Special Projects of National Significance
2005 Report to CARE Act Grantees

Information Technology Initiative

Evaluating the Impact of Information Technology on Optimizing the Delivery and Quality of Care

Background

Given the complexity of HIV treatment and the difficulty of reaching underserved people living with HIV, providers are challenged to provide comprehensive, coordinated, timely, and cost-effective care for HIV-positive patients. Health care providers are being asked to seek innovative interventions to improve quality of care. Information technology (IT) provides one set of tools to providers to meet this demand.

IT is increasingly being used to improve health care services. Rapid advances in IT now make it possible to bring information to both health care providers and patients. Some of these interventions include automated laboratory reporting, electronic medical records (EMRs), computerized provider order entry (CPOE), smart cards, bar coding, and digital imaging. In addition, IT can now be used for provider and patient education and training. For example, patient-oriented IT tools such as computer-based education, self-care and social support modules and IT applications that promote patient adherence to medications and treatment are a few of the interventions that can improve this aspect of care.

The electronic medical record stands at the core of clinical information management systems by bringing information and knowledge management to providers at the point of care and to patients at the point of utilization. Some applications include:

· In concert with EMRs, on-screen reminder alerts and prompts for providers can be used to improve provider productivity and quality of care.

· The integrated clinical workstation provides access to automated medical records, clinical data reports, administrative billing information and knowledge bases, at a single point of entry.

· The comprehensive and portable record also known as the "smart card" utilizes a programmable computer chip imbedded in a card that can store information such as a patient's medical record, insurance and billing information, service utilization, and demographics.

· Automated medication bottles (MEMS caps) and simple medication reminder systems, including automatic pill dispensers, multiple alarms, medical ID watches, personal digital assistant devices (PDAs) support patient adherence in taking medications.

2005 REPORT information technology initiative

· Computer-based interactive health communication (IHC) programs can be used for patient education as well as behavioral change, in concert with other clinical interventions.

Evaluation of such applications is needed on how IT impacts health care quality, including any side effects, complications, or other negative outcome measures. While promising, IT remains in development and has not been utilized or evaluated to a significant degree in the HIV clinical setting. More research is needed to evaluate the benefits of IT use in HIV care so that health care providers and payers are encouraged to adopt and use the technology. Although the literature demonstrates that computerized IHC programs can improve patient knowledge, reduce negative health risk behaviors, and facilitate shared decision-making, studies are needed that can assess the effectiveness of IHC programs on clinically important outcomes. Studies are also needed to assess the effectiveness of IHC programs on increasing access to care and to identify and overcome barriers to implementation, especially for patients of lower socioeconomic status and those patients with lower computer and English literacy skills.

The Information technology initiative

The Information Technology Initiative evaluates the impact of information technology in improving the delivery and quality of care for underserved people living with HIV. The four-year initiative, which began in October 2002, is expected to continue through September 2006. Both the Special Projects of National Significance (SPNS) and the AIDS Education and Training Centers (AETC) of HAB are involved in the initiative. Six grantees will evaluate the application of IT to improving services to people with HIV in primary care. The initiative has three areas of emphasis:

1. Optimizing the delivery of health care;

2. Optimizing outcomes and quality of health care;

3. Assessing the cost-effectiveness of IT interventions.

While an initiative-wide evaluation report is expected at the end of the funding period, preliminary results are currently being communicated through multiple information channels available to the target audiences.

Services provided under this initiative are directed towards users of outpatient or community-based HIV service providers that use IT as a part of service delivery.

The overall goal of the initiative is to evaluate the effectiveness of IT in improving the delivery and quality of care to underserved people with HIV.

Contact Information

HRSA Project Officers

Special Projects of National Significance
5600 Fishers Lane, Rm 7C-07
Rockville, MD 20857

Adan Cajina, MS
Phone: 301-443-3180

Sandra Duggan, MA
Phone: 301-443-7874

Grantees

Columbia University (New York, NY)

An Internet-Based Information Technology to Reduce Prescription Errors with HIV/AIDS Anti-Retroviral Medications

Target Population: Physicians treating people with HIV/AIDS

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THE SPNS MANDATE

The purpose of the Special Projects of National Significance (SPNS) program is to advance knowledge and skills through the support, development and evaluation of innovative models of HIV care for financially disadvantaged and medically underserved populations. The SPNS program, administered by the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB), is part of the Ryan White Comprehensive AIDS Resources Emergency Act, also known as the CARE Act.

