Background Colorectal cancer (CRC) screening rates are suboptimal. The most important barriers identified by patients are poorly understood. A comprehensive assessment of barriers to all recommended modalities is needed. Methods In 2007, a questionnaire was mailed to 6,100 patients, aged 50–75 years, from 12 family medicine practices in the Virginia Ambulatory Care Outcomes Research Network. People aged 65–75 years and African Americans were oversampled. Patients were asked to rate 19–21 barriers to each of four recommended tests. In 2008, responses were coded on a 5-point scale; higher scores reflected stronger barrier endorsement. Results The response rate was 55% (n=3,357). Approximately 40% of respondents were aged ≥65 years, 30% were African-American, and 73% were adherent to screening. A clinician's failure to suggest screening and not knowing testing was necessary received the highest mean scores as barriers. Financial concerns and misconceptions were also cited. Barrier scores differed depending on whether respondents were never-screened, overdue for screening, or adherent to guidelines. The top five barriers for each modality included test-specific barriers (e.g., handling stool, bowel preparation), which often outranked generic barriers to screening. Not knowing testing was necessary was a top barrier for all tests but colonoscopy. Conclusions Although physician advice and awareness of the need for screening are important, barriers to screening are not homogenous across tests, and test-specific barriers warrant consideration in designing strategies to improve screening rates. Barrier scores differ by screening status, highlighting the need to address prior screening experience. Evidence that patients are more familiar with colonoscopy than with other modalities suggests an opportunity to improve screening rates by educating patients about alternative tests.

PURPOSE Americans receive only one-half of recommended preventive services. Information technologies have been advocated to engage patients. We tested the effectiveness of an interactive preventive health record (IPHR) that links patients to their clinician's record, explains information in lay language, displays tailored recommendations and educational resources, and generates reminders. METHODSThis randomized controlled trial involved 8 primary care practices. Four thousand fi ve hundred patients were randomly selected to receive a mailed invitation to use the IPHR or usual care. Outcomes were measured using patient surveys and electronic medical record data and included IPHR use and service delivery. Comparisons were made between invited and usual-care patients and between users and nonusers among those invited to use the IPHR.RESULTS At 4 and 16 months, 229 (10.2%) and 378 (16.8%) of invited patients used the IPHR. The proportion of patients up-to-date with all services increased between baseline and 16 months by 3.8% among intervention patients (from 11.4% to 15.2%, P <.001) and by 1.5% among control patients (from 11.1% to 12.6%, P = .07), a difference of 2.3% (P = .05). Greater increases were observed among patients who used the IPHR. At 16 months, 25.1% of users were up-todate with all services, double the rate among nonusers. At 4 months, delivery of colorectal, breast, and cervical cancer screening increased by 19%, 15%, and 13%, respectively, among users.CONCLUSIONS Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefi ts. Ann Fam Med 2012;10:312-319. doi:10.1370/afm.1383. INTRODUCTIONA mericans receive only one-half of recommended preventive services.1 Among the various causes is poor access to reliable information. Patients need evidence-based information about what is recommended-tailored to their individual risk factors (eg, age, sex, co mbordities, prior testing, family history, health behaviors)-and presented in an understandable format.2 They need reminders when services are due, guidance to deal with inconsistent recommendations, and access to decision aids for choices that require shared decision making. [3][4][5] To act on their choices, patients need written plans and logistical details. 6,7 Clinicians often lack time and resources to provide this information. 8 One proposed solution is to harness the power of information technology, especially personal health records. For the purposes of this article, personal health records are broadly defi ned as health information systems used by patients, whereas electronic health records (EHRs) are systems primarily used by clinicians. 313 INT ER AC T IVE PR E V ENT IV E HE A LT H R ECOR Dgive patients direct access to the EHR of their clinician, 9,10 which is empowering, speeds access to results, and enables patients to discover inaccuracies in their medical record. The next gene...

