1. Barriers & Drivers to Use of Health IT by the Elderly, Chronically, & Underserved Prepared by Oregon Evidence Based Practice Center Holly Jimison, Paul Gorman, Susan Woods, Peggy Nygren, Miranda Walker, Susan Norris, William Hersh

2. Background Better outcomes w/ self management Diabetes - DCCT trial; warfarin; asthma Technologies facilitate process home CBG, BP, INR, expanding array of health IT Questions Which Conditions? Which patients? Which Technologies? especially HIT What are barriers and drivers of use?

3. AHRQ Evidence Report Create analytic framework Define key questions Define inclusion, exclusion criteria Comprehensive literature search Quality assessment of studies Synthesis of results

4. Analytic Framework Use of Consumer HIT Intermediate Outcomes (self-efficacy, physiologic measures) Intermediate Outcomes (self-efficacy, physiologic measures) Patient Outcomes (QoL, Cost, Satisfaction) Patient Outcomes (QoL, Cost, Satisfaction) Patient (age, gender, health status, literacy, etc.) Patient Technology (email, PDA, cellphone, monitoring) Technology Setting (access to care, internet, reimbursement ) Setting

5. Key Question 1 - 4 Use of Consumer HIT Intermediate Outcomes (self-efficacy, physiologic measures) Intermediate Outcomes (self-efficacy, physiologic measures) Patient Outcomes (QoL, Cost, Satisfaction) Patient Outcomes (QoL, Cost, Satisfaction) Patient (age, gender, health status, literacy, etc.) Patient Technology (email, PDA, cellphone, monitoring) Technology Setting (access to care, internet, reimbursement ) Setting 11 Among elderly, chronically ill, and underserved populations, 1.What is the current level of use of health IT? 2.What types are most useful and usable? 3.What barriers hinder use of interactive health IT? 4.What drivers facilitate use of interactive health IT? 22 3,43,4

6. Key Question 5 Use of Consumer HIT Intermediate Outcomes (self-efficacy, physiologic measures) Intermediate Outcomes (self-efficacy, physiologic measures) Patient Outcomes (QoL, Cost, Satisfaction) Patient Outcomes (QoL, Cost, Satisfaction) Patient (age, gender, health status, literacy, etc.) Patient Technology (email, PDA, cellphone, monitoring) Technology Setting (access to care, internet, reimbursement ) Setting 55 Among elderly, chronically ill, and underserved populations, Is interactive consumer health IT effective?Is interactive consumer health IT effective? How does effectiveness vary among these populations?How does effectiveness vary among these populations? How does effectiveness differ from general population?How does effectiveness differ from general population? 55

7. Inclusion: Populations elderly over 65 functional elderly by life experience, health concerns chronically ill chronic condition lasting more than one year AND benefits from ongoing management impairment, limitation impairment in body structure or function problems participating in life situations underserved underserved population Bureau of Health Professions HRSA designated underserved population, region underserved region where individuals are inhibited in ability to receive services

8. Inclusion: Technologies Direct active use by patient not just wearing a device Computer does some processing not just a conduit for information Patient receives tailored information advice, education, feedback Excluded telemonitoring, videoconferencing, general websites, FAQs

9. Information Provided to Client Information Gathered from Client none general knowledge population specific information disease specific recommendations patient specific advice state specific instruction none demographic habits and risks health conditions management plan current state general websites risk calculator tailored advice risk calculator general advice risk calculator general advice tailored reminding systems remote monitoring Spectrum of Information Interventions disease forum interactive education disease FAQ practice guideline self manageme nt systems

10. Published literature since 1990 MEDLINE PsychINFO Cochrane Controlled Trials Register and Database of Systematic Reviews ERIC AARP Ageline Grey literature: conferences, technical reports,. Literature Search

11. 8522 abstracts/title s screened Results: Literature Search 563 papers reviewed 129 studies included

