Contact email

jhaas@partners.org

Overview

• By combining Electronic Health Records (EHRs) with Health Risk Assessments (HRAs), physicians across Brigham and Women’s Primary Care Practice networks hope to increase patient awareness and accuracy of self-perceived risk of various chronic illnesses, increasing personalization of medical care. 

Department

Department of Medicine

Status/Stage of Development

Planning

Funding Sources

Funding sources include the Agency for Healthcare Research and Quality and the National Cancer Institute Population-based Research Optimizing Screening through Personalized Regimens initiative.

Practice Setting

Academic Medical Center

National/Policy Context

• Family health history and lifestyle traits often contribute to increased risk of chronic diseases such as diabetes, coronary heart disease, and cancer. By systematically assessing this information, physicians can identify patients at greater risk and promote informed decision making earlier. 

Tools or Products Developed

• Patient Risk Evaluation and Prevention (PREP): Collects family health history and lifestyle risk factors from primary care patients. PREP produces a personalized HRA for chronic illnesses including coronary heart disease, diabetes, breast cancer (for women), and colorectal cancer prior to the patient’s visit.
  • PREP measured whether high-risk individuals talked about the risk of developing diseases in the future, changes to improve health, and speaking to a genetic counselor at their primary care physicians’ visits.

Tech Involved

• Electronic medical record

Team Members Involved

• Physicians
• Support Staff

Workflow Steps

• In the intervention, pre-visit assessments were mailed four weeks before physician visits, and they included questions for patients to generate an HRA and self-perceived risk for each condition (See Fig. 1). This risk factor data was sent to EHRs to further use in documentation support decisions. 
• Primary care providers (PCPs) received an email alert on the morning of the visit (with a data icon appearing on their daily schedule next to the patient’s name) to review the PREP results before the appointment.
  • During the appointment, PCPs used the patient PREP results to guide discussion towards specific topics, addressing the patient’s questions in regards to high-risk diseases and providing personalized medical treatment depending on the patient’s perceived risk (rather than simply the diagnosis).
• Two to four weeks post-visit, patients re-assessed their self-perceived risks to see the effects of experimental changes in visit structure and content.

Fig. 1: Flow diagram of the PREP data collection period. 

Outcomes

• Number of patients contacted: The study attempted to contact 31,223 individuals. 
  • PREP only reached 20% of potentially eligible participants, as some patients neglected to fill out the information and decided not to utilize the PREP in their normal provider appointments. 
• Likelihood to discuss disease risk with PCP: Patients who used PREP indicated a greater likelihood of speaking with their physician about a chronic disease, from 45.5% to 54.1%.
  • Discussion of changes to improve patient health increased from 78.5% to 74.1%.
  • There was no change in discussion of referral to a genetic counselor among high risk individuals between intervention and control groups. 
• Improvement in accuracy of risk perception: PREP measured for accuracy of self-perceived vs. calculated risk for individuals with inaccurate risk perception before the visit categorized as “average”, “below average”, or “high risk”. 
  • Diabetes: Improvement from 12.6% to 16.0% accuracy of self-perceived risk
  • Colorectal cancer: Improvement from 17.2% to 27.9% accuracy 
  • Coronary heart disease: Improvement from 18.3% to 23.1% accuracy 
  • Breast cancer: Improvement from 15.9% to 21.0% accuracy of self-perceived risk
• Mammogram discussions: PREP also measured if women 40 years or older talked with their PCP about getting a mammogram in the next year. 
  • 68.3% of women documented a mammography screening in the prior year.
  • Compared to 85.7% of women previously discussing receiving a mammogram, after the intervention 88.7% of women discussed the mammography.
• Participation: 55.8% of patients participated by web, and 44.2% of patients by phone. 

Future Outcomes

• There is potential to broaden population-based risk assessment, promoting communication and risk perceptions to create more personalized medical care for specific disease prevention. 

Benefits

• By linking patient-provided information with their healthcare team, PREP improves patient-provider communication and patient understanding of personal health risks. 
• PREP was associated with improved timeliness of disease preventive services.  
• Improvements were found in risk perception, self-reported physical activity, and fruit and vegetable intake, suggesting that patients were more health aware.

Intervention-Specific Challenges

• PREP only reached 20% of potentially eligible participants. If it were implemented as part of a care plan, it may have greater participation. 

Sources

• Haas JS, Baer HJ, Eibensteiner K, Klinger EV, St Hubert S, Getty G, Brawarsky P, Orav EJ, Onega T, Tosteson AN, Bates DW, Colditz G. A Cluster Randomized Trial of a Personalized Multi-Condition Risk Assessment in Primary Care. Am J Prev Med. 2017 Jan; 52(1):100-105. doi: 10.1016/j.amepre.2016.07.013. Epub 2016 Sep 14. PubMed PMID: 27639785; PubMed Central PMCID: PMC5167657.