Investment and expansion of digital healthcare, which includes mobile health (mHealth) and electronic health (eHealth), health information technology, wearable devices, and providing patient care and support through telemedicine,23 has grown significantly in recent years. The COVID-19 public health emergency accelerated this growth, particularly for telemedicine and related technologies. Integrating digital healthcare technology into primary care has the promise of increasing access to services, enhancing care coordination across healthcare settings, supporting clinical decision-making, and improving patient safety and health outcomes. However, research indicates that digital healthcare approaches can exacerbate existing disparities in healthcare, requiring dedicated interventions that center health equity in improved design, implementation, and dissemination of digital healthcare tools to those who have the greatest need.24 Ongoing research continues to explore new avenues for expanding digital healthcare technology in ways that improve equitable access to high-quality health care.
AHRQ’s Division of Digital Healthcare Research produces and disseminates evidence on how digital healthcare can improve the quality, safety, and effectiveness of healthcare while also improving patient experiences. However, many AHRQ grants that have a focus on digital healthcare intersect with other agency priorities. This section of the report includes a summary of AHRQ’s primary care grants, initiatives, and resources with a main focus on digital healthcare.
Grants with a focus on health equity are indicated with this icon.
Grants
Twenty-two AHRQ primary care grants actively funded during FYs 2021 and 2022 were mainly focused on digital healthcare. This included 12 R18s (Research Demonstration and Dissemination Projects), 5 R01s (Research Projects), 3 R21s (Exploratory/ Developmental Grants), 1 U18 (Research Demonstration/Cooperative Agreement), and 1 K08 (Clinical Investigator Award). In addition to these 22 grants, another 38 primary care grants had some focus on digital healthcare and are described in other sections of this report, including Practice and Quality Improvement (15), Person-Centered Care (7), Healthcare Systems and Infrastructure (5), Behavioral Health and Substance Use Disorders (5), COVID-19 (2), Health Equity (1), Primary Care Workforce (1), and Public Health and Community Integration (1).
Below are tables, organized by five subtopics, which include short summaries of each of the 22 primary care grants focused mainly on digital healthcare. Subtopics include clinical decision support tools, other EHR tools, mobile health and electronic health approaches, telemedicine or telehealth, and diagnostic centers of excellence.
Clinical Decision Support Tools
Out of eight grants investigating EHR tools, five focus specifically on clinical decision support (CDS) tools to help clinicians reduce errors and improve the consistency of diagnoses and care recommendations. CDS describes a range of tools that can be used to help support decision-making in the clinical workflow. CDS tools include "computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools."25 All of AHRQ primary care grants with a focus on CDS throughout this report are included in Appendix C: Clinical Decision Support.
| Engaging Patients to Enable Interoperable Lung Cancer Decision Support at Scale (R18) |
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PI: Kensaku Kawamoto Organization: University of Utah; School of Medicine Expands an existing CDS program (Decision Precision+) designed to analyze EHR data to prompt doctors to discuss lung cancer screening with eligible patients with individually tailored information on the benefits and harms of screening. For this grant, the research team will adapt Decision Precision+ to integrate with a patient portal (MyLungHealth) that patients use directly to learn about lung cancer screening. The research team will test how healthcare systems implement MyLungHealth in primary care practices and examine the additional benefit of MyLungHealth for practices that already use Decision Precision+. |
| Averting Diagnostic Error Through Improved Recognition of Child Abuse (K08) |
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PI: Irit R. Rasooly Organization: Children's Hospital of Philadelphia; Independent Hospital Uses EHR data- and systems-analysis to develop CDS strategies that can identify and help diagnose child abuse in primary care settings. The research team is using EHR data to detect and validate markers of physical abuse to help identify children experiencing abuse; using EHR simulations to identify abuse-related diagnostic errors; and working to develop feasible, acceptable, and appropriate CDS strategies for improved child abuse detection and diagnosis. |
| Clinical Decision Support for Disseminating and Implementing Patient-Centered Outcomes Research (R18) |
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PI: Ronilda Lacson Organization: Brigham and Women’s Hospital; Independent Hospital Aims to develop and validate CDS-consumable knowledge artifacts based on clinical evidence for imaging that can be widely adopted. In previous work, a multi-disciplinary team of clinicians and medical informaticists developed and graded artifacts to represent clinical evidence and made them publicly available. Assesses the technical capability of standardized EHR syntax and formats (e.g., FHIR, CQL, and SNOMED CT) to use the knowledge artifacts for imaging CDS. Specifically, the team will look at CDS for using MRI to diagnose a second incidence of breast cancer, using CT scan for pulmonary embolism, and for physician education about the risk for pulmonary embolism. Results will help inform clinical decision making for diagnostic imaging in primary care. |
| Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall Assessment and Prevention Patient-Centered Outcomes Research Findings into Diverse Primary Care Practices (ASPIRE) (U18) |
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PIs: Patricia C. Dykes; Robert J. Lucero Organization: Brigham and Women’s Hospital Aims to develop a shareable, standards-based fall prevention software to improve the implementation of a clinical decision support program into primary care settings using Fall Care Managers to promote fall prevention decision-making. |
| Adaptation and Pilot Implementation of a Validated, Electronic Real Time Clinical Decision Support Tool for Care of Pneumonia Patients in 12 Utah Urgent Care Centers (R18) |
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PI: Nathan C. Dean Organization: IHC Health Services Inc.; Non-Profit Adapts an existing CDS tool containing guidelines for pneumonia (“ePNa”) to urgent care centers. The research team is identifying barriers and facilitators to implementation and uptake of the ePNa tool, and testing it within urgent care centers by examining outcomes related to patient safety, antibiotic prescribing, and diagnoses without chest imaging. While this study is not conducted in primary care practices, it has potential to be implemented in primary care practices, as acute respiratory complaints are commonly seen in primary care. |
Other EHR Tools
Four grants focus on EHR tools other than CDS.
