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Slide 1 © 2003 By Default! Impact of an Automated Test Results Management System Slide 1 © 2003 By Default! Impact of an Automated Test Results Management System on Patients’ Satisfaction of Test Result Communication Michael Matheny, MD MS; Tejal Gandhi, MD MPH; John Orav, Ph. D; Zahra Ladak-Merchant, BDS MPH; David Bates, MD MS; Gilad Kuperman, MD Ph. D; Eric Poon, MD MPH Brigham & Women’s Hospital, Boston, MA A Free sample background from www. powerpointbackgrounds. com

Slide 2 © 2003 By Default! Background Test Result Communication n Test result communication Slide 2 © 2003 By Default! Background Test Result Communication n Test result communication between patients and physicians is a critical part of the diagnostic and therapeutic process n However, follow-up of test results in the primary care setting is often challenging: – High volume of test results – Test results arrive when physician not focused on the patient – Lack of systems to ensure reliability and efficiency n Causes missed and delayed follow-up of normal and abnormal test results A Free sample background from www. powerpointbackgrounds. com

Slide 3 © 2003 By Default! Background Patient Satisfaction n These problems reduce patient Slide 3 © 2003 By Default! Background Patient Satisfaction n These problems reduce patient satisfaction with their medical care, and impair future patient-physician interactions n Improving patient satisfaction has been identified as one of the most important issues currently facing healthcare A Free sample background from www. powerpointbackgrounds. com

Slide 4 © 2003 By Default! Objective n To evaluate the impact of an Slide 4 © 2003 By Default! Objective n To evaluate the impact of an EHR-imbedded automated test results notification system on patient satisfaction of test results communication A Free sample background from www. powerpointbackgrounds. com

Slide 5 © 2003 By Default! Methods Study Setting n Partners Health. Care System Slide 5 © 2003 By Default! Methods Study Setting n Partners Health. Care System n Longitudinal Medical Record (LMR) – – – Brigham & Women’s Hospital Massachusetts General Hospital Faulkner Hospital Mc. Lean Hospital Newton-Wellesley Hospital Free Standing Outpatient Clinics Released July 2000 Scheduling Medication lists Problem lists Health maintenance record Clinic notes (free form & templates) A Free sample background from www. powerpointbackgrounds. com

Slide 6 © 2003 By Default! Methods Study Setting n Baseline state of test Slide 6 © 2003 By Default! Methods Study Setting n Baseline state of test results management – Test results were embedded directly into the patients’ electronic health record – No automated test results tracking – All test results were mailed to the physician’s clinic office – Physicians were paged directly for critical results A Free sample background from www. powerpointbackgrounds. com

Slide 7 © 2003 By Default! Methods Intervention n Results Manager - an electronic Slide 7 © 2003 By Default! Methods Intervention n Results Manager - an electronic test results management system embedded into the LMR – Features: • Tracks and displays all test results associated with an ordering physician • Prioritizes by degree of test result abnormality • Facilitates review of test results in context of patient’s history • Generates test result letters • Allows clinicians to set reminders for future testing A Free sample background from www. powerpointbackgrounds. com

Slide 8 © 2003 By Default! Methods Results Manager Summary Screen A Free sample Slide 8 © 2003 By Default! Methods Results Manager Summary Screen A Free sample background from www. powerpointbackgrounds. com

Slide 9 © 2003 By Default! Methods Results Manager Letter Generation Screen A Free Slide 9 © 2003 By Default! Methods Results Manager Letter Generation Screen A Free sample background from www. powerpointbackgrounds. com

Slide 10 © 2003 By Default! Methods Study Design A Free sample background from Slide 10 © 2003 By Default! Methods Study Design A Free sample background from www. powerpointbackgrounds. com

Slide 11 © 2003 By Default! Methods Randomization n Rolling implementation of Results Manager Slide 11 © 2003 By Default! Methods Randomization n Rolling implementation of Results Manager for participating clinics was completed by March, 2004 n Stratified randomization of 26 primary care clinics based on 3 characteristics: – BWH (13) vs. MGH (7) hospital affiliation • 6 were free-standing – Academic (16) vs. Community setting (10) – Low (12) vs. High (14) average patient socioeconomic status A Free sample background from www. powerpointbackgrounds. com

Slide 12 © 2003 By Default! Methods Study Criteria n Inclusion Criteria – All Slide 12 © 2003 By Default! Methods Study Criteria n Inclusion Criteria – All patients in participating clinics who had any of the following tests: • • • Chemistry Hematology Pathology Microbiology Radiology n Exclusion Criteria – Primary care physician determined that patient should not be contacted A Free sample background from www. powerpointbackgrounds. com

