A Novel Primary Care Planning Informatics Tool Informed by Data-Driven Multimorbidity Grouping: User-Centered Design...

Area of Science:

• Health Informatics
• Primary Care Management
• Chronic Disease Management

Background:

• Patients with multimorbidity present complex healthcare needs and are at high risk for adverse outcomes.
• Primary care teams require effective tools for proactive care planning for these high-risk patients.
• VET-PATHS (Veteran Panel Management Tool for High-Risk Subgroups) was developed as a novel informatics tool for complex primary care patient management.

Purpose of the Study:

• To iteratively adapt the VET-PATHS tool based on user input.
• To test the feasibility and acceptability of VET-PATHS among frontline primary care teams for managing empaneled high-risk patients.

Main Methods:

• User-centered design sessions were conducted with primary care providers and nurses across multiple sites to refine the tool's layout, content, and interface.
• A pilot intervention study assessed tool use and care plan generation through observations, chart reviews, and qualitative interviews.
• Latent class analysis of electronic health record data was used to group patients by chronic condition.

Main Results:

• User feedback led to improvements in VET-PATHS content, context, target users, and display.
• Pilot teams actively reviewed a high percentage of high-risk patients, prompting new clinical actions and care plan documentation.
• The tool facilitated actions such as clinic return requests, referrals, and vaccinations, with a notable percentage of planned actions completed.
• Difference-in-difference analysis indicated a decline in acute hospitalizations post-pilot, while outpatient utilization remained stable or increased.
• Generalist teams reported higher acceptability, while focused teams with homogenous panels found the care steps less useful.

Conclusions:

• User-centered improvements enhanced VET-PATHS' ability to help clinicians manage complex patient information and create care plans efficiently.
• VET-PATHS demonstrated acceptability and feasibility for frontline primary care teams, particularly those managing general patient panels.
• The tool led to tangible improvements in clinical care delivery for patients with multimorbidity.