PURPOSE Health care leaders encourage clinicians to offer portals that enable patients to access personal health records, but implementation has been a challenge. Although large integrated health systems have promoted use through costly advertising campaigns, other implementation methods are needed for small to medium-sized practices where most patients receive their care. METHODSWe conducted a mixed methods assessment of a proactive implementation strategy for a patient portal (an interactive preventive health record [IPHR]) offered by 8 primary care practices. The practices implemented a series of learning collaboratives with practice champions and redesigned workflow to integrate portal use into care. Practice implementation strategies, portal use, and factors influencing use were assessed prospectively.RESULTS A proactive and customized implementation strategy designed by practices resulted in 25.6% of patients using the IPHR, with the rate increasing 1.0% per month over 31 months. Fully 23.5% of IPHR users signed up within 1 day of their office visit. Older patients and patients with comorbidities were more likely to use the IPHR, but blacks and Hispanics were less likely. Older age diminished as a factor after adjusting for comorbidities. Implementation by practice varied considerably (from 22.1% to 27.9%, P <.001) based on clinician characteristics and workflow innovations adopted by practices to enhance uptake.CONCLUSIONS By directly engaging patients to use a portal and supporting practices to integrate use into care, primary care practices can match or potentially surpass the usage rates achieved by large health systems. 2014;12:418-426. doi: 10.1370/afm.1691. Ann Fam Med INTRODUCTIONE lectronic personal health records hold great promise for improving health. High-quality personal health records can facilitate connectivity between patients and clinicians, allow patients to view their medical record, support online clinical and administrative transactions, deliver essential resources to promote informed decision making, and more actively engage patients in care. 1 In the United States, regulations developed by the Office of the National Coordinator and the Centers for Medicare and Medicaid Services to strengthen the functionality of electronic health record systems (meaningful use regulations) encourage practices to engage patients in care through information technology, such as personal health records. 2,3Although patients appear interested, 4,5 practices cannot meet this need without infrastructure, workflow, and cultural changes. Most published experiences with engaging patients online have occurred in integrated health systems that have resources and business models to support adoption, implementation, and maintenance of the personal health record. [6][7][8][9] For example, between 2002 and 2009, Kaiser Permanente and Group Health Cooperative of Puget Sound made major investments to promote online services, resulting in uptake by 27% and 58% of patients, respectively, over 6 to 9 years. 419...

Although clinical preventive services (CPS)—screening tests, immunizations, health behavior counseling, and preventive medications—can save lives, Americans receive only half of recommended services. This "prevention gap," if closed, could substantially reduce morbidity and mortality. Opportunities to improve delivery of CPS exist in both clinical and community settings, but these activities are rarely coordinated across these settings, resulting in inefficiencies and attenuated benefits. Through a literature review, semi-structured interviews with 50 national experts, field observations of 53 successful programs, and a national stakeholder meeting, a framework to fully integrate CPS delivery across clinical and community care delivery systems was developed. The framework identifies the necessary participants, their role in care delivery, and the infrastructure, support, and policies necessary to ensure success. Essential stakeholders in integration include clinicians; community members and organizations; spanning personnel and infrastructure; national, state, and local leadership; and funders and purchasers. Spanning personnel and infrastructure are essential to bring clinicians and communities together and to help patients navigate across care settings. The specifics of clinical–community integrations vary depending on the services addressed and the local context. Although broad establishment of effective clinical–community integrations will require substantial changes, existing clinical and community models provide an important starting point. The key policies and elements of the framework are often already in place or easily identified. The larger challenge is for stakeholders to recognize how integration serves their mutual interests and how it can be financed and sustained over time.

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BackgroundEvidence-based preventive services offer profound health benefits, yet Americans receive only half of indicated care. A variety of government and specialty society policy initiatives are promoting the adoption of information technologies to engage patients in their care, such as personal health records, but current systems may not utilize the technology's full potential.MethodsUsing a previously described model to make information technology more patient-centered, we developed an interactive preventive health record (IPHR) designed to more deeply engage patients in preventive care and health promotion. We recruited 14 primary care practices to promote the IPHR to all adult patients and sought practice and patient input in designing the IPHR to ensure its usability, salience, and generalizability. The input involved patient usability tests, practice workflow observations, learning collaboratives, and patient feedback. Use of the IPHR was measured using practice appointment and IPHR databases.ResultsThe IPHR that emerged from this process generates tailored patient recommendations based on guidelines from the U.S. Preventive Services Task Force and other organizations. It extracts clinical data from the practices' electronic medical record and obtains health risk assessment information from patients. Clinical content is translated and explained in lay language. Recommendations review the benefits and uncertainties of services and possible actions for patients and clinicians. Embedded in recommendations are self management tools, risk calculators, decision aids, and community resources - selected to match patient's clinical circumstances. Within six months, practices had encouraged 14.4% of patients to use the IPHR (ranging from 1.5% to 28.3% across the 14 practices). Practices successfully incorporated the IPHR into workflow, using it to prepare patients for visits, augment health behavior counseling, explain test results, automatically issue patient reminders for overdue services, prompt clinicians about needed services, and formulate personalized prevention plans.ConclusionsThe IPHR demonstrates that a patient-centered personal health record that interfaces with the electronic medical record can give patients a high level of individualized guidance and be successfully adopted by busy primary care practices. Further study and refinement are necessary to make information systems even more patient-centered and to demonstrate their impact on care.Trial RegistrationClinicaltrials.gov identifier: NCT00589173