12. Many studies of use of interactive HIT in populations of interest: rural, elders, underserved but no comparison to general population Use of interactive HIT higher if perceived health benefit and trusted advice Access, ease of use, convenience key to wider use. Most frequently used functions are online peer group support and disease self-management tools. Anonymity, nonjudgmental nature of computer system an advantage with sensitive disorders Major Findings: Use

13. Major Findings: Impact Effective HIT Provided Complete Loop: 1. Monitoring of current patient status 2. Transmission of patient data to clinic or system 3. Interpretation by clinician, comparison to goals 4. Adjustment of management plan 5. Communication back to patient 6. Repeat cycle at intervals appropriate to condition

14. studycondition monitor timing feedback timing feedback source nature of information Cho 2006 RCT Diabetesdaily semi weekly clinician email state specific Kim 2007 RCT Diabetes≥ weekly nurse SMS state specific Green 2008 RCT HTNdailybiweeklypharmacist state specific Kashem 2006 RCT CHF≥ weekly nurse, doctor, state specific LaFrambois e 2003 RCT CHFdaily nurse state specific Rasmussen 2005 RCT Asthma≥ weekly physician with CDSS state specific Impact of Interactive HIT Examples

15. For Patients and Clinicians These systems can help achieve better outcomes in chronic conditions For Developers and Researchers Usability issues must be resolved prior to trials Need clarity, consistency of methods, measures For Policymakers These systems help achieve better outcomes Practice environment does not support use Implications

16. Questions about technology Optimal frequency of use by patient Optimal frequency of interaction with clinician Whether success requires revision of managment plan or just reminding Questions about populations Direct comparison of elderly, underserved, chronically ill with general population Recommendations for Future Research

17. Questions? gormanp at ohsu.edu

18. Basic Research1. Basic principles observed and reported Feasibility2. Technology Concept or Application formulated Technology Development 3. Analytical and experimental function and/or characteristic proof-of-concept 4. Component and/or breadboard validation in laboratory Technology Demonstration 5. Component and/or breadboard validation in relevant environment 6. System/subsystem model or prototype demonstration in relevant environment System Development 7. System prototype demonstration in space environment System Test & Operations 8. Actual system completed and ‘flight qualified’ through test and demonstration 9. Actual system ‘flight-proven’ through successful mission operations NASA Techology Readiness Levels

19. Systematic Review is a Satellite View Let’s you see the forest, obscures the trees

20. On The Ground You Need to Focus On the Trees

21. Driving to Surprise Lake Satellite View Shows the Forest Surprise Lake

22. Hiking to Surprise Lake Sometimes You Need to See the Trees

23. Key Question 2 Use of Consumer HIT Intermediate Outcomes (self-efficacy, physiologic measures) Intermediate Outcomes (self-efficacy, physiologic measures) Patient Outcomes (QoL, Cost, Satisfaction) Patient Outcomes (QoL, Cost, Satisfaction) Patient (age, gender, health status, literacy, etc.) Patient Technology (email, PDA, cellphone, monitoring) Technology Setting (access to care, internet, reimbursement ) Setting 22 Among elderly, chronically ill, and underserved populations, What types of HIT are most useful and easy to use?What types of HIT are most useful and easy to use? How useful are various types of interactive HIT?How useful are various types of interactive HIT? What are usability factors associated with HIT?What are usability factors associated with HIT?

24. Key Question 3 & 4 Use of Consumer HIT Intermediate Outcomes (self-efficacy, physiologic measures) Intermediate Outcomes (self-efficacy, physiologic measures) Patient Outcomes (QoL, Cost, Satisfaction) Patient Outcomes (QoL, Cost, Satisfaction) Patient (age, gender, health status, literacy, etc.) Patient Technology (email, PDA, cellphone, monitoring) Technology Setting (access to care, internet, reimbursement ) Setting 3,43,4 Among elderly, chronically ill, and underserved populations, What barriers and drivers affect use of interactive HIT?What barriers and drivers affect use of interactive HIT? How do these factors vary by population?How do these factors vary by population? How do these factors vary by type of HIT application?How do these factors vary by type of HIT application?