Slide 13 © 2003 By Default! Methods Survey n Outcomes were measured on a Slide 13 © 2003 By Default! Methods Survey n Outcomes were measured on a dichotomized Likert scale n Primary Outcome Measure n Secondary Outcome Measures – Overall satisfaction with test result communication – Satisfaction with PCP listening skills – Satisfaction with information given about treatment and condition – Satisfaction with general PCP communication – Meeting of expectation of method of test result communication A Free sample background from www. powerpointbackgrounds. com

Slide 14 © 2003 By Default! Methods Secondary Outcome Measure n Whether a patient’s Slide 14 © 2003 By Default! Methods Secondary Outcome Measure n Whether a patient’s expectations were met by the method of test result communication was determined by: – Test result type: normal / abnormal • Defined as requiring follow-up or a management plan change – Method of test result receipt – Patient’s expected delivery method for test – Hierarchy of test result communication • • Same Visit > Telephone > Letter > Email > Next Visit > Never If receipt was by a more desired method, it was counted A Free sample background from www. powerpointbackgrounds. com

Slide 15 © 2003 By Default! Methods Data Analysis n Multivariate logistic regression models Slide 15 © 2003 By Default! Methods Data Analysis n Multivariate logistic regression models – Generalized estimating equations (SAS 9. 1) – adjusted for patient age, gender, race, and insurance status – Clustered by primary care physician A Free sample background from www. powerpointbackgrounds. com

Slide 16 © 2003 By Default! Results Demographics Pre Post p Control Intervention p Slide 16 © 2003 By Default! Results Demographics Pre Post p Control Intervention p Patient Age (Mean Years) 56. 0 55. 0 0. 478 55. 3 55. 7 0. 648 Patient Sex (% Female) 72. 5 67. 4 0. 201 64. 6 76. 3 0. 003 White 65. 0 66. 3 0. 791 65. 9 65. 3 0. 929 Black 20. 6 17. 6 0. 394 19. 1 1. 000 Other 14. 4 16. 1 0. 642 14. 9 15. 7 0. 816 Commercial 39. 9 50. 5 0. 012 48. 4 41. 2 0. 092 Medicare/Medicaid 58. 4 49. 1 0. 029 50. 6 57. 6 0. 109 Self Pay 1. 7 0. 4 0. 217 1. 0 1. 1 1. 000 291 279 313 257 Patient Race (%) Patient Insurance (%) Totals A Free sample background from www. powerpointbackgrounds. com

Slide 17 © 2003 By Default! Results Survey Administration n 1531 patients were called Slide 17 © 2003 By Default! Results Survey Administration n 1531 patients were called at least once – – – n 770 patients were successfully contacted – – – n 706 did not answer 20 had incorrect information 35 had numbers that were out of service 128 refused 8 had poor mentation or were too ill (self-report) 64 requested callback but were unavailable for future contact 570 successfully administered surveys – Response Rates: 37% / 74% A Free sample background from www. powerpointbackgrounds. com

Slide 18 © 2003 By Default! Results Responders vs. Non-Responders After Contact Responders Non-Responders Slide 18 © 2003 By Default! Results Responders vs. Non-Responders After Contact Responders Non-Responders P 57. 4 58. 7 0. 304 399 (70. 0%) 126 (63. 0%) 0. 078 White 374 (65. 6%) 120 (60%) 0. 170 Black 109 (19. 1%) 45 (22. 5%) 0. 306 Other 87 (15. 3%) 35 (17. 5%) 0. 500 Commercial 257 (45. 1%) 84 (42. 0%) 0. 458 Medicare/Medicaid 307 (53. 9%) 112 (56. 0%) 0. 621 6 (1. 1%) 4 (2. 0%) 0. 297 570 200 Patient Age (Years) Patient Sex (% Female) Patient Race Patient Insurance Self Pay Totals A Free sample background from www. powerpointbackgrounds. com

Slide 19 © 2003 By Default! Results Outcomes Pre/C Pre/I Post/C Post/I % % Slide 19 © 2003 By Default! Results Outcomes Pre/C Pre/I Post/C Post/I % % Satisfied with Test Result Communication 90 82 85 93 Total Number 148 138 154 OR (95% CI) p* 3. 97 (1. 35 -11. 7) 0. 012 121 * Interaction term of Post & Intervention A Free sample background from www. powerpointbackgrounds. com

Slide 20 © 2003 By Default! Results Outcomes Pre/C Pre/I Post/C Post/I OR (95% Slide 20 © 2003 By Default! Results Outcomes Pre/C Pre/I Post/C Post/I OR (95% CI) p* % % Satisfied with Test Result Communication 90 82 85 93 3. 97 (1. 35 -11. 7) 0. 012 Expectation Met Regarding Test Result Communication Method 61 48 44 58 2. 91 (1. 53 -5. 54) 0. 001 Satisfied with Information Given about Treatment & Condition 95 87 94 96 4. 76 (1. 12 -20. 1) 0. 034 Total Number 148 138 154 121 * Interaction term of Post & Intervention A Free sample background from www. powerpointbackgrounds. com

