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The American Journal of Managed Care January 2014
Patient-Centered Medical Home Transformation With Payment Reform: Patient Experience Outcomes
Leonie Heyworth, MD, MPH; Asaf Bitton, MD, MPH; Stuart R. Lipsitz, ScD; Thad Schilling, MD, MPH; Gordon D. Schiff, MD; David W. Bates, MD, MSc; and Steven R. Simon, MD, MPH
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Felicia J. Bayer, PhD; Deron Galusha, MS; Martin Slade, MPH; Isabella M. Chu, MPH; Oyebode Taiwo, MBBS, MPH; and Mark R. Cullen, MD
Evidence-Based Guidelines to Determine Follow-up Intervals: A Call for Action
Emilia Javorsky, MPH; Amanda Robinson, MD; and Alexa Boer Kimball, MD, MPH
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Electronic Health Risk Assessment Adoption in an Integrated Healthcare System
Diana S. M. Buist, PhD, MPH; Nora Knight Ross, MA; Robert J. Reid, MD, PhD; and David C. Grossman, MD, MPH
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Susan H. Busch, PhD; Andrew J. Epstein, PhD; Michael O. Harhay, MPH; David A. Fiellin, MD; Hyong Un, MD; Deane Leader Jr, DBA, MBA; and Colleen L. Barry, PhD, MPP
Evaluation of Electronic Medical Record Administrative Data Linked Database (EMRALD)
Karen Tu, MD, MSc; Tezeta F. Mitiku, BSc, MSc; Noah M. Ivers, MD; Helen Guo, BSc, MSc; Hong Lu, PhD; Liisa Jaakkimainen, MD, MSc; Doug G. Kavanagh, BSEng, MD; Douglas S. Lee, MD, PhD; and Jack V. Tu, MD, PhD
Specialist Participation in Healthcare Delivery Transformation: Influence of Patient Self-Referral
Oluseyi Aliu, MD, MS; Gordon Sun, MD, MS; James Burke, MD, MS; Kevin C. Chung, MD, MS; and Matthew M. Davis, MD, MAPP
Optimal Management of Diabetes Among Overweight and Obese Adults
Denison S. Ryan, MPH; Karen J. Coleman, PhD, MS; Jean M. Lawrence, ScD, MPH, MSSA; Teresa N. Harrison, SM; and Kristi Reynolds, PhD, MPH
Why Are Medicare and Commercial Insurance Spending Weakly Correlated?
Laurence C. Baker, PhD; M. Kate Bundorf, PhD; and Daniel P. Kessler, JD, PhD

Electronic Health Risk Assessment Adoption in an Integrated Healthcare System

Diana S. M. Buist, PhD, MPH; Nora Knight Ross, MA; Robert J. Reid, MD, PhD; and David C. Grossman, MD, MPH
Significant additional outreach and engagement strategies and incentives are likely required to increase adoption and ongoing use of health risk assessment tools among target populations.
Objectives: To examine uptake patterns of the electronic health risk assessment (eHRA) and compare characteristics of early adopters among adults in 1 healthcare system with those of the potentially eligible population.

Study Design: Retrospective cohort study (September 2006-March 2009).

Methods: We designed and implemented an integrated eHRA to improve individual health plan members’ self-management of their health risks and chronic illness. We included individuals aged 21 to 85 years who had been enrolled at Group Health Cooperative for 12 or more months before September 2006, when the eHRA was first introduced. Study participants had to be registered users of the health plan’s secure Web portal by March 2009 in order to complete the eHRA.

Results: A total of 332,381 adults were potentially eligible; of these 39.3% were eligible to complete the eHRA. One or more eHRAs were completed by 22.4% of registered Web portal users over the study period with slow but consistent uptake. Completers were more likely to be women, to be middle-aged (41-65 years), and to have had a recent well-care visit and fewer comorbid conditions.

Conclusions: Significant additional outreach, engagement strategies, and incentives are likely required by health systems to increase adoption and ongoing use of an eHRA among target populations. Future research on eHRA uptake in primary care should focus on whether the use of these tools leads to patient action and provider engagement that improve health outcomes in moderate-risk and  high-risk individuals, as well as on modalities to reach broader audiences for higher completion rates.

Am J Manag Care. 2014;20(1):62-69
The demographic and health risk profile of early electronic health risk assessment (eHRA) adopters was primarily characterized by age (41-65 years), sex (women), recent well-care visit, and fewer comorbid conditions.
  • Significant additional outreach and engagement strategies and incentives are likely required to increase eHRA adoption and use among target populations and may decrease demographic differences between early adopters and later adopters.

