Integrating Community-Based Health Information System with a Patient-Centered Medical Home to Improve Care of Patients with Hypertension: A Longitudinal Observational Study Protocol

Introduction Vertical health delivery models in Pakistan focus on providing episodic, disease-based care. Health care for middle-class communities is largely through a fee-for-service model that ignores preventive care. The growing burden of cardiovascular illnesses requires restructuring of primary health care system allowing well-coordinated efforts between patients and providers. We propose a model of care that integrates a Patient-Centered Medical Home (PCMH) with a Community-Based Health Information System (CBHIS) for bidirectional communication at the patient and community level. This protocol describes the integration and evaluation of the PCMH-CBHIS infrastructure using hypertension (HTN) as a model. Methods This is a population-based, observational, longitudinal study in an urban setting in Pakistan. Through convenience sampling, participants will be enrolled in CBHIS and followed longitudinally over two years for HTN outcomes. A mixed-methods approach will be used to evaluate the process of integrating PCMH with CBHIS. This will involve building partnerships with the community through formal and informal meetings, focus group discussions, and a household health assessment survey. Community members identified with HTN will be linked to PCMH for disease management and skills to improve self-management. A customized electronic medical record system will be developed to link community-level data with family and patient-level data to track changes in disease burden. The RE-AIM evaluation framework will be used to monitor community and individual-level metrics to guide implementation assessment, the potential for generalization, and the effectiveness of the PCMH in improving health outcomes. Ethics and dissemination plan Ethical clearance was obtained from Ethics Review Committee at Aga Khan University (2022-6723-20985). We plan to present the findings from this research at conferences and publish them in peer-reviewed journals. Additionally, we intend to leverage findings from this research to obtain funds focusing on chronic disease care in similar settings. Article Summary Strengths and limitations of this study The study integrates a comprehensive health assessment survey to assess the disease burden at the community level to guide the prioritization of health services and prevention efforts at the health facility. A mixed methods approach will be used to measure the effectiveness of hypertension management through the proposed model of care. The development of a customized electronic medical record system will allow aligning clinic- and community-based activities. Community members may migrate from the catchment area, limiting the longitudinal assessment of hypertension management. With a patient-driven model, we cannot predict how many community participants would choose the health facility for ongoing care.