SPNS models of innovative care for HIV-positive patients have been designed to respond to the needs of the HIV epidemic. Currently, it is estimated that about 650,000 to 950,000 persons are infected with HIV and approximately 40,000 new infections occur every year in the United States. Only about one-third of HIV-infected adults are currently receiving regular or ongoing medical care for HIV infection. The most affected populations are traditionally underserved and hard-to-reach groups, particularly women, injection drug users and their heterosexual partners, gay and bisexual men of color and youth. HIV/AIDS is now most heavily impacting minority communities and individuals living in poverty.

SPNS response to the epidemic began in 1991 with some of the first Federal grants to target adolescents and women living with HIV. Today, a portfolio of 72 grants funded either solely by the HIV/AIDS Bureau or in partnership with other Federal agencies addresses the cutting-edge issues in HIV care.

The SPNS program is an integral link to all CARE Act programs. While it provides an opportunity to develop and evaluate new services, the program places great emphasis on the dissemination of these services. SPNS promotes the dissemination and replication of effective models of care relevant to the present challenges of the epidemic. These models include the integration of HIV primary care services to the needs of individuals who present with multiple diagnoses such as substance abuse, mental health, and other psycho-social burdens that complicate the effective delivery of health care.

As CARE Act grantees develop innovative services, the SPNS program will provide the funding and technical assistance for grantees to evaluate innovations and disseminate findings to the HIV community.

Within each multi-site SPNS initiative, grantees focus their interventions on a specific population or treatment issue, either by implementing components of existing interventions or designing new models. These models are evaluated for effectiveness, efficiency, and replicability. An important corollary is an examination of the contextual issues that contribute to the success or failure of an intervention in a particular setting or with a particular population.

Evaluation of Models

The structure of most of the multi-site initiatives is designed to collect data and evaluate interventions across sites. The projects are grouped by type of intervention or topic (e.g., outreach, prevention) with the guidance of an evaluation center, whose tasks include:

· facilitating cross-site evaluation, with technical assistance provided

· developing standardized data collection instruments

· assuring data quality

· disseminating findings

· and assessing policy implications of study findings.

Each grantee is required to participate in development of the evaluation plan for the overall initiative and most collect uniform data that can be analyzed and compared across programs. The SPNS initiatives have demonstrated that collaboration for multi-site evaluation of care programs is possible and rewarding, and that it requires time and effort on the part of all stakeholders: the evaluation centers, HRSA/SPNS, and the projects.

Current SPNS Initiatives

To date, SPNS sponsors a variety of demonstration programs, each with a set of unique, yet initiative specific goals and strategies designed to have the greatest impact on their respective targets. While SPNS has funded numerous innovative programs over the past decade, the table below summarizes eight initiatives that are currently funded through 2009.

Lessons learned from these and other initiatives are helping the HIV/AIDS Bureau develop effective strategies for addressing the demand for HIV services among underserved infected populations.

Current priorities include:

US-Mexico Border: Demonstrating and evaluating models that advance HIV service innovation along the US-Mexico Border

Outreach: Evaluating effective outreach strategies for bringing individuals into HIV primary care treatment

Information Technology: Assessing and evaluating the use of information technology to improve HIV medical care

American Indian/Alaska Native: Supporting the coordination and integration of existing services for Native Americans/Alaska Natives living with HIV and other co-morbidities

Caribbean: Improving care and treatment of HIV-infected persons of Caribbean descent through culturally appropriate strategies

Prevention with Positives: Assessing prevention strategies in primary care settings for HIV-positive persons

Buprenorphine: Developing, implementing and evaluating innovative methods for integrating Buprenorphine Opioid Abuse Treatment in HIV primary care settings

Young MSM of Color: Implementing and evaluating models of outreach, care and prevention targeted to young HIV seropositive men who have sex with men (YMSM) of color

2005 REPORT information technology initiative

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Goal: To reduce prescription errors by improving the prescribing behaviors of providers, thereby improving patient health outcomes

Strategies: HIV Tailored Information Provider Service (TIPS), a web-based, interactive decision-support and information system designed to: 1. Provide clinicians with assistance when formulating patient medication regimens; 2. Provide clinicians with medication adherence plans tailored to each patient's situation

Evaluation: The study design is a randomized clinical trial which will measure outcome data on medical errors, resource utilization, and patient health status through chart abstraction

Contact Information:

Peter A. Messeri, PhD, Principal Investigator
630 West 168^th Street
New York, NY 10032
E-mail: pam9@columbia.edu
Phone: 212-305-1549

Cornell University Weill Medical College (New York, NY)

Evaluation of a Patient-Centered Electronic Medical Record in a Medicaid Special Needs Program