| Understanding CancelRx: Impact on Clinical Workflows, Medication Safety Risks, and Patient Outcomes (R21) |
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PI: Samantha Pitts Organization: Johns Hopkins University; School of Medicine; Genetics Conducts formative research on the development and optimization of CancelRx, an EHR functionality that sends electronic prescription cancellations from the EHR to pharmacies, to help reduce adverse drug events in ambulatory care settings. |
| Care System Analytics to Support Primary Care Patients with Complex Medical and Social Needs (R18) |
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PI: Richard W. Grant Organization: Kaiser Foundation Research Institute; Research Institute Develops and tests an EHR-based dashboard to help clinical teams ensure patients with multiple chronic conditions and socially determined barriers to care receive high-quality primary care. |
| Prescription Drug Monitoring Program Integration in the Electronic Health Record (R21) |
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PI: Daniel M. Hartung Organization: Oregon State University; School of Pharmacy; Other Health Professions Evaluates how integrating Oregon’s electronic registry of controlled-substance prescription dispensing data (prescription drug monitoring program) into the EHR of primary care clinics impacts provider use of registry data and prescribing behavior. |
| A Turn-Key EHR Simulation Program to Reduce Diagnostic Error in Ambulatory Care (R18) |
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PIs: Jeffery A. Gold; Raj M. Ratwani Organization: Oregon Health & Science University; Domestic Higher Education Develops a library of validated EHR-based simulations to improve diagnostic safety in ambulatory care. The research team is using a combination of administrative and claims data to identify diagnoses at risk for diagnostic error in ambulatory care settings and the EHR use errors associated with those errors. The researchers will use this data to develop simulations for five ambulatory care settings, including primary care, and validate the use of the simulation activities as a training tool to change EHR use patterns and reduce diagnostic errors. |
Mobile Health and Electronic Health
Eight grants focus on mHealth or eHealth interventions.
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PI: Sunit Jariwala Organization: Albert Einstein College of Medicine; Domestic Higher Education Develops and evaluates an app for asthma control in adults and tests its implementation and scaling within primary care settings. |
| Integrating Patient-Reported Outcomes into Routine Primary Care: Monitoring Asthma Between Visits (R18) |
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PI: Robert Samuel Rudin Organization: RAND Corporation; Research Institute Refines an app for reporting asthma symptoms for use in a primary care setting, implements it in four primary care clinics, and evaluates the effect of patient use on quality of life and healthcare utilization. |
| Impact and Sustainability of a Digitally-Based Diabetes Prevention Program (R01) |
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PI: Yoshimi Fukuoka Organization: University of California, San Francisco; School of Nursing; Other Health Professions This randomized controlled trial assesses the effectiveness and sustainability of a digitally-based diabetes prevention program for reducing body weight and HbA1c in adults with prediabetes and obesity. The findings from this study have clear implications for primary care, where diabetes prevention is a common part of care. |
| Feasibility Study of a Mobile Digital Personal Health Record for Family-Centered Care Coordination for Children and Youth with Special Healthcare Needs (R21) |
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PI: David Y. Ming Organization: Duke University; School of Medicine; Pediatrics Develops an app for families of children and youth with special healthcare needs to manage digital personal health records that span healthcare and EHR systems. The study will explore app adoption, barriers and facilitators, and outcomes among families of children with special healthcare needs in a pediatric primary care clinic. |
| Improving Medication Safety for Medically Complex Children with MHealth Across Caregiving Networks (R18) |
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PIs: Ryan J. Coller; Nicole E. Werner Organization: University of Wisconsin—Madison; School of Medicine; Pediatrics Develops an app (MedS@HOME) to improve medication safety for children with medical complexity. The app supports standardized medication management across the caregiving network to increase administration accuracy and reduce medication-related adverse events. Learn more about this study in a recent NCEPCR webinar: Innovative Use of Technology for Primary Care Delivery. |
| Care Transitions App for Patients with Multiple Chronic Conditions (R01) |
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PIs: Lipka Samal; Patricia C. Dykes Organization: Brigham and Women’s Hospital; Independent Hospital Develops and tests the effectiveness of an app to support care transitions between the hospital, home, and primary care clinic to reduce post-discharge adverse events. The app contains a digital post-discharge transitional care plan, modules for multiple chronic conditions, relevant lab values, education specific to the patient’s prescribed medications, and a functionality that allows patients to ask questions to support their recovery goals. |
| An Evaluation of the Spread and Scale of PatientToc from Primary Care to Community Pharmacy Practice for the Collection of Patient-Reported Outcomes (R18) |
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PI: Margie E. Snyder Organization: Purdue University; School of Pharmacy; Pharmacology Implements a patient-reported outcomes app for patients using community pharmacies to improve medication adherence and ultimately patient health outcomes. |
| Using Smart Devices to Implement an Evidence-based eHealth System for Older Adults (R18) |
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PIs: David H. Gustafson; Marie-Louise Mares Organization: University of Wisconsin—Madison; Biomedical Engineering/College of Engineering; Engineering |
Telemedicine or Telehealth
Three grants with a primary focus on Digital Healthcare examine the use of telemedicine or telehealth, including providing direct medical care and services using video conferencing or phone calls. [A total of 13 AHRQ primary care grants had a focus on telehealth, including the three described here. A table with all 13 of these grants is included in Appendix C: Telehealth.]
