A nurse-led, multidisciplinary health team can manage a population of diabetic patients in an online disease management program. INT patients achieved greater decreases in A1C at 6 months than UC patients, but the differences were not sustained at 12 months. More INT than UC patients achieved improvement in A1C (>0.5% decrease). Trial registered in clinical trials.gov: #NCT00542204.

Time spent by physicians is a key resource in health care delivery. This study used data captured by the access time stamp functionality of an electronic health record (EHR) to examine physician work effort. This is a potentially powerful, yet unobtrusive, way to study physicians' use of time. We used data on physicians' time allocation patterns captured by over thirty-one million EHR transactions in the period 2011-14 recorded by 471 primary care physicians, who collectively worked on 765,129 patients' EHRs. Our results suggest that the physicians logged an average of 3.08 hours on office visits and 3.17 hours on desktop medicine each day. Desktop medicine consists of activities such as communicating with patients through a secure patient portal, responding to patients' online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. Over time, log records from physicians showed a decline in the time allocated to face-to-face visits, accompanied by an increase in time allocated HHS Public AccessAuthor manuscript Health Aff (Millwood). Author manuscript; available in PMC 2017 August 07. Author Manuscript Author ManuscriptAuthor Manuscript Author Manuscript to desktop medicine. Staffing and scheduling in the physician's office, as well as provider payment models for primary care practice, should account for these desktop medicine efforts.Physician time is a key resource in health services delivery. Understanding how physicians spend their clinical time is essential, given the need to understand practical capacity; guide staffing, scheduling, and support models in the physician's office; and improve the accuracy of payment for physician services. Fee-for-service payments are intended to reflect resources (captured as relative value units, or RVUs) used before, during, and after clinical encounters associated with face-to-face ambulatory care visits. 1-3 Questions have been raised about whether the reports underlying the RVU estimates are accurate and representative of true physician effort in providing patient care services. In the age of electronic health records (EHRs) with patient portals, patients often request services (such as prescription refills and medical advice) online, without face-to-face visits. Physician effort in addressing these online requests was absent from the original RVU calculations. [1][2][3] In addition to physician reports of their own efforts, 2,4,5 researchers have used time-andmotion studies 6 and video 7 and audio recordings. 8 While these methods capture significant physician effort, 6,9-11 they are costly to use and often evaluate only a limited number of physicians. Even the resource-based relative values scale (RBRVS) was built, for some specialties, on survey responses to vignettes from about twenty physicians. 1 This scale is still the chief tool used to determine the periodic updates to the Medicare Fee Schedule. Furthermore, concerns about the Hawthorne effect preclude ongoing, broad-based direct observa...

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BackgroundEMPOWER-H (Engaging and Motivating Patients Online With Enhanced Resources-Hypertension) is a personalized-care model facilitating engagement in hypertension self-management utilizing an interactive Web-based disease management system integrated with the electronic health record. The model is designed to support timely patient-provider interaction by incorporating decision support technology to individualize care and provide personalized feedback for patients with chronic disease. Central to this process were patient-generated health data, including blood pressure (BP), weight, and lifestyle behaviors, which were uploaded using a smartphone.ObjectiveThe aim of this study was to evaluate the program among patients within primary care already under management for hypertension and with uncontrolled BP.MethodsUsing a 6-month pre-post design, outcome measures included office-measured and home-monitored BP, office-measured weight, intervention contacts, diet, physical activity, smoking, knowledge, and health-related quality of life.ResultsAt 6 months, 55.9% of participants (N=149) achieved office BP goals (<140/90 mm Hg; P<.001) and 86.0% achieved clinically meaningful reduction in office BP (reduction in systolic BP [SBP] ≥5 mm Hg or diastolic BP [DBP] ≥3 mm Hg). At baseline, 25.2% of participants met home BP goals (<135/85 mm Hg), and this percentage significantly increased to 71.4% (P<.001) at 6 months. EMPOWER-H also significantly reduced both office and home SBP and DBP, decreased office-measured weight and consumption of high-salt and high-fat foods (all P<.005), and increased intake of fruit and vegetables, minutes of aerobic exercise, and hypertension knowledge (all P<.05). Patients with higher home BP upload frequencies had significantly higher odds of achieving home BP goals. Patients receiving more total intervention, behavioral, pharmaceutical contacts had significantly lower odds of achieving home BP goals but higher improvements in office BP (all P<.05).ConclusionsEMPOWER-H significantly improved participants’ office-measured and home-monitored BP, weight, and lifestyle behaviors, suggesting that technologically enabled BP home-monitoring, with structured use of patient-generated health data and a personalized care-plan facilitating patient engagement, can support effective clinical management. The experience gained in this study provides support for the feasibility and value of using carefully managed patient-generated health data in the day-to-day clinical management of patients with chronic conditions. A large-scale, real-world study to evaluate sustained effectiveness, cost-effectiveness, and scalability is warranted.

BACKGROUND Routinely recommended screening for breast, cervical, and colorectal cancers can significantly reduce mortality from these types of cancer, yet screening is underutilized among Asians. Surveys rely on self-report and often are underpowered for analysis by Asian ethnicities. Electronic health records include validated (as opposed to recall-based) rates of cancer screening. In this paper we seek to better understand cancer screening patterns in a population of insured Asian Americans. METHODS We calculated rates of compliance with cervical, breast, and colorectal cancer screening among Asians from an EHR population, and compared them to non-Hispanic whites. We performed multivariable modeling to evaluate potential predictors (at the provider- and patient- level) of screening completion among Asian patients. RESULTS Aggregation of Asian subgroups masked heterogeneity in screening rates. Asian Indians and Native Hawaiians and Pacific Islanders had the lowest rates of screening in our sample, well below that of non-Hispanic whites. In multivariable analyses, screening completion was negatively associated with patient-physician language discordance for mammography (OR:0.81 95% CI:0.71–0.92) and colorectal cancer screening (OR:0.79 CI:0.72–0.87) and positively associated with patient-provider gender concordance for mammography (OR:1.16 CI:1.00–1.34) and cervical cancer screening (OR:1.66 CI:1.51–1.82). Additionally, patient enrollment in online health services increased mammography (OR:1.32 CI:1.20–1.46) and cervical cancer screening (OR:1.31 CI:1.24–1.37). CONCLUSIONS Language- and gender- concordant primary care providers, and culturally tailored online health resources may help improve preventive cancer screening in Asian patient populations. IMPACT This study demonstrates how use of EHR data can inform investigations of primary prevention practices within the healthcare delivery setting.