Integrating Patient Data to Improve Medication Adherence

March 1, 2016

Brian E. Dixon, MPA, PhD, FHIMSS

David G. Marrero, PhD

Conflict of Interest

Brian Dixon, MPH, PhD, FHIMSS

Has no real or apparent conflicts of interest to report.

David G. Marrero, PhD

Has no real or apparent conflicts of interest to report.

Agenda

• Background and Significance

• Objective and Study Design

• Technical System Overview

• Results of Pilot Study to Improve Adherence

• Lessons Learned from Conducting Pilot

Learning Objectives

• Identify the challenges to medication adherence in patients with

type 2 diabetes

• Explain the outcomes of a pilot study designed to improve

medication adherence in patients with type 2 diabetes

• Describe the technical, behavioral and system-level challenges to

integrating clinical, pharmacy and patient-reported data to inform

provider-patient conversations about medication adherence

Our HIT Intervention Seeks to

TREATMENT/CLINICAL

Improve management of diabetes as well

as health outcomes

ELECTRONIC INFO/DATA

Enhance communication between providers

and patients regarding compliance and

barriers to self-management

PREVENTION & PATIENT EDUCATION

Engage patients in self-management of

diabetes through better med utilization

http://www.himss.org/ValueSuite

Background and Significance

• Diabetes Mellitus / Type 2 Diabetes

– 285+ affected worldwide

– 4th cause mortality

– Costs are 11% higher for poor control

• Existing data shows that poor control linked to poor medication adherence

– Adherence linked to all-cause mortality

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Prior Approaches in T2DM

• Many prior mHealth interventions offer narrowly scoped solutions with limited success

• 22 of 52 (42%) interventions resulted in modest improvements in adherence

– Just 9 (17%) improved both adherence and glycemic control

– Sapkota et al. PloS one. 2015;10(2):e0118296.

Innovation

• Diabetes Translational Research Center

– Mission is to promote the prevention and care of diabetes through research on patient and provider education, health services, community participation and policy

• Regenstrief Center for Biomedical Informatics

– International leader in development of health informatics interventions and evaluation

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Eskenazi Health

One of the largest safety net health

systems in the U.S.

Over 1 million served each year

Part of the county public health agency

Includes a single 315-bed hospital and 11 community health centers

Level 1 trauma center; adult burn center

Large outpatient mental health system

Project Objectives

• Develop an integrated dashboard with information relevant to medication adherence

– Recent lab, vitals from the EHR

– Adherence to prescribed medications

– Patient-reported barriers to adherence

• Pilot the dashboard in three (3) Eskenazi Health primary care clinics / PCMH sites

Proportion of Days Covered (PDC)

• PDC is a ratio representing whether the patient possessed a drug or a class of drugs during a defined measurement period

– T2DM drug classes; HTN drug classes

– 180 day measurement period

• Thresholds

– >80% Good / Green

– Between 60% and 80% Okay / Yellow

– <60% Poor / Red

Dixon et al. JMIR Med Inform. 2016

http://medinform.jmir.org/2016/1/e4/

Data Sources

• Physiological data

– Local EHR System – last BP, HbA1c, etc.

• Medication data

– Surescripts network data from HIE

• Patient-reported barriers

– Patient portal / PHR

System Development

• Dashboard developed and implemented in the CareWeb framework and integrated with the CDS Hub and G3 platform

– https://github.com/carewebframework

• Java-based module that provides a Web-based interface into the Regenstrief Medical Record System (RMRS)

14

System Development

• In addition, implement method to collect psychosocial data from patients using a personal health record (PHR) platform

• Designed modules on the OpenMRS platform

– Used in many countries for EHR

– http://openmrs.org/

15

System Architecture

Dixon et al. JMIR Med Inform. 2016

http://medinform.jmir.org/2016/1/e4/

Dixon et al. JMIR Med Inform. 2016

http://medinform.jmir.org/2016/1/e4/

• Recruit CHCs and Physicians

• Collect baseline data

• Train Physicians in situ

Providers

• Recruit patients via phone

• Collect consent and baseline data

Patients • GA monitors clinic

schedules and reminds patients

• Measure usage and challenges

Monitor

Pilot Study Design

End

Results and Lessons Learned

Challenges in Enrollment

2,369 Patients identified by the EHR

906 Called by ResNet

203 Screened

131 Eligible

106 Consented

96 Enrolled

Patient Demographics

Characteristic N (%)

