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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, PhD; Zahra Ladak-Merchant, BDS MPH; David Bates, MD MS; Gilad Kuperman, MD PhD; Eric Poon, MD MPH - PowerPoint PPT Presentation
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Slide 1
Impact of an Automated Test Impact of an Automated Test Results Management System Results Management System on Patients’ Satisfaction of on Patients’ Satisfaction of
Test Result CommunicationTest Result Communication
Michael Matheny, MD MS; Tejal Gandhi, MD MPH;Michael Matheny, MD MS; Tejal Gandhi, MD MPH;John Orav, PhD; Zahra Ladak-Merchant, BDS MPH;John Orav, PhD; Zahra Ladak-Merchant, BDS MPH;
David Bates, MD MS; Gilad Kuperman, MD PhD;David Bates, MD MS; Gilad Kuperman, MD PhD;Eric Poon, MD MPHEric Poon, MD MPH
Brigham & Women’s Hospital, Boston, MABrigham & Women’s Hospital, Boston, MA
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Slide 2
BackgroundBackgroundTest Result CommunicationTest Result Communication
Test result communication between patients and Test result communication between patients and physicians is a critical part of the diagnostic and physicians is a critical part of the diagnostic and therapeutic processtherapeutic process
However, follow-up of test results in the primary However, follow-up of test results in the primary care setting is often challenging:care setting is often challenging:
– High volume of test resultsHigh volume of test results– Test results arrive when physician not focused on the Test results arrive when physician not focused on the
patientpatient– Lack of systems to ensure reliability and efficiencyLack of systems to ensure reliability and efficiency
Causes missed and delayed follow-up of normal Causes missed and delayed follow-up of normal and abnormal test resultsand abnormal test results
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Slide 3
BackgroundBackgroundPatient SatisfactionPatient Satisfaction
These problems reduce patient satisfaction These problems reduce patient satisfaction with their medical care, and impair future with their medical care, and impair future patient-physician interactionspatient-physician interactions
Improving patient satisfaction has been Improving patient satisfaction has been identified as one of the most important issues identified as one of the most important issues currently facing healthcarecurrently facing healthcare
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Slide 4
ObjectiveObjective
To evaluate the impact of an EHR-imbedded To evaluate the impact of an EHR-imbedded
automated test results notification system on automated test results notification system on patient satisfaction of test results patient satisfaction of test results communicationcommunication
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Slide 5
MethodsMethodsStudy SettingStudy Setting
Partners HealthCare SystemPartners HealthCare System– Brigham & Women’s HospitalBrigham & Women’s Hospital– Massachusetts General HospitalMassachusetts General Hospital– Faulkner HospitalFaulkner Hospital– McLean HospitalMcLean Hospital– Newton-Wellesley HospitalNewton-Wellesley Hospital– Free Standing Outpatient ClinicsFree Standing Outpatient Clinics
Longitudinal Medical Record (LMR)Longitudinal Medical Record (LMR)– Released July 2000Released July 2000– SchedulingScheduling– Medication listsMedication lists– Problem listsProblem lists– Health maintenance recordHealth maintenance record– Clinic notes (free form & templates)Clinic notes (free form & templates)
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MethodsMethodsStudy SettingStudy Setting
Baseline state of test results managementBaseline state of test results management
– Test results were embedded directly into the Test results were embedded directly into the patients’ electronic health recordpatients’ electronic health record
– No automated test results trackingNo automated test results tracking
– All test results were mailed to the physician’s All test results were mailed to the physician’s clinic officeclinic office
– Physicians were paged directly for critical resultsPhysicians were paged directly for critical results
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MethodsMethodsInterventionIntervention
Results Manager - an electronic test results Results Manager - an electronic test results management system embedded into the management system embedded into the LMRLMR
– Features:Features:• Tracks and displays all test results associated with an Tracks and displays all test results associated with an
ordering physicianordering physician• Prioritizes by degree of test result abnormalityPrioritizes by degree of test result abnormality• Facilitates review of test results in context of patient’s Facilitates review of test results in context of patient’s
historyhistory• Generates test result lettersGenerates test result letters• Allows clinicians to set reminders for future testingAllows clinicians to set reminders for future testing
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Slide 8
MethodsMethodsResults Manager Summary ScreenResults Manager Summary Screen
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Slide 9
MethodsMethodsResults Manager Letter Generation ScreenResults Manager Letter Generation Screen
