Background Colorectal cancer (CRC) screening rates are suboptimal. The most important barriers identified by patients are poorly understood. A comprehensive assessment of barriers to all recommended modalities is needed. Methods In 2007, a questionnaire was mailed to 6,100 patients, aged 50–75 years, from 12 family medicine practices in the Virginia Ambulatory Care Outcomes Research Network. People aged 65–75 years and African Americans were oversampled. Patients were asked to rate 19–21 barriers to each of four recommended tests. In 2008, responses were coded on a 5-point scale; higher scores reflected stronger barrier endorsement. Results The response rate was 55% (n=3,357). Approximately 40% of respondents were aged ≥65 years, 30% were African-American, and 73% were adherent to screening. A clinician's failure to suggest screening and not knowing testing was necessary received the highest mean scores as barriers. Financial concerns and misconceptions were also cited. Barrier scores differed depending on whether respondents were never-screened, overdue for screening, or adherent to guidelines. The top five barriers for each modality included test-specific barriers (e.g., handling stool, bowel preparation), which often outranked generic barriers to screening. Not knowing testing was necessary was a top barrier for all tests but colonoscopy. Conclusions Although physician advice and awareness of the need for screening are important, barriers to screening are not homogenous across tests, and test-specific barriers warrant consideration in designing strategies to improve screening rates. Barrier scores differ by screening status, highlighting the need to address prior screening experience. Evidence that patients are more familiar with colonoscopy than with other modalities suggests an opportunity to improve screening rates by educating patients about alternative tests.

PURPOSE Americans receive only one-half of recommended preventive services. Information technologies have been advocated to engage patients. We tested the effectiveness of an interactive preventive health record (IPHR) that links patients to their clinician's record, explains information in lay language, displays tailored recommendations and educational resources, and generates reminders. METHODSThis randomized controlled trial involved 8 primary care practices. Four thousand fi ve hundred patients were randomly selected to receive a mailed invitation to use the IPHR or usual care. Outcomes were measured using patient surveys and electronic medical record data and included IPHR use and service delivery. Comparisons were made between invited and usual-care patients and between users and nonusers among those invited to use the IPHR.RESULTS At 4 and 16 months, 229 (10.2%) and 378 (16.8%) of invited patients used the IPHR. The proportion of patients up-to-date with all services increased between baseline and 16 months by 3.8% among intervention patients (from 11.4% to 15.2%, P <.001) and by 1.5% among control patients (from 11.1% to 12.6%, P = .07), a difference of 2.3% (P = .05). Greater increases were observed among patients who used the IPHR. At 16 months, 25.1% of users were up-todate with all services, double the rate among nonusers. At 4 months, delivery of colorectal, breast, and cervical cancer screening increased by 19%, 15%, and 13%, respectively, among users.CONCLUSIONS Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefi ts. Ann Fam Med 2012;10:312-319. doi:10.1370/afm.1383. INTRODUCTIONA mericans receive only one-half of recommended preventive services.1 Among the various causes is poor access to reliable information. Patients need evidence-based information about what is recommended-tailored to their individual risk factors (eg, age, sex, co mbordities, prior testing, family history, health behaviors)-and presented in an understandable format.2 They need reminders when services are due, guidance to deal with inconsistent recommendations, and access to decision aids for choices that require shared decision making. [3][4][5] To act on their choices, patients need written plans and logistical details. 6,7 Clinicians often lack time and resources to provide this information. 8 One proposed solution is to harness the power of information technology, especially personal health records. For the purposes of this article, personal health records are broadly defi ned as health information systems used by patients, whereas electronic health records (EHRs) are systems primarily used by clinicians. 313 INT ER AC T IVE PR E V ENT IV E HE A LT H R ECOR Dgive patients direct access to the EHR of their clinician, 9,10 which is empowering, speeds access to results, and enables patients to discover inaccuracies in their medical record. The next gene...

PURPOSE Health care leaders encourage clinicians to offer portals that enable patients to access personal health records, but implementation has been a challenge. Although large integrated health systems have promoted use through costly advertising campaigns, other implementation methods are needed for small to medium-sized practices where most patients receive their care. METHODSWe conducted a mixed methods assessment of a proactive implementation strategy for a patient portal (an interactive preventive health record [IPHR]) offered by 8 primary care practices. The practices implemented a series of learning collaboratives with practice champions and redesigned workflow to integrate portal use into care. Practice implementation strategies, portal use, and factors influencing use were assessed prospectively.RESULTS A proactive and customized implementation strategy designed by practices resulted in 25.6% of patients using the IPHR, with the rate increasing 1.0% per month over 31 months. Fully 23.5% of IPHR users signed up within 1 day of their office visit. Older patients and patients with comorbidities were more likely to use the IPHR, but blacks and Hispanics were less likely. Older age diminished as a factor after adjusting for comorbidities. Implementation by practice varied considerably (from 22.1% to 27.9%, P <.001) based on clinician characteristics and workflow innovations adopted by practices to enhance uptake.CONCLUSIONS By directly engaging patients to use a portal and supporting practices to integrate use into care, primary care practices can match or potentially surpass the usage rates achieved by large health systems. 2014;12:418-426. doi: 10.1370/afm.1691. Ann Fam Med INTRODUCTIONE lectronic personal health records hold great promise for improving health. High-quality personal health records can facilitate connectivity between patients and clinicians, allow patients to view their medical record, support online clinical and administrative transactions, deliver essential resources to promote informed decision making, and more actively engage patients in care. 1 In the United States, regulations developed by the Office of the National Coordinator and the Centers for Medicare and Medicaid Services to strengthen the functionality of electronic health record systems (meaningful use regulations) encourage practices to engage patients in care through information technology, such as personal health records. 2,3Although patients appear interested, 4,5 practices cannot meet this need without infrastructure, workflow, and cultural changes. Most published experiences with engaging patients online have occurred in integrated health systems that have resources and business models to support adoption, implementation, and maintenance of the personal health record. [6][7][8][9] For example, between 2002 and 2009, Kaiser Permanente and Group Health Cooperative of Puget Sound made major investments to promote online services, resulting in uptake by 27% and 58% of patients, respectively, over 6 to 9 years. 419...

Although clinical preventive services (CPS)—screening tests, immunizations, health behavior counseling, and preventive medications—can save lives, Americans receive only half of recommended services. This "prevention gap," if closed, could substantially reduce morbidity and mortality. Opportunities to improve delivery of CPS exist in both clinical and community settings, but these activities are rarely coordinated across these settings, resulting in inefficiencies and attenuated benefits. Through a literature review, semi-structured interviews with 50 national experts, field observations of 53 successful programs, and a national stakeholder meeting, a framework to fully integrate CPS delivery across clinical and community care delivery systems was developed. The framework identifies the necessary participants, their role in care delivery, and the infrastructure, support, and policies necessary to ensure success. Essential stakeholders in integration include clinicians; community members and organizations; spanning personnel and infrastructure; national, state, and local leadership; and funders and purchasers. Spanning personnel and infrastructure are essential to bring clinicians and communities together and to help patients navigate across care settings. The specifics of clinical–community integrations vary depending on the services addressed and the local context. Although broad establishment of effective clinical–community integrations will require substantial changes, existing clinical and community models provide an important starting point. The key policies and elements of the framework are often already in place or easily identified. The larger challenge is for stakeholders to recognize how integration serves their mutual interests and how it can be financed and sustained over time.

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