Target Population: HIV-infected Medicaid patients in New York City

Goal: To enhance shared decision making during the clinic visit, improve patient outcomes and quality of care, and test the feasibility and cost-effectiveness in a Medicaid managed care environment

Strategies: Computer work stations in HIV clinics where patients complete confidential screening questionnaires and review quality of care information

Evaluation: The completed evaluation will assess process, delivery, clinical outcome variables, and cost effectiveness in addition to patient and clinician acceptance

Contact Information:

Bruce R. Schackman, PhD, Principal Investigator
Weill Medical College of Cornell
411 East 69^th Street
New York, NY 10021
E-mail: brs2006@med.cornell.edu
Phone: 212-746-6625

HIV Integration and Health Outcomes Project Evaluation

Target Population: HIV-positive people living in central and eastern North Carolina

Goal: To improve quality of care and reduce healthcare costs

Strategies: A statewide computer network supporting Provide, a Lotus Notes-based set of relational HIV/AIDS databases

Evaluation: Evaluation activities will focus on measuring the impact of the IT intervention on cost effectiveness, service delivery, and quality of care

Contact Information:

Kate Whetten Goldstein, PhD, Principal Investigator

Frank M. Lombard, LCSW, Assoc. Director
Health Inequalities Program (HIP)
Center for Health Policy, Law and Mgmt.
110 Swift Avenue
Durham, NC 27708
E-mail: frank_lombard@ncsip.duke.edu
Phone: 919-416-4598

Johns Hopkins University (JHU) HIV Outcomes Program (Baltimore, MD)

The Impact of a Computer-Assisted Self-Interview on the Delivery and Clinical Outcomes of HIV Care

Target Population: Patients in the JHU HIV Outcomes Program who are starting a HAART regimen

Goal: To better identify medication errors, early problems with adherence and side effects, patient misconceptions, and prompt early treatment decisions and improved provider-client interaction with a focus on improved patient health

2005 REPORT information technology initiative

Strategies: Computer workstations for patients in the clinic incorporating a computerized patient questionnaire using an Audio Computer Assisted Self Interview (ACASI) system, which is then used as the basis for discussion during the visit

Evaluation: A randomized clinical trial designed to measure viral load suppression, CD4 lymphocyte change, duration of HAART use, and acceptance of ACASI by providers and patients

Contact Information:

Richard D. Moore, MD, MHS, Principal Investigator
1830 E. Monument Street, Suite 8059
Baltimore, MD 21287
E-mail: rdmoore@jhmi.edu
Phone: 410-955-2144

Los Angeles County Department of Health Services Office of AIDS Programs and Policy (Los Angeles, CA)

HIV/AIDS Interface Technology Systems (HITS)

Target Population: People who test HIV-positive at OAPP-funded public HIV counseling and testing sites

Goal: To promote a continuum of care and expedite the transition of newly-diagnosed individuals into that system of care

Strategies: HITS is a series of IT interfaces designed to: 1. tailor referrals to individual patient needs; 2. prompt follow-up by counselors when patients do not return for test result and/or fail to access care; 3. migrate already collected patient information from one data system to another in order to expedite intake/eligibility

Evaluation: Variables to be examined include the impact, frequency, and speed of clients entry into care, satisfaction with the referral process, and impact of IT innovations on the care system

Contact Information:

Ijeoma Nwachuku, PhD, Principal Investigator, Research Support Manager
Office of AIDS Programs and Policy
600 South Commonwealth Avenue, 6^th Fl
Los Angeles, CA 90005
Phone: 213-351-8301

Louisiana State University Health Sciences Center (New Orleans, LA)

Evaluating Information Technology's Impact on a Statewide System of HIV Care

Target Population: HIV patients in a statewide public hospital system of eight LSUHSC-administered facilities

Goal: 1. To optimize the delivery of HIV care; 2. To improve morbidity and mortality outcomes among HIV-infected individuals; 3. To improve the quality of HIV outpatient care being delivered

Strategies: Incorporate LabTracker, an electronic patient database with linkages to receive patient information from hospital information systems and to allow provider input. This program: 1. Enables providers to have immediate access to medical records; 2. Creates educational materials for summary medical information for provider use with patients

Evaluation: The project will use several evaluation strategies to measure changes in health care utilization, provider and patient satisfaction, clinician adherence to standards of care, patient health status, patient adherence to treatment, and cost effectiveness of the intervention

Contact Information:

Michael Kaiser, MD, Principal Investigator
LSUHSC Health Care Service Division
8022 Cohn Street
New Orleans, LA 70118
Phone: 504-866-5844