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MethodsMethodsStudy DesignStudy Design
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MethodsMethodsRandomizationRandomization
Rolling implementation of Results Manager for Rolling implementation of Results Manager for participating clinics was completed by March, 2004participating clinics was completed by March, 2004
Stratified randomization of 26 primary care clinics Stratified randomization of 26 primary care clinics based on 3 characteristics:based on 3 characteristics:
– BWH (13) vs. MGH (7) hospital affiliationBWH (13) vs. MGH (7) hospital affiliation• 6 were free-standing6 were free-standing
– Academic (16) vs. Community setting (10)Academic (16) vs. Community setting (10)
– Low (12) vs. High (14) average patient socioeconomic Low (12) vs. High (14) average patient socioeconomic statusstatus
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Slide 12
MethodsMethodsStudy CriteriaStudy Criteria
Inclusion Criteria Inclusion Criteria – All patients in participating clinics who had any of All patients in participating clinics who had any of
the following tests:the following tests:• ChemistryChemistry• HematologyHematology• PathologyPathology• MicrobiologyMicrobiology• RadiologyRadiology
Exclusion CriteriaExclusion Criteria– Primary care physician determined that patient Primary care physician determined that patient
should not be contactedshould not be contacted
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Slide 13
MethodsMethodsSurveySurvey
Outcomes were measured on a dichotomized Likert Outcomes were measured on a dichotomized Likert scalescale
Primary Outcome MeasurePrimary Outcome Measure– Overall satisfaction with test result communicationOverall satisfaction with test result communication
Secondary Outcome MeasuresSecondary Outcome Measures– Satisfaction with PCP listening skillsSatisfaction with PCP listening skills– Satisfaction with information given about treatment and Satisfaction with information given about treatment and
conditioncondition– Satisfaction with general PCP communicationSatisfaction with general PCP communication– Meeting of expectation of method of test result Meeting of expectation of method of test result
communicationcommunication
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MethodsMethodsSecondary Outcome MeasureSecondary Outcome Measure
Whether a patient’s expectations were met by the Whether a patient’s expectations were met by the method of test result communication was method of test result communication was determined by:determined by:
– Test result type: normal / abnormalTest result type: normal / abnormal• Defined as requiring follow-up or a management plan changeDefined as requiring follow-up or a management plan change
– Method of test result receiptMethod of test result receipt
– Patient’s expected delivery method for testPatient’s expected delivery method for test
– Hierarchy of test result communicationHierarchy of test result communication• Same Visit > Telephone > Letter > Email > Next Visit > NeverSame Visit > Telephone > Letter > Email > Next Visit > Never• If receipt was by a more desired method, it was countedIf receipt was by a more desired method, it was counted
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Slide 15
MethodsMethodsData AnalysisData Analysis
Multivariate logistic regression modelsMultivariate logistic regression models
– Generalized estimating equations (SAS 9.1)Generalized estimating equations (SAS 9.1)– adjusted for patient age, gender, race, and adjusted for patient age, gender, race, and
insurance statusinsurance status– Clustered by primary care physicianClustered by primary care physician
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Slide 16
Results Results DemographicsDemographics
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
Patient Race (%)
White 65.0 66.3 0.791 65.9 65.3 0.929
Black 20.6 17.6 0.394 19.1 19.1 1.000
Other 14.4 16.1 0.642 14.9 15.7 0.816
Patient Insurance (%)
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
Totals 291 279 313 257
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Slide 17
ResultsResultsSurvey AdministrationSurvey Administration
1531 patients were called at least once1531 patients were called at least once
– 706 did not answer706 did not answer– 20 had incorrect information20 had incorrect information– 35 had numbers that were out of service35 had numbers that were out of service
770 patients were successfully contacted770 patients were successfully contacted
– 128 refused128 refused– 8 had poor mentation or were too ill (self-report)8 had poor mentation or were too ill (self-report)– 64 requested callback but were unavailable for future 64 requested callback but were unavailable for future
contactcontact
570 successfully administered surveys570 successfully administered surveys– Response Rates: 37% / 74%Response Rates: 37% / 74%
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Results Results Responders vs. Non-Responders After ContactResponders vs. Non-Responders After Contact
Responders Non-Responders P
Patient Age (Years) 57.4 58.7 0.304
Patient Sex (% Female) 399 (70.0%) 126 (63.0%) 0.078
Patient Race
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
Patient Insurance
Commercial 257 (45.1%) 84 (42.0%) 0.458
Medicare/Medicaid 307 (53.9%) 112 (56.0%) 0.621
Self Pay 6 (1.1%) 4 (2.0%) 0.297
