Integrating Patient Generated Family Health History From Varied Electronic Health Record (EHR) Entry Portals

Study Overview
=================
Brief Summary
-----------------
In the 21st century, the importance of family health history will increase as it will be essential to put detailed personal genetic information into the context of an individual's health, namely the context of how the shared code has played out in an individual and his/her closest relatives. These scientific developments in the investigators' understanding of genetics will demand a more comprehensive family history dataset for all patients, and the time limitations on healthcare providers demand a technology-driven solution that integrates an individual's knowledge of their family history with the medical records maintained by their health care providers. A solution does not currently exist by which most Americans can organize their family health history and then place it into their electronic health record (EHR). The investigators propose to develop and compare three different ways of proactively collecting family history information from patients using computer technology independent of a health care visit, including telephone (interactive voice response technology), tablet computers in a physician's waiting room, and a secure internet portal at home. These tools will be based on the US Surgeon General's My Family Health Portrait, an electronic family history collection tool. Family history data will be transferred and integrated with a patient's EHR in a large primary care network. This project will seek to demonstrate that family history data can be accurately reported by diverse patients using these technologies, and that these data can be integrated to tailor an individual's health care based on their familial risk.

Detailed Description
-----------------
Background: The long established wisdom of including family health history as a key part of an individual's medical record has been invigorated by the new emphasis on personalized medicine. While in the past, family health history was used to understand an individual's disease risk and to focus disease prevention efforts, in 21st century medicine, family health history's importance will increase as it will be essential to put detailed personal genetic information into a clinical context, namely the context of how the shared code has played out in a person's closest relatives. This new need for family health history will demand a more comprehensive family history dataset for all patients, and the time limitations faced by healthcare providers demand a technology-driven solution whereby the patient performs primary data entry and the provider then refines these data. Solutions do not currently exist by which most Americans can organize their family health history and then place it into their electronic health record (EHR). My Family Health Portrait (MFHP) is an open source, electronic family history collection tool developed by the Surgeon General that offers interoperability with EHRs, yet to our knowledge has not been widely integrated because of limitations in the capacity of many EHRs to accept these data, and barriers to the systematic collection of these data in clinical practice. Additionally, obstacles exist for those individuals who are not computer literate or do not have access to a home computer. In order to capture patient-generated family history data across diverse patient populations, EHR's may need to offer patients a variety of data entry options which allow for differences in preference, convenience, computer literacy, and computer availability. This proposal seeks to develop new resources for family history data entry into the EHR. These resources will be developed, tested and validated in a primary care setting within of a large complex healthcare system. Research Plan: The proposed project will examine the reach, effectiveness, adoption and implementation of three innovative portals to transfer and integrate patient generated family history data with an EHR. Specific Aim 1 (technical development) is to develop the three portals for entry of patient generated family history data integrated with an EHR. The pathways will include: : (1) computer tablets in waiting rooms to complete the MFHP, (2) a secure internet portal to transfer data collected by patients at home using MFHP, and (3) an interactive voice response (IVR) system to collect the necessary data elements by phone. Each of these modalities will interface with the EHR of a large health delivery system using current data standards. Each of these modalities will be designed to interface with the EHR of a large health delivery system using current data standards using current data standards. Specific Aim 2 (content development and validation) is to evaluate facilitators and barriers to the adoption, and implementation of these three electronic portals by assessing differences in patient preferences, privacy concerns, convenience, and understanding. The validity of the family history data collected by each of these three portals will also be assessed by a genetic counselor. Specific Aim 3 (pilot randomized controlled trial) is to conduct a 4-armed pilot randomized controlled trial (RCT) to measure the reach and effectiveness of integrating this family history data with a patient's EHR. The trial will examine and compare changes in family history documentation, patient-doctor discussion of family history, and patient and provider satisfaction with each data entry portal described in Aim 1, as well as a control arm. The trial will be conducted as a pilot cluster RCT in selected practices within the Brigham and Women's Primary Care Practice-Based Research Network. Potential Impact: The impact of obtaining accurate family history data and integrating this with an individual's health record are substantial, and will be of growing importance as our understanding of the genome advances. This project will ultimately contribute to a better understanding of how available technologies can be integrated with EHR's to obtain accurate family history in ways that allow for widespread acquisition and integration of accurate family history data in a variety of settings and diverse patient populations. The technology and lessons learned from this project will be exportable to healthcare settings throughout the United States.