| Patient Choice of Telemedicine Encounters (R01) |
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PI: Mary Reed Organization: Kaiser Foundation Research Institute; Research Institute Examines the broad-scale implementation of telemedicine for primary care encounters within a healthcare system prior to the COVID-19 pandemic to understand how telemedicine compares in quality, care processes, and patient outcomes to in-person care; and to understand which patient characteristics are most closely associated with telemedicine utilization. |
| Evaluating the Impact of Telemedicine on Ambulatory Care (R01) |
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PIs: Michael Patrick Thompson; Chandy Skaria Ellimootil Organization: University of Michigan at Ann Arbor; School of Medicine; Surgery Uses a national cohort of Medicare beneficiaries to understand the impact of ambulatory care telemedicine visits on hospital admissions for ambulatory care-sensitive conditions (such as congestive heart failure, diabetes, and hypertension), and on healthcare spending. |
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PI: Peter M. Yellowless Organization: University of California at Davis; School of Medicine; Psychiatry Tests and validates an automated online interpretation tool to improve access to high-quality mental health services for people with limited English proficiency. In this intervention, a trained mental health interviewer-researcher interviews a patient in Spanish, the interview is translated and transcribed using the automated translation tool, and then a video with embedded transcribed subtitles is viewed by the psychiatrist. The research team is testing diagnostic accuracy, inter-rater reliability, patient satisfaction, and language and syntax accuracy. |
Diagnostic Centers of Excellence
Two grants support the implementation of Diagnostic Centers of Excellence focused on using digital healthcare to reduce diagnostic errors and improve patient safety.
| Diagnostic Safety Center for Advancing E-triggers and Rapid Feedback Implementation (DISCOVERI) (R18) |
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PI: Hardeep Singh Organization: Baylor College of Medicine; School of Medicine; Internal Medicine Develops a center that supports the implementation of surveillance and feedback systems to improve diagnostic safety in healthcare organizations. The center will work to accelerate the uptake of electronic trigger (e-trigger) tools, which mine large sets of clinical and administrative data to identify signals for likely adverse events. E-trigger algorithms can efficiently identify patterns of care indicating missed or delayed diagnoses in primary care as well as other settings. |
DECODE: Diagnostic Excellence Center on Diagnostic Error (R18) |
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PIs: Ramin Khorasani; Ronilda Lacson Organization: Brigham and Women’s Hospital; Independent Hospital Develops a Diagnostic Center of Excellence to reduce failures in timely performance of clinically necessary diagnostic imaging exams and interpretation errors. The team will implement information technology- enabled functions and workflows to enhance a clinical dashboard with improved EHR-integration and monitoring and learning capabilities to help reduce diagnostic errors and health disparities. In addition, they will provide opportunities for peer learning to reduce interpretive errors and convene a team of clinicians to develop consensus recommendations for the management of lung, prostate, pancreatic and adrenal cancers and embed the recommendations into the EHR. |
Initiatives and Resources
Below we share an important resource related to digital healthcare in primary care that AHRQ developed in 2021.
Integrating Patient-Generated Health Data into Electronic Health Records in Ambulatory Care Settings: A Practical Guide is designed to support ambulatory care settings in the design and implementation of patient-generated health data (PGHD) programs, with the goal of improving patient outcomes.
PGHD are "health-related data created, recorded, or gathered by or from parents (or family members or other caregivers) to help address a health concern."26 PGHD includes data reported in patient surveys or tracked in remote monitoring devices (i.e., health apps or wearable devices).
The guide includes tools and resources that support the planning, implementation, evaluation, and scaling of PGHD into ambulatory care settings.
