Table 2.

Contextual Factors Related to Implementation and Patient Reach* of the My Own Health Report Health Risk Assessment

Contextual FactorHow Factor Influenced Implementation and ReachIllustrative Quote(s)
Factors internal to a practice
    Practice members' motivationsPractice leaders perceived added value of the MOHR in identifying at-risk patients“The MOHR fits right in to what we are trying to do. Nowadays, we are all about prevention and getting our patients to take better care of themselves. I like how it asks about eating fast food.” (site 3, time point 1)
Patient and provider reports helped identify problem behaviors and streamlined goal-setting process“She [the clinic's director of initiatives] is hoping to tie the MOHR project into the clinic's patient-centered medical home initiative goals that address providing patients with support in self-management, self-efficacy, and behavior change by providing self-management tools.” (site 8, time point 1)
MOHR could help with reporting requirements to external agencies“MOHR also addresses the [patient-centered medical home] initiative goals related to documenting self-management plans and goals and counseling patients to adopt healthy behaviors.” (site 8, time point 1)
Added time burden on clinicians and staff and disrupted workflowThe CEO, COO, and site supervisor described the resistance that they were getting from providers and MAs to actually administer the MOHR survey. The MAs were under too much time pressure to field the survey (taking about 15–20 min). (site 9, time point 2)
Created redundancy with existing health risk assessment questionsWhile the director of initiatives is the project's biggest champion, she expresses concern about the length of time and duplication of the questions in other assessments. (site 8, time point 2)
    Practice staff capacityPractice staff took on additional responsibilities to help patients complete MOHR, further adding to time burden and disruptions in workflowThroughout the course of the study, more practice leaders assisted with coordination and became hands-on with the project. For instance, the clinic practice manager and the manager of the nurse operators were heavily involved with tracking MOHR completions and monitoring the process. By the end of the study, E-mail and phone communication between the clinic staff, the calling center manager, and study coordinator occurred multiple times throughout the week. (site 3, time point 3)
The MAs were under too much time pressure to field the survey (taking about 15–20 min), and the provider was actually instructing the MAs to stop fielding the survey if they were falling too far behind schedule. (site 9, time point 2)
Research staff assisted with implementation when practice staff lacked capacityThe graduate assistant and student worker (research staff) assist the staff with MOHR completions 3 half-days a week. Although the research team has agreed to help with patient recruitment, the clinic staff prefer to approach the patient first and obtain verbal consent. The research staff then enter the exam room while the patient is reading/signing the consent form, provides the patient with any additional information needed, and assists with completing the MOHR assessment. (site 8, time point 3)
    Practice information system capacityDelays in printing or faxing patient and provider reports hindered goal-setting discussionsPhysician enthusiasm and use of summaries have been mixed. Because of the modest frequency of missing physician summaries, certain physicians have diminished enthusiasm and participation. There is a clear feeling that they do not want paper summaries and want the activities integrated into EHR. There is also a concern that without a more clearly available pathway for initiating practice support, use will remain inadequate. (site 3, midpoint)
Changes in existing health information technology infrastructure hindered consistent implementation and reach“The practice does have an online patient portal, but it is underutilized at the moment …”; this trend may support the ease of adoption for the online patient portal. (site 9, time point 1)
Factors external to a practice
    Linkages with the larger health systemAccess to information technology and human resources of health systems that practices were affiliated with fostered implementation and reachSite 4 (health system) has done considerable work to make it easy for us to get, review, and use the health reports. This work included activities related to getting patients to initially complete the MOHR assessment (eg, mailing them invitations) and conducting the research study (eg, mailing and coordinating the Patient Experience Survey). Site 4 (health system) has a very sophisticated research workshop with extensive experience that made this process smooth and easy for the practice. (site 4, time point 1)
Sharing details and challenges with MOHR completion at the program meeting for a weight-loss project led to the suggestion to engage the health care system's nurse operators with the project. The nurse operators are comfortable with conducting surveys and asking patients sensitive health questions. To date, the operators' experience and capacity for making calls has proven beneficial to the project. (site 3, time point 2)
Competing demands from other initiatives on health system resources could pose a barrier to implementation“There was developing concern that a large, emerging, cross-system primary care initiative would put the project [MOHR] at risk. Because of increasing demands of [the] office manager the responsibility for organizing and distributing physician feedback, changed to a line staff member which improved efficiency, and decreased overall amount of time.” (site 5, time point 2)
    Linkages with community resourcesLack of community resources to refer patients for additional counseling influenced goal settingThe practice is located in a rural community and it is difficult to reach the practice without a long drive. The community does not have many resources for health behavior change. (site 4, time point 1)
There were a significant number of mental health issues and not a very robust referral system to outside resources (one counselor at the delayed site who saw 1 patient per week, but the position was unfilled for about a month during the study period). (site 9, endpoint)
Lack of a systematic referral process for more intensive counseling reduced clinician enthusiasm for MOHRNurse operators did not feel prepared when a patient responded positively to having suicidal thoughts and/having a desire to harm himself. Once the team received this comment, a study co-investigator and the medical director outlined a protocol for instant transfer to the health care system's Connect hotline. Before transfer, the patient was provided the crisis line's toll-free number and instructed to seek medical attention. The clinic also received notation from the manager of the nurse operators for patient follow-up. (site 3, time point 3)
    Fit of implementation strategy with patientsSome patient subgroups (eg, older patients, those with low literacy) required more resources to administer the MOHRThe MAs will be administering the MOHR to patients since there was a concern that the level of literacy among patients is too low for self-reported measures. (site 9, time point 1)
It is easier for most patients to do the paper version (particularly elderly patients). (site 6, time point 2)
  • * Patient reach is defined as the number, proportion, and representativeness of eligible patients offered and completing the My Own Health Report (MOHR) assessment.28 Patient reach was calculated by dividing the number of patients who completed the MOHR assessment by the number of patients offered MOHR.15

  • EHR, electronic health record; MA, medical assistant.