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 Valory Pavlik, PhD

2. Disclosure Information AHRQ Conference, September 18-21, 2011 Anthony 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 / Medicamentos Actuales","","",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