  • Future research on uptake of risk assessment tools in primary care should also address whether their use leads to increased uptake of activities that improve health outcomes in moderate-risk and high-risk individuals.
Unhealthy lifestyles have a substantial impact on the incidence of chronic conditions and impaired health outcomes for US residents.1-6 Rising healthcare expenditures are associated with increasing chronic disease incidence and prevalence, as exemplified by the association of obesity and increased healthcare  costs.7 Some of these conditions or complications can be prevented or averted by reducing behaviors that increase health risk such as the use of tobacco, poor diet, physical inactivity, and risky alcohol use.8,9 Healthcare providers, and the systems in which they work, are well positioned to systematically identify high-risk individuals and provide assistance for behavior change leading to improved health and reduced healthcare costs associated with the downstream chronic illness.10

Increasingly, innovative healthcare systems use population management strategies to identify at-risk individuals to provide behavioral interventions,self-management programs, and clinical interventions to reduce health risks. Helping people identify their risky  behaviors can contribute to better health status when linked with targeted wellness programs.11,12 One approach that is gaining  momentum has been for employers and healthcare organizations to administer health risk assessments (HRAs) to individuals, often electronically. The information collected is used to identify risk factors to provide tailored feedback and programs aimed at  changing unhealthy behaviors and promoting evidence-based screening, immunization, and preventive medications.12 Several systematic reviews on the effectiveness of HRAs concluded that when used alone, there was limited evidence on their effectiveness, with a broad range in evidence quality.13-15 However, the prevailing view is that HRAs, coupled with additional interventions including worksite health promotion activities and primary care interventions, have the potential to improve population health and to be cost-effective mechanism for comprehensively and systematically improving health outcomes.12-15

New rules from the Centers for Medicare & Medicaid Services (CMS) call for the use of HRAs as a key part of the Medicare Annual Wellness Visit and require providers to use an HRA for prevention planning. Because of this rule, HRAs are likely to become much  more common in clinical practice.16

Group Health Cooperative, an integrated health plan and delivery system based in Seattle, Washington, developed an interactive, online electronic HRA (eHRA) in September 2006.17 Through a secure member website (MyGroupHealth,, the  comprehensive risk assessment tool collects self-reported information from adult members of all ages and integrates it with laboratory and biometric data from their electronic medical records (EMRs). The eHRA was developed as a new feature of  MyGroupHealth, the health system’s full-featured secure patient Web portal designed to provide patients with access to personalized health information and a mechanism for communication with their clinical teams.18 Tailored feedback for behavior  change, preventive services, and chemoprevention, as well as targeted referrals to wellness programs, are fed directly back to patients and their clinical teams after eHRA completion.

This study was designed (1) to examine the adoption of the eHRA and compare the characteristics of early eHRA adopters with  those of the potentially eligible population and (2) to understand adoption trends in the setting of an integrated health system. Understanding the characteristics of early eHRA adopters is critical for downstream evaluation of the effectiveness of eHRAs on  outcomes and for refining strategies to boost outreach and engagement for providers and healthcare systems to reach nonresponders.


Study Design and Population

The retrospective cohort study was conducted at Group Health Cooperative between September 2006 and March 2009. Group  Health is an integrated healthcare system that currently serves approximately 675,000 patients in Washington State. Approximately  two-thirds of members receive primary and some specialty care in the 25 medical centers from a single large multispecialty physician group practice. The remaining “network” members receive their healthcare from contracted providers. All members have the opportunity, and are encouraged, to sign up for free access to the electronic patient portal,18 which is integrated with their EMR in the Group Health medical centers but not in the network.18,19 The Group Health Human Subjects Review Committee approved all study procedures.

Potentially eligible individuals were the 332,281 members aged 21 to 85 years who had been enrolled in one of Group Health’s medical centers for at least 12 months before September 2006 (baseline). To complete the eHRA, members had to be registered with the secure patient Web portal18; 39.3% (130,735) had registered access to the Web portal and were eligible to complete the  eHRA by March 2009. Completers were defined as individuals who were registered to use the patient Web portal and who  completed the eHRA anytime between September 2006 and March 2009; noncompleters were individuals who were registered to use the patient Web portal but who did not complete the eHRA by March 2009.

