Paper of the Month: If you build it, will they come?

This month's featured paper is from Melinda Davis Ph.D. It is titled, "A Qualitative Study of Rural Primary Care Clinician Views on Remote Monitoring Technologies." The paper was published in The Journal of Rural Health.

Collaborating with Rural Primary Care Clinician Stakeholders to Improve Adoption of Remote Monitoring Technologies

paper-authors-73013July 30, 2013

Studies demonstrate that rural populations tend to be older and in poorer health than their urban counterparts. In Oregon, like in many rural communities, this is because rural patients tend to have access to fewer health care providers, frequently receive care in facilities with a limited scope of service, have longer distances to travel, higher costs associated with accessing health care, and experience disparities in the receipt of medical services.

In recent years, aging of the population has greatly contributed to development of new market niches for e-health technologies to support healthy aging, control rising health care costs, and circumvent the limited health workforce availability. Use of remote monitoring technology (RMT), one form of e-health technology, is touted as a way to facilitate proactive patient management and alleviate barriers to the receipt of medical care. Patients and caregivers in rural communities may greatly benefit from these technological advancements. However, scarcity in technical infrastructure and expertise as well as limited financial resources have made adoption of health information technologies (HIT) especially challenging for rural clinicians.

Melinda Davis, Ph.D., and team of multidisciplinary researchers from Oregon Health & Science University (OHSU), Intel Corporation, and Portland State University are investigating the use of RMT and how it may reduce care access barriers, enable early detection of disease onset, and facilitate proactive patient care. The goal of their recent investigation was to better understand rural primary care clinician interest in RMTs and to identify the resources necessary to incorporate these emerging technologies into routine practice. The team published their findings in The Journal of Rural Health, in a paper titled, A Qualitative Study of Rural Primary Care Clinician Views on Remote Monitoring Technologies.

Currey73013"RMTs may improve the quality of care, reduce access barriers, and help control medical costs," said Melinda Davis, Ph.D., lead author of the study and a research assistant professor in the department of family medicine. "However, despite the role of primary care clinicians as key users of RMTs, few studies explore their views toward these technologies or engage them as partners in the development or implementation of these tools. Our study is a first step in addressing this critical gap by exploring rural primary care clinician interest in and the resources necessary to incorporate RMTs into routine practice."

Working in collaboration with the Oregon Center for Aging and Technology (ORCATECH), the team conducted 15 in-depth interviews with rural primary care clinician members of the Oregon Rural Practice-based Research Network (ORPRN) from November 2011 to April 2012. The team used thematic analysis to identify emergent themes and a cross-case comparative analysis to explore variation by participant and practice characteristics.

The investigators asked questions about participant's naïve level of knowledge and interest in RMTs, then provided an overview of common technologies – such as those for chronic disease management or supporting aging in place. "We wanted to know which RMTs were of most interest, which resources were necessary to incorporate the technologies into practice, and how clinicians might utilize the data to inform patient care," said Dr. Davis.

DeSordi73013The team's work showed that clinicians in rural communities expressed interest in RMTs most relevant to their clinical practice, such as in supporting chronic disease management, noting the potential benefit to patients of all ages, not just elders.

"Clinicians expressed concern about the quantity of data, patient motivation to utilize equipment, and potential changes to the patient-clinician encounter," said Dr. Davis. "This is an important discovery because even if a technology demonstrates promise for enhancing patient care, implementation requires attention to the local context – for example the needs, resources, and concerns of the target users – in this case primary care clinicians."

The study also showed that direct transfer of RMT data into the clinic's electronic health record (EHR), summary data availability in multiple formats, and preliminary review by ancillary staff could facilitate implementation. In rural as well as urban communities, this would be an advantage because it would facilitate rapid review of critical information and tailored presentation depending on the target audience (e.g., patients, caregivers). "Participants wanted systems in place so that the time spent reviewing the data did not overshadow the time actually spent with the patient," said Dr. Davis.

Although participants acknowledged the potential system-level benefits of using RMTs, some noted adoption would be difficult in primary care without payment reform. "Despite the potential benefit of using RMTs and concurrent health reform efforts supporting proactive patient management, many clinicians still rely on face-to-face encounters to generate revenue and they may not be compensated for helping patients make health behavior changes," said Dr. Davis.

