Chronic Diseases

Small Business Innovation Research

In 2018, Impactivo received a Small Business Innovation Research (SBIR) Phase I award from the National Science Foundation (NSF) to work on strategies to significantly reduce primary care physician shortages and improve the quality of care for low-income patients in the United States.  After successfully completing Phase I, Impactivo was awarded a Phase II NSF SBIR grant in May 2020 which will support the further development of the project.  

The objectives of the SBIR Phase II grant are the following:

  • Establish the feasibility of interfacing SMART PCMH with at least two different EHR software solutions in a production environment.
  • Use machine learning (ML) and artificial intelligence (AI) to design a statistical relevance model for EHR and SDOH patient data to identify patients at risk of negative health outcomes
  • Promote reliability in the clinical data used to assign patients to risk levels, make decisions with regards to patient workflows, measure care team effectiveness, and monitor patient outcomes
  • Use ML and AI, including user preferences and patient outcomes, to refine patient workflow assignment system algorithms
  • Develop a Learning Management System using a content recommendation algorithm to provide support to medical staff and patients with just-in-time training and information

Well-implemented patient-centered, team-based care has the potential to significantly reduce physician shortages and the burden of chronic disease, which disproportionately affects low-income communities. However, efforts to move and sustain FQHCs participation in this model have had limited success, with only 66% attaining patient-centered medical home (PCMH) recognition in 2016. Various public initiatives, including the Health Resources and Service Administration (HRSA) Quality Improvement Award and Medicare Access and CHIP Reauthorization Act (MACRA), are providing additional financial incentives to move primary care practices towards PCMH Recognition. Nevertheless, current approaches to practice transformation are cumbersome and difficult to sustain.

This project seeks to disrupt continued health professional education at FQHCs by assessing the feasibility of developing a tool that leverages electronic health record data to identify gaps in patient-centered, team-based care for patients and deploys asynchronous individualized e-Learning support to each member of the care team based on their needs and performance.

Contact us if you would like more information about this and other research opportunities with Impactivo.

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