Study Variables

Group Health electronic enrollment and claims databases were used to collect demographic variables (age, sex), RxRisk  comorbidity score,20 well-care preventive visit in the year before baseline, duration of health plan enrollment before baseline, and is enrollment or death during the study period. Among individuals who completed at least 1 eHRA, we collected the first completion rate and the total number completed. We used self-reported eHRA data to provide more detailed health information on completers.

Electronic Health Risk Assessment

The eHRA was designed to be completed in 15 to 20 minutes through the secure Web portal. The extensively branched algorithm  resents questions on medical history and health-related behaviors, demographics, functional and  self-reported health status, social  and occupational history, medication use, and prior use of recommended preventive services (maximum number of questions was   63). After completion, members and their clinical teams receive personalized reports with tailored feedback on health status, risk  estimations for cardiovascular and other chronic diseases, screening and immunization recommendations, and lifestyle behavior  assessment and recommendations. Tailored educational material and Web links to specific resources (eg, tobacco cessation  rograms, lifestyle coaches) are also provided. A complex algorithm that accounts for the constellation of risk factors, demographics, medical history, and readiness to change is used to generate recommendations.17 Group Health’s clinical guidelines,21 which are  in large part based on the those of the US Preventive Services Task Force  recommendations, form the basis for many of the algorithms to provide recommendations about screening, immunization, chemoprevention, chronic disease management, and health behavior change.

Self-perceived health status, lifestyle risks, and chronic illness control (diabetes, hypertension, asthma, depression, heart failure) were assessed in the eHRA using standard approaches and measurement tools. Biometric data from the EMR (glycated hemoglobin and blood pressure) were prepopulated in the eHRA, but individuals had the ability to alter these imported numbers, so  we refer to all these data as self-reported. Self-perceived health status was collected with a single question and rated as excellent,  ery good, good, fair, or poor.22 

Lifestyle factors included body mass index (kg/m2), physical activity, tobacco use, and alcohol use. The International Physical  Activity Questionnaire was used to classify individuals as active, minimally active, or inactive.23 No lifestyle changes were  ecommended for nonsmokers or ex-smokers who had quit during or before the past year, whereas change was recommended for  urrent smokers. The Alcohol Use Disorders Identification Test24 was used to identify individuals with possible alcohol abuse or dependence and those with risky drinking behaviors.25,26

The eHRA also evaluates control of diabetes, depression, and hypertension among persons reporting having these conditions. Diabetes questions were presented to every member who reported a personal history of diabetes (except for gestational or  secondary diabetes), and control was categorized using clinical laboratory data on glycated hemoglobin levels. Individuals who  eported seeing a counselor or taking antidepressant medications completed the first 8 questions of the Patient Health Questionnaire 9 tool.27

As a strategy to promote uptake, the eHRA was promoted to primary care providers as a tool to prepare for adult prevention visits.  Rather than a typical paper questionnaire, patients were encouraged to complete the eHRA before a scheduled  well visit. During the study period, all Group Health clinics were provided financial incentives to promote eHRA use. The 3 clinics with the highest  esponse rates received a clinic-level cash reward for discretionary use. No financial incentives were offered by the health plan or the  medical group to patients or individual providers to complete an eHRA.


Individuals could have completed more than 1 eHRA in the study period; only the first completed questionnaire was included to  compare completers with noncompleters. We characterized individuals who completed more than 1 HRA during the study period.  data from the 2007 Group Health Wellness Inventory28 were used to compare the prevalences of health conditions reported by the completers. The Wellness Inventory included a stratified random telephone survey of 590 adult Group Health members and obtained  prevalence estimates on demographics, health conditions, and lifestyle risk factors. We used descriptive frequencies to compare completers with noncompleters on demographic and health services data with Pearson’s x2 test for categorical variables and means and standard deviations for continuous variables using SPSS version 10.1 (SPSS Inc, Chicago, Illinois). Significance was defined as 2-sided P <.05.


Characteristics of the Study Population

Of the 332,381 adults potentially eligible for inclusion in the study based on age and duration of enrollment before implementation of  he eHRA, 29,321 (8.8% of all potentially enrolled and eligible subjects and 22.4% of registered Web portal users) completed 1 or  ore eHRAs (Table 1). The average enrollment duration before the start of the study was 10.3 years (standard deviation = 6.77 years). During the study period, 16% of members disenrolled or died (only 8.1% of completers). Patient enrollment in the Web portal  teadily increased between September 2006 (29.7% enrollment) and March 2009 (39.3% enrollment).

Comparison of Health Profile Completers and Noncompleters

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