Addressing antihypertensive medication adherence through EHR-enabled teamlets in primary care - Resubmission - 1

Project Summary Medication nonadherence is common among patients with hypertension and is associated with increased cardiovascular morbidity and mortality. Nonetheless, medications adherence is often not addressed in clinical practice due to a number of factors, including lack of readily available assessment tools and provider competing demands. Recent uptake of electronic prescribing from the electronic health record (EHR) to pharmacies offers the opportunity for scalable, real-time measurement of medication adherence that can be used for interventions at the point of care. In addition, we have demonstrated that an intervention utilizing medical assistants (MAs) trained as health coaches can improve medication adherence among patients with hypertension. The objective of this application is to implement a multicomponent intervention that utilizes linked EHR-pharmacy data and teamlets, consisting of primary care providers (PCPs) and MAs who will receive brief training in health coaching, to pragmatically address medication adherence in a real-world, primary care setting. The intervention consists of four components: 1) patients with hypertension will be automatically screened for low medication adherence using linked EHR–pharmacy data at the time of a PCP encounter; 2) MAs will deliver a validated, rapid, 12-item survey of common causes of non-adherence; 3) MAs will address specific barriers to adherence tailored to survey response, including delivery of brief health coaching based on motivational interviewing; and 4) PCPs will address specific barriers to adherence based on survey response. The central hypothesis is that this multicomponent intervention will improve medication adherence and blood pressure for patients with hypertension. We will test this hypothesis in a hybrid type I effectiveness- implementation pragmatic, cluster-randomized trial in 22 diverse primary care clinics. We will also evaluate the implementation of the intervention, including adoption, acceptability, fidelity, cost-effectiveness, and sustainability. The project is innovative because it proposes to: 1) measure adherence using pharmacy fill data available in the EHR for use in real-time clinical interventions; 2) utilize teamlets in which MAs will be given the tools to assess reasons for non-adherence and deliver tailored health coaching in a pragmatic, scalable way; and 3) incorporate user centered design principles to maximize incorporation of the intervention into both PCP and MA workflows. The proposed project is significant because it is expected to provide a scalable implementation model that utilizes linked EHR-pharmacy fill data, clinical decision support, and teamlets to improve anti-hypertensive medication adherence. If shown to be successful, this multicomponent, clinic-based intervention can be scaled to ultimately improve cardiovascular outcomes for millions of patients with hypertension.