Transforming Health Outcomes for Patients with Chronic Conditions Using Tailored Health Information Technology
David Dorr, M.D.
Chief Research Information Officer
Vice Chair of Clinical Informatics
Professor of Medical Informatics and Clinical Epidemiology
Oregon Health & Science University
“The knowledge of how to address the needs of people with multiple chronic conditions and health-related social needs has been substantially advanced by AHRQ’s funding. My work funded by AHRQ has helped to understand how we can adapt health information technology to the needs of at-risk, vulnerable populations.”
Designing health information technology (health IT) to be more patient-centric can improve outcomes for patients with chronic conditions and provide more engaging and efficient approaches to primary care. This is what drives the research of AHRQ grantee David Dorr, M.D. He is Chief Research Information Officer, Vice Chair of Clinical Informatics, and Professor of Medical Informatics and Clinical Epidemiology at Oregon Health & Science University.
Chronic care management— a set of activities to help patients and their clinicians more effectively manage their complex health conditions—is one of the best ways to ensure patient safety and quality of care. It improves communication among all the patient’s treating clinicians and other caregivers and encourages patient self-management. However, care management for these patients requires a high level of coordination to ensure patient-centered care. Key to the coordination is sharing information from electronic health records (EHRs), but most EHRs cannot document care coordination and chronic care management in a practical and effective way.
Dr. Dorr received his first AHRQ grant in 2008 to study an integrated care coordination information system (ICCIS) to determine whether it could be implemented in a diverse set of clinics using certified EHRs. He found that an ICCIS can be built, incorporated, and sustainably used in daily workflows and across multiple EHR systems.
“Some of the clinics that participated in the research have continued to use this health IT system for their quality improvement, care coordination efforts, and to ensure patients with chronic conditions receive appropriate care,” Dr. Dorr said. In addition, this four-year research project helped to inform the health IT requirements of the Centers for Medicare & Medicaid Services’ Comprehensive Primary Care Initiative.
With a one-year exploratory grant from AHRQ awarded in 2014, Dr. Dorr expanded on his previous work to develop and validate a “gold standard” dataset of measures for patient diagnosis and care. This project involved linking different data sources and using advanced processing and algorithms to create multiple chronic conditions (MCC) risk prediction models. The models help providers tailor proactive strategies to prevent the onset of or delay the progression of chronic diseases, particularly in minority populations.
“Consideration of the adequacy of data to understand and address the needs of people with MCCs is important in designing interventions” said Dr. Dorr.
Despite the near universal adoption of EHRs (which has resulted in an increased amount of clinical data available to improve patient care), challenges remain about how best to leverage health IT for clinical decision support. In 2019, Dr. Dorr began a two-year AHRQ-funded project to translate high blood pressure guidelines and protocols into interoperable and sharable clinical decision support, tailored for each patient, to ensure healthcare teams receive accurate and timely health information to inform their clinical decisions. He developed a health IT application, called Collaboration-Oriented Approach for Controlling High Blood Pressure or COACH, which combines hypertension guidelines and protocols with patient data to help improve diagnosis and outcomes. This also helps increase patient satisfaction and engagement.
“The goal is to deliver the right information, to the right person, in the right format and channel, and at the right time to enhance self-management and engagement to control high blood pressure and reduce heart attack and strokes,” explained Dr. Dorr.
Dr. Dorr’s current AHRQ project, which builds on his COACH health IT application, aims to understand how engaging patients through an application on their cell phones and computers can help them to control their blood pressure and improve health outcomes. The project is scheduled to conclude in 2025.
Dr. Dorr has served on the Public Policy Committee at the American Geriatrics Society for almost a decade and as an Advisor for Clinical Quality Measurement at the Oregon Health Authority. He also is a co-editor-in-chief for Applied Clinical Informatics Open. Dr. Dorr is a member of the American Medical Informatics Association, for which he previously served on the Board of Directors, and was recently elected to the American College of Medical Informatics Executive Committee.
Related AHRQ Resources
Principal Investigator: David Dorr, M.D.
Institution: Oregon Health & Science University
Grantee Since: 2008
Type of Grant: Various
Consistent with its mission, AHRQ provides a broad range of extramural research grants and contracts, research training, conference grants, and intramural research activities. AHRQ is committed to fostering the next generation of health services researchers who can focus on some of the most important challenges facing our Nation's health care system.
To learn more about AHRQ's Research Education and Training Programs, please visit https://www.ahrq.gov/training.