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The American Journal of Managed Care January 2014
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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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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.
The eHRA completers were more likely than noncompleters to be female (64.6% vs 56.9%), to be middle-aged (41- 65 years, 64.3%  vs 59.2%), and to have had a well-care visit (31.3% vs 27.7%). Based on comparisons from the Wellness Inventory, there  as no difference between completers and Group Health members as a whole in health status, body mass  index, physical activity,  or diabetes; in contrast, completers were less likely to be current smokers (8.1% vs 15.7%28), have depression (15.2% vs  3.1%28), or have hypertension (17.8% vs 27.3%28).

The majority of respondents indicated their health was good (37.0%), very good (39.3%), or excellent (13.1%) (Table 2).  Approximately one-third of respondents fell into each body mass index category. One in 5 (21.8%) reported they were physically inactive. Fewer than 10% (8.1%) were current smokers or had a moderate (4.8%) or high (0.6%) Alcohol Use Disorders Identification  est score. Diabetes was  reported by 7.6% of the respondents. Just over 15% reported being depressed; among  hese, 53.8% had mild, 24.5% moderate, and 21.0% severe depression. Hypertension was slightly more prevalent (17.8%), with  41.0% having poor control (>140/90 mm Hg or >130/80 mm Hg with diabetes).

Time to eHRA Completion

Among individuals who completed any eHRA during the study period, 17% had completed it within 3 months of its implementation, 4% within 9 months, and 66% within 15 months (Figure). A minority (17.6%) of completers completed 2 or more eHRAs.


The eHRA uptake rate was slow but reasonably constant over implementation and resulted in just over 20% of individuals with  registered Web portal access completing the eHRA over a 31-month period (8.8% of all potentially enrolled and eligible subjects). Understanding whether individuals who complete eHRAs are representative of underlying populations is relevant for several reasons. First, if eHRAs are to be used to characterize the health status of enrolled populations, it is important to understand how individuals who complete these assessments differ from those who do not; without this knowledge, health systems could make a biased  assessment of the health status of their covered populations and could poorly target resources. Second, understanding selection  factors for completion will be critical for assessing whether use of these tools leads to improved health outcomes and population health. Finally, characterizing individuals who do not complete these tools provides an opportunity for reaching broader audiences for higher completion rates.

Consistent with prior literature,29 we found that women, middle-aged individuals, and individuals with recent well-care visits and fewer  omorbid conditions were most likely to complete the assessment. Possible reasons for these findings are that younger people tend to be in good health and less concerned about their health status,30 while older people may feel that significant   improvements in health outcomes are not possible in the late stages of life.31 Or this finding may reflect patients’ interest in properly managing their risk factors.32

During the study period, Group Health members had to carry out a 2-step process to complete their eHRA: first they had to sign up to use the secure Web patient portal and then  they had to sign onto the website to complete their questionnaire. Also at the time of  this study, the eHRA was only available in English, potentially limiting access for those with other primary languages. The  additional steps required to complete the eHRA could have further influenced the profile of completers, but appeared to have little  ssociation with who completed the eHRA among potentially eligible respondents. Despite these additional steps required to complete the eHRA, there were only a few notable differences in the prevalence of conditions and lifestyle risks between completers and Group Health members in general.28

The eHRA represents an innovation in preventive care because it uses self-reported data on health risks and chronic condition management to provide recommendations that are shared with the patients and their providers and healthcare teams by integrating information from the Web portal with the EMR. Paper HRAs or eHRAs can be used to assist with clinical management by providers  and population management by medical groups and health plans; they also can be used by employers to improve population health.  Risk stratification of populations requires comprehensive diagnostic information, which includes integrating information from  diagnoses, laboratory values, pharmacy fills, and prior use patterns. For HRAs to improve population health, there needs to be broad uptake by patients to augment the medical record data with self-reported data and their use needs to be tied to patient and provider action that leads to improved outcomes.

Though eHRAs are not a new concept in clinical preventive care, their use has not taken root systematically in most healthcare systems. Health risk assessments have been used extensively by employers as part of worksite wellness programs to promote  health risk reductions among employees. The Community Preventive Services Task Force endorses the use of eHRAs as part of  these programs.15,33 In 2012, as part of new guidance regarding the requirements for annual wellness visits,16 the CMS has  stipulated that a comprehensive HRA should be offered as a routine part of covered annual wellness visits for all Medicare beneficiaries. However, little is known about the characteristics of people who voluntarily complete these assessments and how they differ from the characteristics of people who do not. It is an important priority to evaluate the types of additional training and   resources that are needed by healthcare teams and systems to use HRAs to improve patient outcomes needs. Another high priority is to examine whether HRAs can provide actionable information for healthcare teams to improve health outcomes through patient action and provider engagement.

Financial incentives have been shown to improve uptake of risk assessment tools in worksite settings, but far less is known about  the role of incentives in delivery systems.34 We found the clinics with the highest response rates used direct outreach from the  physician’s office (telephone or e-mail) to patients, requesting completion of the eHRA as part of clinical care and population  management. Most of the individuals completed their first eHRA in the fourth quarter of 2006 and the third quarter of 2007, as the result of special promotions by Group Health Cooperative. The first peak (3-5 months after implementation) corresponded to the introduction of the Health Profile Questionnaire within Group Health staff. The second peak (13-15 months) corresponded to a clinic-level contest giving extra incentives for completing questionnaires. While these types of incentives may increase uptake, it is unknown whether increasing uptake alone will lead to improved receipt of preventive services and improved overall outcomes. 


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. Among patients in an integrated health system, the demographic and health risk profile of early eHRA adopters (completers) was primarily characterized by age and sex, a recent well-care visit, and fewer comorbid conditions. These types of risk assessment tools have the potential to address and integrate the interests of  patients and other stakeholders, including employers, clinical teams, and health plans, as long as they can provide actionable information for patients and healthcare teams with linkages to effective programs to mitigate health risks. Future research on the uptake of risk assessment tools in primary care should also address whether the use of these tools leads to increased uptake of activities that improve health outcomes in moderate-risk and high-risk individuals.

Author Affiliations: From Group Health Cooperative (DSMB, NKR, RJR, DCG), Seattle, WA.

Funding Source: Data collection was supported by the Group Health Research Institute’s Development Fund.

Author Disclosures: The authors (DSMB, NKR, RJR, DCG) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DSMB, NKR, RJR, DCG); analysis and interpretation of data (DSMB, NKR, RJR, DCG); drafting of the manuscript (DSMB, NKR); critical revision of the manuscript for important intellectual content (DSMB, NKR, RJR, DCG); statistical analysis (NKR); obtaining funding (DSMB, NKR, RJR, DCG); and supervision (DSMB, RJR).

Address correspondence to: Diana S. M. Buist, PhD, MPH, Group Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101. E-mail:
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