mass index were recorded during the enrollment visit, and low density lipoprotein and hemoglobin A1c levels were collected.  

The ePHR tool provides educational resources, instant data exchange, patient-physician communication, and efficient interaction with the healthcare system. While the ePHR has the potential to enhance knowledge, understanding, communication, and efficacy for patients, thereby improving patient engagement, use cannot be assumed with accessibility. Using the Technology Acceptance Model (TAM) proposed by Davis (1985) as a guide, the patient survey also assessed patient attitudes to identify potential facilitators and barriers to adoption of ePHRs. The TAM describes technology acceptance in terms of consumer motivation and attributes of a system. The actual use of a technology can be predicted directly from consumer attitudes and beliefs, which are influenced by the features of the system.¹² Potential facilitators and barriers to ePHR adoption include the ease with which a patient can navigate the system and the satisfaction they receive from its operability and usefulness. The survey, vitals examination, and laboratory findings were repeated at 6 months and are currently being deployed at 12 months post enrollment. The number of ePHR log-ins and electronic data exchange are concurrently measured as an objective indication of ePHR use. In addition to the patient’s perspective, provider attitudes regarding the ePHR will also be considered at the conclusion of the study. 

Engaged patients are much more likely to follow through with instructions to take better care of themselves, as they are active in the process and demonstrate understanding of their disease and acceptance of treatment plans.⁹ Technologies such as the ePHR have the potential to activate, inform, and improve efficiency for patients in the management of their health care.¹ This electronic tool provides an opportunity to deliver educational content in a timely fashion to patients with CAD after revascularization and improve compliance with medical therapy as well as lifestyle modification; goals crucial in the prevention of future cardiac events.¹³ The potential for ePHR technology to serve as a platform for patient engagement reinforces the need to explore patient perceptions and attitudes about the technology as well as appropriate training and encouragement for use. Results of the study will guide how to implement these tools and technology for future advancements in patient-centered chronic disease management.

The authors may be contacted via Carly Daley, BA, at Carly.Daley@parkview.com.

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