Slide 21 © 2003 By Default! Results Outcomes Pre/C Pre/I Post/C Post/I OR (95% Slide 21 © 2003 By Default! Results Outcomes Pre/C Pre/I Post/C Post/I OR (95% CI) p* % % Satisfied with Test Result Communication 90 82 85 93 3. 97 (1. 35 -11. 7) 0. 012 Expectation Met Regarding Test Result Communication Method 61 48 44 58 2. 91 (1. 53 -5. 54) 0. 001 Satisfied with Information Given about Treatment & Condition 95 87 94 96 4. 76 (1. 12 -20. 1) 0. 034 Satisfied with PCP Listening Skills 99 93 99 98 2. 90 (0. 13 -64. 9) 0. 501 Satisfied with General PCP Communication 96 91 97 96 2. 12 (0. 41 -10. 9) 0. 367 Total Number 148 138 154 121 * Interaction term of Post & Intervention A Free sample background from www. powerpointbackgrounds. com

Slide 22 © 2003 By Default! Discussion n Patient Satisfaction with Overall Test Result Slide 22 © 2003 By Default! Discussion n Patient Satisfaction with Overall Test Result Commutation OR ~4 n Patient Satisfaction with Diagnosis & Treatment Information OR ~4. 5 n Meeting of Patient Expectations of Test Result Receipt Method A Free sample background from www. powerpointbackgrounds. com OR ~3

Slide 23 © 2003 By Default! Discussion n Intervention included a number of potential Slide 23 © 2003 By Default! Discussion n Intervention included a number of potential workflow improvements – Tracking of test results ordered by provider, and concise summary page for management – Template-based results letter generator • Can imbed actual test results into letter • Improve patient-friendly interpretations of results – One-click patient contact information A Free sample background from www. powerpointbackgrounds. com

Slide 24 © 2003 By Default! Discussion n Improvements in Secondary Outcomes suggested that Slide 24 © 2003 By Default! Discussion n Improvements in Secondary Outcomes suggested that they were significant factors in improving overall patient satisfaction – Method of Test Results Delivery More Commonly Met Patient Expectations – Patients were More Satisfied with Discussion regarding Diagnosis & Treatment relating to test results A Free sample background from www. powerpointbackgrounds. com

Slide 25 © 2003 By Default! Discussion Limitations n Generalizibility – Tool custom built Slide 25 © 2003 By Default! Discussion Limitations n Generalizibility – Tool custom built within an internally developed outpatient electronic health record (LMR) – Commercial vendors have been quick to adopt successful new functionality – Number and Variety of clinics should mitigate this problem as well A Free sample background from www. powerpointbackgrounds. com

Slide 26 © 2003 By Default! Discussion Limitations n Survey Response Rate – Bias Slide 26 © 2003 By Default! Discussion Limitations n Survey Response Rate – Bias introduced by method of patient contact: • Distrust of Medical System or Surveyor • Poor Health, Mentation, or Hearing • SES Bias from Lack of Telephone Service • Reduced by the same bias effect across all arms A Free sample background from www. powerpointbackgrounds. com

Slide 27 © 2003 By Default! Conclusions n An automated management system that provides Slide 27 © 2003 By Default! Conclusions n An automated management system that provides centralized test result tracking and facilitates contact with patients improved overall patient satisfaction with communication of test results n Increased patient satisfaction with the method of test results delivery and discussion of treatments/conditions suggest that the improvements in overall satisfaction found are related to these factors A Free sample background from www. powerpointbackgrounds. com

Slide 28 © 2003 By Default! Acknowledgements n Co-Authors – Tejal K. Gandhi, MD Slide 28 © 2003 By Default! Acknowledgements n Co-Authors – Tejal K. Gandhi, MD MPH – John Orav, Ph. D – Zahra Ladak-Merchant, BDS MPH – David W. Bates, MD MS – Gilad J. Kuperman, MD Ph. D – Eric G. Poon, MD MPH n Funding – AHRQ U 18 -HS-11046 – NLM T 15 -LM-07092 A Free sample background from www. powerpointbackgrounds. com

Slide 29 © 2003 By Default! The End Michael Matheny, MD MS mmatheny@dsg. harvard. Slide 29 © 2003 By Default! The End Michael Matheny, MD MS [email protected] harvard. edu Brigham & Women’s Hospital Thorn 309 75 Francis Street Boston, MA 02115 A Free sample background from www. powerpointbackgrounds. com