Association for Public Policy Analysis & Management

The Office of the National Coordinator for Health Information Technology (ONC) in the Department of Health and Human Services is tasked with nationwide implementation of health information technology (IT). Patient-generated health data, information regarding an individuals’ health that is collected by the patient, is considered to be an important area for advancing person-centered and self-managed health.^[1] In particular, electronic sharing of patient-generated health data -- such as patients’ glucose levels -- between visits is a potentially valuable tool for patients with diabetes performing self-monitoring of blood glucose.^[2] Doctors can electronically remind patients to perform self-monitoring of blood glucose and share the information with them using electronic blood glucose flowsheets. This information can then be used by doctors to monitor patients’ glucose levels between visits frequently, and more effectively.

ONC, the Inova Medical Group, and the Office of Evaluation Sciences (OES) designed provider- and patient-facing interventions to increase patient use of flowsheets to track blood glucose electronically.

In the provider-focused intervention, providers were invited to attend a virtual training, encouraged to place a bulk order for flowsheets which enabled patients with diabetes to track blood glucose electronically, and offered in-person support, including a template for reaching out to patients. Using a cluster randomized controlled trial design with 20 primary care practices in the DC metro area, we randomly assigned ten practices (34 doctors and 3,411 patients) to receive the aforementioned training and encouragement, and ten practices (34 doctors and 3,641 patients) were assigned to the control condition of business as usual.

Patients at treatment practices were 63.6 percentage points (p=.001, CI[32.5,94.7]) more likely to receive an electronic flowsheet order than patients in the control group. Patients at treatment practices were also 4.7 and 2.3 percentage points (p<.001, CI[3.2,6.3]; p=.001, CI[1.3,3.2] ) more likely to use the flowsheet during the 1-14 and 15-26 week periods (respectively) following the provider training.

In the patient-focused intervention, we designed three reminders encouraging patients to use flowsheets: (1) a generic reminder signed by Inova, (2) a physician accountability reminder signed by the patient’s physician, and (3) a generic reminder signed by Inova with a chance to win a $50 gift card. The reminders were tested by assigning 2,182 patients with flowsheet orders to one of three bi-weekly email reminder groups based on the first letter of their last name, or a business as usual control group with no reminders.

The physician accountability reminder increased patient use of flowsheets by 3.1 percentage points relative to a 3.5% use rate in the no reminder group (p=0.052, CI[ 0,6.2]). Receiving the physician accountability reminder also led to 1.8 fewer prescription orders during the study period (p=.009, CI[-3.2,-0.4]), and 0.2 fewer diabetes-related prescriptions (p=.014, CI[-0.4, 0.0]).

^[1] Office of the National Coordinator for Health Information Technology. Federal Health IT Strategic Plan 2015-2020. 2014. Available at https://www.healthit.gov.

^[2] Kirk JK, Stegner J. Self-Monitoring of Blood Glucose: Practical Aspects. Journal of Diabetes Science and Technology. 2010;4(2):435-439.