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.

Grant Number: 5R01HL156355-05
NIH Institute/Center: NIH
Principal Investigator: Saul Blecker