Research Activities, February 2012: Feature Story: Tough questions get answers through health IT

There's no doubt that health information technology (health IT) is a major force in efforts to improve health care for Americans. But making sure that we're using the most effective approaches requires real-world research. How can we reach patients in rural areas? It's not always feasible for patients and clinicians to travel hundreds of miles. An Internet-based network can help. How can we convince inner city asymptomatic patients with hypertension to take care of themselves? One answer wouldn't have been feasible or even fathomable a decade ago. How do we learn who is in patients' social networks so we can better reach them? Interview questions revealed that patients' networks extend beyond the expected doctors and family members.

The Agency for Healthcare Research and Technology (AHRQ) has invested over $300 million in contracts and grants to over 200 communities, hospitals, providers, and health care systems in 48 States to promote access to and encourage the adoption of health IT. The projects described here show how health IT reaches and improves care for at-risk populations.

Rural clinicians get current

Patients with hepatitis C in rural New Mexico would often travel 200 to 250 miles each way to see Sanjeev Arora, M.D. The journey was not only tough for his patients, it was hard on Arora, who says, "I had this nagging thought that if I had just been able to treat them earlier, I would have been able to prevent problems." Now he can and does.

Hepatitis C affects about 32,000 people or 1.5 percent of people in New Mexico. Although this blood-born infection is treatable, it's not easy to treat. It requires a year-long regimen of weekly injections with advanced drugs like Interferon and often causes side effects such as anemia and depression. Many rural clinicians lack the expertise needed to treat hepatitis C.

Through Project ECHO (Extension for Community Healthcare Outcomes), Arora participates in an Internet-based, audiovisual network at the University of New Mexico that helps him train rural doctors, nurses, physician assistants, and other clinicians to care for patients with hepatitis C.

"AHRQ funding allowed us to set up these Internet systems and support rural sites, and that paved the way for an ongoing State-funded program," said Arora, professor of medicine for the Department of Internal Medicine at the University of New Mexico Medical School, and a driving force behind ECHO. "The AHRQ grant also enables us to share our data with other people."

Since ECHO started in 2003, the project has linked the University of New Mexico Medical School with dozens of clinics and has grown to include other diseases and conditions. In 2011, Project ECHO expanded to Washington State and Chicago. You could call it the "ECHO effect."

Phones give instant access to health tips

Alfred Bove, M.D., Ph.D, of Temple University in Philadelphia, faces the challenge of reaching a disadvantaged urban population with asymptomatic hypertension. As former chief of cardiology, he is well aware of the potential dangers of hypertension. Helping hundreds of people with hypertension who don't feel sick but need help isn't easy.

Through an AHRQ grant, Bove recruited 250 people who were in treatment for hypertension, but as Bove says, "were relatively asymptomatic. They weren't paying much attention to their hypertension, but they needed to. About 50 percent of people in our study live at or below the poverty line, only about 60 percent have a high school education or better, and 80 percent are African American." Bove and his team communicated by computer with 35 percent of the participants and by automated telephone messages with the rest. "Everyone has a phone, but not everyone has access to a computer," says Bove. "We
recommended they check in twice a week and on average they responded seven times a month."

Nurses who the participants had met sent them recorded reminders to check blood pressure and weigh themselves, supportive messages about salt intake, and reminders to come in for appointments. Not only were the nurses familiar, they were friendly, not punitive. "They were like the GPS system when you take a wrong turn; they never sound angry," says Bove.

Each message was about 15 seconds long. "Most of the participants buy phone cards with minutes. They don't want to burn their minutes," explains Bove. Not only were the messages short, they were also simple. "They were at a sixth grade reading level."

At the end of the study, 54 percent improved their blood pressure to below hypertensive levels, but 50 percent of the control group did the same. "We were surprised," says Bove, "but the control group had to select themselves. They already had an incentive to participate, because they were interested."
"In this world of chronic disease, patients need to be engaged and participating in their health care," says Bove. "This is a way to reach out to people without overwhelming the health care system."

A multicultural approach

By reaching at-risk, diverse groups, health IT holds the promise of reducing disparities. But knowing how to communicate with diverse groups through social networks is as critical as choosing the right technology. Rupa Valdez, M.S., Ph.D. candidate in the Department of Industrial and Systems Engineering at the University of Wisconsin-Madison, asks, "In the long run, how can culturally informed approaches to health IT help reduce racial and ethnic disparities in health care?"

To start, Valdez is interviewing patients with type 2 diabetes who seek care at federally funded health clinics to learn what decisions people make about sharing health information within their social networks. "Health care is very personal, so we need to be culturally informed," she explains. "From icons that represent males and females to colors used to represent health and wellness to a patient's belief that she must always share medical information with her parents, our backgrounds are important."

Her research focuses on four factors: whom patients communicate with, why they communicate, how they communicate, and what they communicate. When asked who they communicated with, patients not only said their family members and doctors, they also named Jesus and God. Some patients also mentioned people who had died or former relatives such as ex-daughter-in-laws. Sometimes patients can be particular about who they would share information with, as they may not want to burden a close relative or friend.

"Other reasons that people may not want to communicate is that they are trying to avoid negative feedback from others or that they don't want conversations about their health to always take priority," says Valdez. To design technologies for in-home and out-of-home use for a culturally diverse group of patients, Valdez acknowledges, "We may need an array of approaches."

Editor's Note: To find out more about AHRQ's health IT program, go to http://www.healthit.ahrq.gov/.
Research Activities, February 2012: Feature Story: Tough questions get answers through health IT