Project: COMPETE II

Canada Health Infostructure Partnerships Program

Project Synopsis

The COMPETE II project (Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness) was an 18-month study led by the Centre for Evaluation of Medicines, St Joseph's Hospital in Hamilton, Ontario. The project focus was a randomized controlled trial to investigate the impact of a Web-based, real-time, updated, patient-specific diabetes tracker available to patient and physician. It also included an automated telephone reminder service for patients on access, quality, satisfaction and continuity of care. The trial involved three primary regions - Hamilton area, Sault Ste. Marie, and Ottawa. Forty-seven providers and 512 patients were recruited to participate in the COMPETE II diabetes study.

A standardized, core data set for health with diabetes extensions was to be developed and evaluated. The extended core data set (ECDS) will serve a key health Infostructure function: the ability to standardize patient data from multiple electronic health record (EHR) systems for the purposes of sharing information and providing clinical decision support in a sustainable and scalable manner.

Outcomes

Project COMPETE II demonstrated a positive impact on service by:

• Changing the way policy makers think about the care of diabetes and, by corollary, other chronic diseases;
• Highlighting that there are many deficiencies in patient care and that new tools are required to improve care;
• Underlining that traditional methods of driving/encouraging physician behavior change have not worked and that technology may be an appropriate solution that needs to be investigated further.
• The unexpected enthusiasm for such tools on the part of patients, and their relative lack of concern about data privacy emphasizes the motivating power of electronic self-management by patients;
• Calling attention to the potential power of electronic guidance linked to the patient's own medical file, given the lack of access of many communities to tertiary health care resources or best evidence regarding chronic diseases;
• Meshing extremely well with community-based diabetes outreach projects such as Diabetes Hamilton: This can be generalized to other communities; and
• Offering the opportunity to enhance other organized diabetes self-management program.

Impacts to patients, to health care professionals, or to an organization's management and structure:

• The COMPETE II Diabetes Tracker has helped streamline the care of patients with diabetes by ensuring that they get their lab tests done before they see their doctor; and
• Patients are pleased to have access to their own information and appreciate receiving practice advice customized for them in an understandable manner.

Research Implications

Providers, particularly physicians, are the key stakeholder in any e-health strategy and the continued disregard for their needs, their complex workflow requirements and unprecedented information demands, may jeopardize Canada's entire EHR strategy. Only two major groups work directly with clinicians to advance their EHR and decision support needs - both are academic and unsupported by e-health strategy groups. It is strongly recommended that support for ongoing investigation, implementation and evaluation of clinical e-health systems are continued.

One of the major lessons learned was the surprising lack of appreciation for the need for research and an intolerance for the research process in this area of electronic health technologies.

Lessons Learned

The COMPETE II project reported many lessons learned, some of which have been summarized into the following three concepts:

• Patients appear willing to put up with a potential loss of privacy of their health data in exchange for the benefit of improving their care;
• A significant number of older adults (mean age 61 years in this project cohort) - 50% - never use a computer and preferred a printed version of the tracker; and
• Interventions such as the COMPETE II system need to have and adhere to data standards, save physicians time but not cost them large sums of money, and be well supported. Provision of updated lab and medication information is a good place to start.

The Future

Sustainability is a major problem without a coordinated federal or provincial approach to EHRs and clinical decision support systems. The current exclusive interest in infrastructure is counterproductive to Canada's e-health development which should be very much focused on the frontlines of health care.

Appendix A: Documents or Products Generated

Document/Product Name

Template(s) for vendor contract(s):

• COMPETE II Physician contract - blank
• COMPETE II Partner Contribution Form

User Guide(s) and/or Training Manual(s):

• COMPETE II Physician's User Guide
• COMPETE II Patient's User Guide

Template(s) for equipment testing:

• COMPETE II Test Patient templates

Policy and Procedure Manual(s):

• COMPETE II Code of Conduct
• COMPETE II Physician Site Checklist

Job Descriptions and / or recruitment material:

• COMPETE II Recruitment Presentation
• COMPETE II Sales and Marketing Plan (Change Management Process)

Software Application(s), includes:

• COMPETE II Diabetes Tracker webshots - Patient
• COMPETE II Diabetes Tracker webshots - Physician
• COMPETE II Data Flow - Clinical Diagram
• COMPETE II Data Flow - Technical Diagram
• Clinical Integration for COMPETE II
• COMPETE II Data Integration Review
• COMPETE II Diabetes Tracker Algorithms

Standards, includes:

Data (includes minimal data sets)

• COMPETE II extended Core Data Set

Clinical Training Protocols:

• COMPETE II Physician's User Guide

Clinical Program Protocol(s):

• COMPETE II Evaluation Plan

Quality Assurance Procedures:

• Sample of COMPETE II Randomization Allocations
• TAGGE Flow chart and scripts

Confidentiality and Privacy documents:

• COMPETE II Code of Conduct
• COMPETE II Confidentiality Letter

Consent Forms:

• COMPETE II Patient Consent Package

Sustainability Plan:

• COMPETE II Commercialization Notes- July 11, 2002

For additional information, please contact: Dr. Anne Holbrook at Holbrook@macmaster.ca or at 905-522-1155, Ext.5269