Jeff Kaye PhotoDr. Davis pointed out that adoption of RMTs by rural primary care clinicians may be influenced by its purpose and functionality. "But these and other barriers can be overcome by giving adequate attention to the clinical relevance of the RMT and by supporting the technological and staffing infrastructure needed to review and respond to the data."

The team's results are important because they show how rural clinicians view RMTs and provide an informed foundation for designing subsequent interventions. The team's approach highlights the need to engage stakeholders (e.g., primary care clinicians, health department staff, patients, or other community members) early on as collaborative partners in the development, implementation, and evaluation of interventions. Dr. Davis commented, "Researchers who choose not to engage end users may end up developing products and interventions that may not be valued or feasible to implement in the local environment. Partnering with organizations that already have staff embedded as part of a local community, such as the practice facilitators in the Oregon Rural Practice-based Research Network, can help facilitate research partnerships and ensure the study methods are suited to the local context."

boise82013In reviewing this study, associate dean for clinical science Eric Orwoll, M.D., a professor in the department of medicine, noted, "This seemingly modest report is fascinating and important for several reasons. First, it highlights the emerging importance of research in health care delivery, and the challenges of providing medical care in rural areas in an increasingly electronic era. Second, it takes advantage of one of the burgeoning research strengths at OHSU – community-based investigation – and particularly the Oregon Rural Practice Based Research Network, which is just one of the several, strong platforms that are available for this sort of research. Finally, the research team represents an interesting collaboration that will be increasingly important and productive as we continue to expand in this area – notably OHSU, Portland State University, and Intel."

Moving forward, Dr. Davis said the team plans to continue partnering with clinicians and community members to study the impact of RMT implementation on patient quality of care and provider satisfaction. One recently funded ORCATECH study (co-PIs Tamara Hayes, Ph.D., and Jeffrey Kaye, M.D.) is a collaboration with retirement community administrators and staff to explore the potential for RMTs to facilitate care transitions. Dr. Davis said, "It is critical to build bridges between the great ideas that come from academia and the needs of our on-the-ground partners who will ultimately decide whether or not to use these new technologies to enhance patient care."


Pictured from top down:

1. (L to R) Lyle Fagnan, M.D.; Melinda Davis, Ph.D.; Sonya Howk, MPA, HA; Nancy Vuckovic, Ph.D.

2. Jillian Currey, MPH

3. Molly DeSordi

4. Jeffrey Kaye, M.D.

5. Linda Boise, Ph.D.

Paper Authors

jrh73013Melinda Davis Ph.D., Jillian Currey MPH, Sonya Howk MPA:HA, Molly DeSordi, Linda Boise Ph.D., Lyle Fagnan M.D., Nancy Vuckovic Ph.D.


*See affiliations below


Melinda Davis, Ph.D. and Lyle Fagnan, M.D.
  • Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR.
  • Department of Family Medicine, Oregon Health & Science University, Portland, OR.
Sonya Howk, MPA:HA, Jillian Currey, MPH, and Molly DeSordi
  • Oregon Rural Practice-based Research Network (ORPRN)
Nancy Vuckovic, Ph.D.
  • Intel Corporation, Hillsboro, OR.
Jeffrey Kaye, M.D.
  • Oregon Center for Aging & Technology, Oregon Health & Science University, Portland, OR.
  • Department of Neurology, Oregon Health & Science University, Portland, OR.
  • Department of Neurology, Portland VA Medical Center, Portland, OR.
Michele Freeman, MPH
  • VA Evidence-based Synthesis Program, Portland VA Medical Center, Portland, OR.
David Buckley, M.D., MPH
  • Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR.
  • Department of Family Medicine, Oregon Health & Science University, Portland, OR.
  • Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR.
  • Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR.
Linda Boise, Ph.D.
  • Institute on Aging, School of Community Health, Portland State University, Portland, Oregon
  • Layton Aging & Alzheimer’s Disease Center, Oregon Health & Science University, Portland, Oregon

About the Paper of the Month

The School of Medicine newsletter spotlights a recently published faculty research paper in each issue. The goals are to highlight the great research happening at OHSU and to share this information across departments, institutes and disciplines. The monthly paper summary is selected by Associate Dean for Basic Science Mary Stenzel-Poore, Ph.D., and Associate Dean for Clinical Science Eric Orwoll, M.D.

More Published Papers

The entire list of OHSU papers published this month is here.