EvidenceNOW: Oklahoma Cooperative

EvidenceNOW: Advancing Heart Health in Primary Care is an initiative of the Agency for Healthcare Research and Quality (AHRQ) to transform health care delivery by building a critical infrastructure to help smaller primary care practices improve the heart health of their patients by applying the latest medical research and tools. EvidenceNOW establishes seven regional cooperatives composed of public and private health partnerships that provide a variety of quality improvement services typically not available to small primary care practices. The goal of this initiative is to ensure that primary care practices have the evidence they need to help their patients adopt the ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure control, Cholesterol management, and Smoking cessation. The initiative also includes an independent national evaluation designed to determine if and how quality improvement support can accelerate the dissemination and implementation of new evidence in primary care.

The State of Oklahoma.Cooperative Name: Healthy Hearts for Oklahoma (H2O)


Principal Investigator: F. Daniel Duffy, M.D., University of Oklahoma Health Sciences Center

Cooperative Partners:
University of Oklahoma Health Sciences Center
Public Health Institute of Oklahoma Community
Service Council of Greater Tulsa
Oklahoma Primary Care Association
Oklahoma Center for Healthcare Improvement
National Resource Center for Academic Detailing
Oklahoma Foundation for Medical Quality
Brigham and Women’s Hospital

Geographic Area: Oklahoma

Project Period: 2015–2018

Region and Population

Oklahoma has a population of 3.9 million, of which 75.1 percent is White, 7.7 percent is African American, 9.0 percent is Native American, 2.1 percent is Asian, and 9.8 percent is Hispanic.1 Oklahoma's health statistics are among the worst in the Nation, with cardiovascular disease (CVD) as the most frequent cause of premature death. Within the State, 21.1 percent of residents are current smokers, 37.5 percent have hypertension, 28.3 percent are physically inactive, and 33.0 percent are obese.2

Specific Aims

  1. Construct an effective, sustainable Oklahoma Primary Healthcare Improvement Center (OPHIC) that can serve as a resource to the emerging Oklahoma Primary Healthcare Extension System (OPHES), supporting dissemination and implementation of patient-centered outcomes research (PCOR) findings into practices.
  2. Provide technical support to primary care practices to help them implement PCOR-based methods to improve their management of patients at risk for CVD events, especially methods such as smoking cessation, blood pressure control, statins, and low-dose aspirin.
  3. Evaluate the impact of the intervention’s support strategy and of contextual factors, such as practice characteristics, on practice performance and outcomes.


  • Goal for Number of Primary Care Professionals Reached: 623.
  • Goal for Population Reached: 900,000.

Updates on Key Project Components

Support Strategy

Each participating practice will receive a 1-year intervention consisting of:

  • Baseline and monthly performance feedback and coaching. Lessons learned from high performingpractices will be disseminated to all practices to helpthem improve performance.
  • Academic detailing (expert consultation) visits with practice clinicians and staff that involve conversations about findings from evidence, what the practice is currently doing, and lessons learned from high performing practices. These conversations will lead to a quality improvement plan.
  • Practice facilitation, in which practice enhancement assistants become temporary members of the practices, acting as change agents to facilitate tailored solutions though plan-do-study-act quality improvement cycles.
  • Information technology support to help practices make more effective use of their electronic health records and the State’s Health Information Exchange services.
  • Participation in a collaboration Web site and listserv to support ongoing quality improvement.
  • Community-level interventions, such as smoking quit line referral and blood pressure medication assistance programs, in selected counties to encourage patients to address CVD risk factors.