Totals 570 200
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Slide 19
Results Results OutcomesOutcomes
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
Total Number 148 138 154 121
** Interaction term of Post & InterventionInteraction term of Post & Intervention
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Slide 20
Results Results OutcomesOutcomes
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 & InterventionInteraction term of Post & Intervention
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Slide 21
Results Results OutcomesOutcomes
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 & InterventionInteraction term of Post & Intervention
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Slide 22
DiscussionDiscussion
Patient Satisfaction with Overall Test Result Patient Satisfaction with Overall Test Result CommutationCommutation OR ~4OR ~4
Patient Satisfaction with Diagnosis & Patient Satisfaction with Diagnosis & Treatment Information Treatment Information OR ~4.5OR ~4.5
Meeting of Patient Expectations of Test Meeting of Patient Expectations of Test Result Receipt MethodResult Receipt Method OR ~3OR ~3
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Slide 23
DiscussionDiscussion
Intervention included a number of potential Intervention included a number of potential workflow improvementsworkflow improvements
– Tracking of test results ordered by provider, and Tracking of test results ordered by provider, and concise summary page for managementconcise summary page for management
– Template-based results letter generatorTemplate-based results letter generator• Can imbed actual test results into letterCan imbed actual test results into letter• Improve patient-friendly interpretations of resultsImprove patient-friendly interpretations of results
– One-click patient contact informationOne-click patient contact information
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Slide 24
DiscussionDiscussion
Improvements in Secondary Outcomes Improvements in Secondary Outcomes suggested that they were significant factors suggested that they were significant factors in improving overall patient satisfactionin improving overall patient satisfaction
– Method of Test Results Delivery More Commonly Method of Test Results Delivery More Commonly Met Patient ExpectationsMet Patient Expectations
– Patients were More Satisfied with Discussion Patients were More Satisfied with Discussion regarding Diagnosis & Treatment relating to test regarding Diagnosis & Treatment relating to test resultsresults
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Slide 25
DiscussionDiscussionLimitationsLimitations
GeneralizibilityGeneralizibility
– Tool custom built within an internally developed Tool custom built within an internally developed outpatient electronic health record (LMR)outpatient electronic health record (LMR)
– Commercial vendors have been quick to adopt Commercial vendors have been quick to adopt successful new functionalitysuccessful new functionality
– Number and Variety of clinics should mitigate Number and Variety of clinics should mitigate this problem as wellthis problem as well
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Slide 26
DiscussionDiscussionLimitationsLimitations
Survey Response RateSurvey Response Rate
– Bias introduced by method of patient contact:Bias introduced by method of patient contact:
• Distrust of Medical System or SurveyorDistrust of Medical System or Surveyor
• Poor Health, Mentation, or HearingPoor Health, Mentation, or Hearing
• SES Bias from Lack of Telephone ServiceSES Bias from Lack of Telephone Service
• Reduced by the same bias effect across all armsReduced by the same bias effect across all arms
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Slide 27
ConclusionsConclusions
An automated management system that An automated management system that provides centralized test result tracking and provides centralized test result tracking and facilitates contact with patients improved facilitates contact with patients improved overall patient satisfaction with overall patient satisfaction with communication of test resultscommunication of test results
Increased patient satisfaction with the Increased patient satisfaction with the method of test results delivery and method of test results delivery and discussion of treatments/conditions suggest discussion of treatments/conditions suggest that the improvements in overall satisfaction that the improvements in overall satisfaction found are related to these factorsfound are related to these factors
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Slide 28
AcknowledgementsAcknowledgements
Co-AuthorsCo-Authors– Tejal K. Gandhi, MD MPHTejal K. Gandhi, MD MPH– John Orav, PhDJohn Orav, PhD– Zahra Ladak-Merchant, BDS MPHZahra Ladak-Merchant, BDS MPH– David W. Bates, MD MSDavid W. Bates, MD MS– Gilad J. Kuperman, MD PhDGilad J. Kuperman, MD PhD– Eric G. Poon, MD MPHEric G. Poon, MD MPH
FundingFunding– AHRQ U18-HS-11046AHRQ U18-HS-11046– NLM T15-LM-07092NLM T15-LM-07092
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Slide 29
Michael Matheny, MD MS Michael Matheny, MD MS
[email protected]@dsg.harvard.edu Brigham & Women’s HospitalBrigham & Women’s Hospital
Thorn 309Thorn 30975 Francis Street75 Francis Street
Boston, MA 02115Boston, MA 02115
The EndThe End