Gender

Male 40 (42%)

Female 56 (58%)

Race

Caucasian / White 47 (49%)

African American / Black 41 (43%)

Unknown 8 (8%)

Account Created 92 (96%)

Completed Pilot 24 (26%)

Patient Characteristics

Variable Mean (Median) Std Dev

Age 53 (52) 11.00

HbA1c (%) 8.79 (8.24) 1.98

LDL (mg/dL) 95.6 (92.5) 34.18

BMI (kg/m2) 39.87 (37.14) 11.95

PCP VISITS 5.45 (5) 4.71

ED VISITS 1.02 (1) 1.35

Change in PDC

Pre Post Difference (p)

Biguanides 74% 88% 14% (<.001)

Thiazolidinediones 77% 93% 16% (0.004)

Sulfonylureas 73% 93% 20% (<.001)

ACE Inhibitors 85% 91% 6% (0.04)

Angiotensin II Receptor

Antagonists (ARB)

80% 93% 13% (0.02)

Calcium Channel

Blockers

87% 95% 8% (0.03)

Beta Blockers 75% 91% 16% (<.001)

Clinical Outcomes

• No change in the following outcomes

– HbA1c

– LDL

– BMI

• Significant changes to the following

– PCP Visits

– ED Visits

Commonly Reported Barriers

Questionnaire Item Mean Score

I just don't like taking medicine in general 5.69 I just forget to take them 5.36 I can't afford them 5.19 I ran out of medication before I could call or visit my doctor or nurse

5.17

My medicines make me feel bad or have side effects I don't like

5.15

Provider Engagement and Use

• Out of 29 eligible providers, 15 volunteers

– At end of study 12 still practiced

• Only 4 of 6 providers reported using the dashboard at least once

• Several providers indicated “neutral” feedback

– Some questioned whether this is necessary

Challenges to Patient Engagement

• Integration into routine life

– Although patients indicated they had routine access to the Internet, often their access was mediated by a family member or the library

– Email was not a good way to get hold of patients

– Access required logging into a portal that was distinct from other health and information systems

– Portal worked best in a browser, not so good on a mobile device

• Integration into clinical workflow

– DM2 visits are challenging with many topics to cover in 15 minutes

• Clinical FTE Target May Be Off

– Physicians may not be the best end user of the integrated portal

– Changing role of nurses, pharmacists, social workers in medicine

Challenges to Patient Engagement

For More Information

Dixon BE, et al. Integration of Provider, Pharmacy, and Patient-Reported Data to Improve Medication Adherence for Type 2 Diabetes: A Controlled Before-After Pilot Study. JMIR Med Inform 2016;4(1):e4

Available for FREE at http://medinform.jmir.org/2016/1/e4/

Acknowledgements

• Research Team

– Abdul M. Jabour (PhD Student, SOIC)

– Abdullah Alzeer (PhD Student, SOIC)

– Erin O’Kelly Phillips (Research Coordinator, DRTC)

• The work presented was supported by a grant from the NIDDK (R34DK092769), U.S. National Institutes of Health (NIH)

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A Summary of Benefits for the Value of Health IT

TREATMENT/CLINICAL

Significant and clinically meaningful

change in medication adherence, yet no

change in T2DM indicators

ELECTRONIC INFO/DATA

Implemented an integrated solution that is

feasible and met with some enthusiasm

but translated into little usage

PREVENTION & PATIENT EDUCATION

Engaging patients using a standalone

portal is challenging

http://www.himss.org/ValueSuite

Questions • Brian E. Dixon, MPA, PhD, FHIMSS

– Assistant Professor, IU Fairbanks School of Public Health;

– Research Scientist, Regenstrief Institute;

– Health Research Scientist, Department of Veterans Affairs

– http://tinyurl.com/fsphbed

– Twitter: @dpugrad01

• David G. Marrero, MD

– J.O. Ritchey Professor, IU School of Medicine

– Director, Diabetes Translational Research Center

– dgmarrer@iu.edu