Official Title
-----------------
Integrating Patient Generated Family Health History From Varied Electronic Health Record Entry Portals

Conditions
-----------------
Family Characteristics, Health Status, Family Research

Intervention / Treatment
-----------------
* Other: Electronic Health Portals for collecting Family History data


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Male and Female Patients who: receive primary care at one of the study selected Primary Care Practices, are between 18-75 years old, are English or Spanish speakers, and have appointments scheduled in the upcoming 1 - 3 months for an annual or comprehensive visit. Exclusion Criteria: We will not include individuals over the age of 75 because the role of family risk assessment and prevention is less established. Also will not include non-English or non-Spanish speakers. Patients will also be excluded if they are hearing impaired.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Interactive Voice Response Practice<br>The introductory letter to patients will allow them an opportunity to opt-out of the study using a toll-free number. If they do not opt-out within 2 weeks of receiving the letter, the IVR system will make up to 15 call attempts over a 2 week period to reach the patient. The system will make outbound calls during preset hours. The system continuously checks the call list for the next scheduled call. Once contact is made, the spoken script greets the patient by name, authenticates identify, and will ask the patient the programmed questions. The IVR server will send completed family history assessments to the patients EHR as an HL7 compliant summary note as well as transmitting the separate coded responses for each condition/ family member to coded family history fields in the EHR. | Other: Electronic Health Portals for collecting Family History data<br>* Comparison of multiple portals for integrating patient generated family history data into the electronic health record.<br>|
| Experimental: Wireless Tablet PC Practice<br>Patients will receive an info letter in advance of their visit explaining the project with description of what information they will be asked to provide. Study staff will train the practice staff to hand out and collect the tablets for the patient. Staff will be trained to verify a patient's identity to ensure that the family history is sent to the correct EHR record. The initial screen of the tablet PC portal will include a paragraph of informed consent, and patients in this practice will be given the opportunity to decline participation. For patients who participate, the completed family history data will be transmitted to the patient's EHR as an HL7 compliant note and transmitting separate coded responses for each condition/ family member to coded family history fields. | Other: Electronic Health Portals for collecting Family History data<br>* Comparison of multiple portals for integrating patient generated family history data into the electronic health record.<br>|
| Experimental: Internet Portal Practice<br>Patients in this practice will receive the informational letter either by email or mail one month before their scheduled visit. It will have directions to access the MFHP website and how to transfer data through the hospitals secure internet portal (Patient Gateway). About 1/3 of patients are signed up to use this service. Those who do not have a Patient Gateway account will be provided with directions on how to establish this service. Patients will be required to have a Gateway account to ensure that the MFHP data file is sent securely to the correct EHR record. Patients in this arm will receive an initial email or letter with a single follow-up reminder sent 2 weeks later. For patients who participate, the completed family history data will be transmitted to the patient's EHR. | Other: Electronic Health Portals for collecting Family History data<br>* Comparison of multiple portals for integrating patient generated family history data into the electronic health record.<br>|
| Active Comparator: Usual Care Physician Assesment Practice<br>Usual standard family history assessments will be conducted by physicians during the patient visit. This arm will allow us to account for any temporal trends in family history assessment. | Other: Electronic Health Portals for collecting Family History data<br>* Comparison of multiple portals for integrating patient generated family history data into the electronic health record.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Project will seek to demonstrate that family history data can be accurately reported by 5000 diverse patients using three portals, and that these data can be used to tailor an individual's health care based on their familial risk. |  | 2.5 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Develop three portals for collection of patient generated family history data integrated with an EHR: computer tablets in waiting rooms; a secure internet portal for use at home; and an interactive voice response system to get data by phone. |  | 1.5 years | 
| Evaluate facilitators and barriers to adoption and implementation of these portals by assessing differences in patient preferences, privacy, convenience, and understanding. Validate data collected by each portal by a genetic counselor. |  | 1.5 years | 
| To conduct a 4-armed pilot RCT to measure the reach and effectiveness of integrating family history data with a patient's EHR. |  | 2 years | 
| For patients in the RCT who report a family history that is associated with an increased risk of coronary artery disease, we will examine how often their physician initiates screening and/ or primary prevention based on the family history information. |  | 2 years | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Family History, Electronic Health Record