Unhealthy behaviors are major contributors to costly chronic health conditions including heart disease, diabetes, cancer, and obesity that play a large role in the rising, unsustainable cost of healthcare. Recognizing the scope of this problem, the US Congress passed the Patient Protection and Affordable Care Act, expanding healthcare access to 30 million Americans and increasing focus on quality and patient-centered care.1
Further supporting this concern, the Health Information Technology for Economic and Clinical Health (HITECH) Act places new emphasis on the widespread and meaningful use of electronic health records (EHR).2
The Office of the National Coordinator for Health Information Technology within the Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS) are responsible for implementing HITECH and coordinating efforts to facilitate the nationwide adoption of health information technology. The focus of HITECH is on promoting the exchange and meaningful use of health information to improve population health, reduce healthcare costs, and empower individuals to improve their health through the use of health information technology. The HITECH legislation also created an incentive programme for health professionals and hospitals to begin implementing and demonstrating the ‘meaningful use’ of EHR. In short, meaningful use requires that providers demonstrate the use of certified EHR technology in ways that can be measured through the electronic exchange of health information to improve the quality of care.2
The meaningful use programme has been organized as a multistage process to build up system capabilities with each stage increasing the bar for what constitutes meaningful use. Stage 1 is ongoing and includes basic EHR functionality (e-prescribing, maintaining active problems, medication, and allergy lists, etc). To demonstrate success the provider must report clinical quality measures (CQM) to CMS. CQM are endorsed standards for defining the logic for measurement of processes, outcomes, observations or treatments that relate to the meaningful use quality aims. CMS and the Office of the National Coordinator for Health Information Technology have recently released proposed criteria for stage 2 and are working to define criteria for stage 3 meaningful use, successive stages will have an increasing focus on improvements in quality and health outcomes.2
The development of well-validated CQM for behavioral health and psychosocial factors will be critical for promoting their inclusion in meaningful use.
While meaningful use of EHR has promise for improving health outcomes, there is a gap in current legislation and advancements in EHR technology as it relates to addressing key patient reported behavioral and psychological outcomes as well as other patient characteristics. From an epidemiological and behavioral perspective, it is clear that the rates of tobacco use, physical inactivity, poor diet, alcohol abuse, and other poor health behaviors are key preventable causes of death.4–6
Currently, only smoking behavior is addressed in the criteria for meaningful use; however, subsequent stages of the incentive programme are likely to include additional CQM addressing behavioral and psychosocial factors. Gordon and colleagues7
reviewed the cost-effectiveness of behavioral interventions to reduce smoking, improve eating habits, and increase regular physical activity. They concluded that behavioral interventions frequently produced positive outcomes at a lower cost than alternative treatments. Perhaps the strongest evidence for the cost effectiveness of behavioral interventions comes from the diabetes prevention programme.8
In that large multicentered trial, the cost per quality-adjusted life-year was US$1100 for the physical activity and nutrition intervention compared with US$31 000 for an intervention based on medication use.9
Furthermore, the benefit was maintained over an extended period of time.10
From a psychological perspective, strong evidence also exists that treating subclinical and identifying psychosocial conditions such as depression or anxiety can reduce the high costs of these disorders and lead to cost-effective treatment through primary care.11
While there are clear health outcome and care delivery benefits that would be associated with systematically collecting behavioral, psychological, and other patient-reported variables in EHR, there are practical limitations. Many clinical practices are under-staffed and under-resourced and struggle with meeting all of the current competing demands they face.13–15
The past decade has given rise to new mandates for practice change. Practices are being asked to re-engineer their activities and functions and transform themselves into patient-centered medical homes.16
HITECH and meaningful use are encouraging the adoption and implementation of EHR as well as mandating further workflow changes such as the expanded electronic capture of clinical data and electronic prescribing. Healthcare reform is even encouraging practices to reconsider their identity in the context of a larger care delivery system (eg, accountable care organizations). These competing demands and policy changes have led to a rapidly shifting landscape in which details such as behavioral and psychosocial measures, no matter how valuable, are likely to be lost or ignored. To be successful with systematically collecting these measures it is imperative that measures are standardized, practical, feasible, actionable, and consistent with these broader practice redesign initiatives.
Scientists from the health policy committee of the Society of Behavioral Medicine and the National Institutes of Health recently highlighted the need for a set of standards for core behavioral, psychological, and patient characteristics and identified a set of methodological criteria to identify appropriate measurement tools that could be integrated within EHR systems (box 1
The specific domains were identified because they are: (1) prevalent in the population; (2) strong determinants of health; (3) regularly encountered in primary care and public health settings; (4) relevant to how a physician delivers care; and (5) actionable (Glasgow et al
These domains also align well with the national prevention strategy released in the USA in July 2011.18
One of the main goals of the prevention strategy is to shift the focus of the healthcare system from responding to illness and disease to promoting prevention and wellness. The initiative also emphasizes the importance of standard metrics to measure progress.
Box 1. Targeted behavioral, psychological, and patient characteristic domains
- Eating patterns
- Medication taking
- Physical activity
- Risky drinking
- Sleep quality
- Smoking/tobacco use
- Substance use
- Anxiety and depression
- Quality of life
- Health literacy/numeracy
- Patient goals
The purpose of this paper is to describe a collaborative engagement process to involve key stakeholders from healthcare practice, consumer groups, researchers, policy makers, and healthcare organizations in the identification and recommendation of core behavioral, psychological, and patient characteristic data elements for inclusion in EHR. More specifically, the goal of the paper is to describe a mixed-methods approach that was used to track a three-step process of: (1) convening subject matter experts to identify and evaluate candidate data elements; (2) gathering feedback from a broad cross-section of stakeholders using the National Cancer Institute grid-enabled measures (GEM) wiki platform; and (3) developing consensus through a town hall meeting to engage scientists, practitioners, policy makers, and patient/consumer representatives. The resulting recommended data elements, along with the recommended frequency of administration for each domain, will be presented. In addition, we will discuss recommendations for the next steps and how this relates to the broader policy context.