PURPOSEThe purpose of this analysis and commentary was to explore the rationale for an integrated approach, within and outside the offi ce, to help patients pursue healthy behaviors. METHODSWe examined the role of integration, building on (1) patterns observed in a limited qualitative evaluation of 17 Prescription for Health projects, (2) several national policy initiatives, and (3) selected research literature on behavior change. RESULTS The interventions evaluated in Prescription forHealth not only identifi ed unhealthy behaviors and advised change, but also enabled patients to access information at home, use self-help methods, obtain intensive counseling, and receive follow-up. Few practices can replicate such a model with the limited staff and resources available in their offi ces. Comprehensive assistance can be offered to patients, however, by integrating what is feasible in the offi ce with additional services available through the community and information media.CONCLUSIONS Blending diverse clinical and community services into a cohesive system requires an infrastructure that fosters integration. Such a system provides the comprehensive model on which the quality of both health promotion and chronic illness care depend. Integrating clinical and community services is only the fi rst step toward the ideal of a citizen-centered approach, in which diverse sectors within the community-health care among them-work together to help citizens sustain healthy behaviors. The integration required to fulfi ll this ideal faces logistical challenges but may be the best way for a fragmented health care system to fully serve its patients. INTRODUCTIONA ddressing health behaviors in primary care involves a familiar sequence of steps: (1) identifying the behavior(s) in question, (2) giving brief advice, (3) setting goals, (4) arranging for more intensive assistance, and (5) ensuring follow-up. 1 This sequence of tasks is embodied in a variety of models for behavioral counseling, notably the 5 A' s-assess (ask about the behavior status and the factors affecting change), advise (give a clear, personal message of encouragement to change), agree (set goals based on readiness to change), assist (use behavior change techniques, such as self-help, counseling, or both, to promote acquisition of the skills, confi dence, and environmental supports for change, supplemented by medical treatments when appropriate), and arrange (schedule follow-up contacts, including referral for more intensive treatment). 2 The effectiveness of clinicians in promoting healthy behaviors and the quality of their service to patients are probably maximized when practices have systems in place to support this entire counseling sequence-all of the 5 A' s-rather than simply components of the process.3 Systematic reviews and clinical experience have shown that practices that use multifaceted inter- How might such a comprehensive system look in conventional primary care practices? In a perfect world, it would include a redesigned system of offi ce prac...

PURPOSE Guidelines encourage primary care clinicians to document smoking status when obtaining patients' blood pressure, temperature, and pulse rate (vital signs), but whether this practice promotes cessation counseling is unclear. We examined whether the vital sign intervention infl uences patient-reported frequency and intensity of tobacco cessation counseling. METHODSThis study was a cluster-randomized, controlled trial conducted in the Virginia Ambulatory Care Outcomes Research Network (ACORN). At intervention practices, nurses and medical assistants were instructed to assess the tobacco use status of every adult patient and record it with the traditional vital signs. Control practices did not use any systematic tobacco screening or identifi cation system. Outcomes were the proportion of smokers reporting clinician counseling of any kind and the frequency of 2 counseling subcomponents: simple quit advice and more intensive discussion.RESULTS A total of 6,729 adult patients (1,149 smokers) at 18 primary care practices completed exit questionnaires during a 6-month comparison period. Among 561 smokers at intervention practices, 61.9% reported receiving any counseling, compared with 53.4% of the 588 smokers at control practices, for a difference of 8.6% (P = .04). The effect was largely restricted to simple advice, which was reported by 59.9% of intervention patients and 51.5% of control patients (P = .04). There was no signifi cant increase in more extensive discussion, with 32.5% and 29.3% of patients at intervention and control practices, respectively, reporting this type of counseling (P = .18). CONCLUSIONSThe vital sign intervention promotes tobacco counseling at primary care practices through a modest increase in simple advice to quit. When implemented as a stand-alone intervention, it does not appear to increase intensive counseling.