  • The performance feedback and coaching is underway in all practices. Each practice receives two academic detailing (expert consultation) visits by clinicians over the course of the intervention, and 62 of the 255 practices have received their initial visit.
  • Practice facilitators, called "practice enhancement assistants (PEAs)" by the Oklahoma cooperative, have already made more than 1,200 telephone, email, and—most important—in-person contact with practices to explain, implement, and support the interventions. A key goal is for the PEAs to become integral to the practice staff to facilitate practice improvement.
  • Practice advisors that provide information technology support have begun helping practices pull baseline and quarterly data on ABCS measures from their electronic health records and improving connectivity with the Health Information Exchange Organization.
  • The cooperative has created two tools to provide performance feedback to the practices: a patient satisfaction survey that will be used at regular intervals during each intervention period and a dashboard with practice-level demographic and quality data.


The cooperative is using a geographic stepped-wedge design, in which practices are randomized by county and stratified by geographic quadrant to four waves of 58–72 practices, with each wave beginning 2 months after the previous wave. A second randomization will assign practices to work first on either (1) smoking cessation and blood pressure control or (2) lipid management and low-dose aspirin, switching to the other two after 6 months.


  • Randomization of practices and the first two waves of the intervention are underway.

Strategies for Disseminating Study Findings and Lessons Learned


  • The cooperative has developed a comprehensive communications plan. A key focus is providing community newspapers with information about EvidenceNOW, names of local participating practices, and materials to assist in conducting interviews with the practices.
  • The cooperative has created door clings for practices, which announce their participation in EvidenceNOW.

Spotlight on Recruitment

Comment From Principal Investigator

Daniel Duffy, M.D.

"We have completed the first year of the 3-year EvidenceNOW Healthy Hearts for Oklahoma study of the effectiveness of a primary health care improvement extension system. Initially, we targeted 300 practices of 10 or fewer clinicians and have worked harder than we imagined to land 255 practices! We have succeeded in recruiting practices from across the State, with nearly every county represented by at least one practice. The major incentives to participation have been the prospect of preparation for value-based payment, and prior experience with practice transformation and the practice research network. A letter from Blue Cross Blue Shield also had a profound effect. In the long run, however, it was the boots-on-the ground, knocking on doors, and frequent follow-up by practice facilitators that made the day."

Recruitment Specifics

The cooperative's recruitment process has concluded, with 255 practices successfully enrolled. More than 375 practices completed the interest survey, and 266 were eligible to participate.

Factors That Contributed to Recruitment Success

  • Persistence: The PEAs were responsible for recruitment, and they worked diligently to find practices and explain the benefits of participating. Many practices were initially reluctant, but after the in-person coaching sessions, are now enthusiastic participants.
  • Opportunity to become a Track 2 Practice in CMS' Comprehensive Primary Care Plus (CPC+) Program: The PEAs helped practices understand that EvidenceNOW dovetails with CPC+ and that participation would prepare them to join that initiative at a higher level, with enhanced benefits.

Challenges to Recruitment and How the Cooperative Responded

  • Concerns about burden: The cooperative initially thought that practices would be eager to join, but recruitment was more difficult and much more labor intensive than anticipated. Some practices were reluctant to join because they were concerned that it would interrupt their work. PEAs were able to allay this concern, and practices have found that working with the PEAs to engage in quality improvement activities has been valuable.
  • Out-of-date information about practices: Most existing practice lists or databases were incomplete or out-of-date, and the number of providers, especially in rural areas, was smaller than anticipated. PEAs had to do considerable “boots on the ground” work to find practices and update registries.
  • Absorption of practices into larger health care systems: PEAs were not able to deal directly with some practices but had to go through layers of corporate approval, which took time and effort.
  • Developing the right message: PEAs met once a week to share their recruitment experiences and spent time honing their message for practices about what EvidenceNOW is, why it is important, and how and why it is going to benefit practices.

1 http://www.census.gov/quickfacts/table/PST045215/40. Accessed May 24, 2016.
2 http://www.healthyamericans.org/states/?stateid=OK. Accessed May 24, 2016.

Page last reviewed October 2016
Page originally created October 2016
Internet Citation: EvidenceNOW: Oklahoma Cooperative. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/evidencenow/cooperatives/oklahoma-cooperative.html