© 2003 By Default! A Free sample background from Slide 1 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 Brigham & Women’s Hospital, Boston, MA

© 2003 By Default! A Free sample background from Slide 2 Background Test Result Communication Test result communication between patients and physicians is a critical part of the diagnostic and therapeutic process Test result communication between patients and physicians is a critical part of the diagnostic and therapeutic process However, follow-up of test results in the primary care setting is often challenging: 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 Causes missed and delayed follow-up of normal and abnormal test results Causes missed and delayed follow-up of normal and abnormal test results

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

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

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

© 2003 By Default! A Free sample background from Slide 6 Methods Study Setting Baseline state of test results management 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

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

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

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

© 2003 By Default! A Free sample background from Slide 10 Methods Study Design

© 2003 By Default! A Free sample background from Slide 11 Methods Randomization Rolling implementation of Results Manager for participating clinics was completed by March, 2004 Rolling implementation of Results Manager for participating clinics was completed by March, 2004 Stratified randomization of 26 primary care clinics based on 3 characteristics: Stratified randomization of 26 primary care clinics based on 3 characteristics: –BWH (13) vs. MGH (7) hospital affiliation 6 were free-standing6 were free-standing –Academic (16) vs. Community setting (10) –Low (12) vs. High (14) average patient socioeconomic status

© 2003 By Default! A Free sample background from Slide 12 Methods Study Criteria Inclusion Criteria Inclusion Criteria –All patients in participating clinics who had any of the following tests: ChemistryChemistry HematologyHematology PathologyPathology MicrobiologyMicrobiology RadiologyRadiology Exclusion Criteria Exclusion Criteria –Primary care physician determined that patient should not be contacted

© 2003 By Default! A Free sample background from Slide 13 Methods Survey Outcomes were measured on a dichotomized Likert scale Outcomes were measured on a dichotomized Likert scale Primary Outcome Measure Primary Outcome Measure –Overall satisfaction with test result communication Secondary Outcome Measures Secondary Outcome Measures –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

© 2003 By Default! A Free sample background from Slide 14 Methods Secondary Outcome Measure Whether a patient’s expectations were met by the method of test result communication was determined by: 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 changeDefined 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 > > Next Visit > NeverSame Visit > Telephone > Letter > > Next Visit > Never If receipt was by a more desired method, it was countedIf receipt was by a more desired method, it was counted

© 2003 By Default! A Free sample background from Slide 15 Methods Data Analysis Multivariate logistic regression models Multivariate logistic regression models –Generalized estimating equations (SAS 9.1) –adjusted for patient age, gender, race, and insurance status –Clustered by primary care physician

© 2003 By Default! A Free sample background from Slide 16 Results Demographics PrePostpControlInterventionp Patient Age (Mean Years) Patient Sex (% Female) Patient Race (%) White Black Other Patient Insurance (%) Commercial Medicare/Medicaid Self Pay Totals

© 2003 By Default! A Free sample background from Slide 17 Results Survey Administration 1531 patients were called at least once 1531 patients were called at least once –706 did not answer –20 had incorrect information –35 had numbers that were out of service 770 patients were successfully contacted 770 patients were successfully contacted –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 570 successfully administered surveys –Response Rates: 37% / 74%

© 2003 By Default! A Free sample background from Slide 18 Results Responders vs. Non-Responders After Contact RespondersNon-RespondersP Patient Age (Years) Patient Sex (% Female)399 (70.0%)126 (63.0%)0.078 Patient Race White374 (65.6%)120 (60%)0.170 Black109 (19.1%)45 (22.5%)0.306 Other87 (15.3%)35 (17.5%)0.500 Patient Insurance Commercial257 (45.1%)84 (42.0%)0.458 Medicare/Medicaid307 (53.9%)112 (56.0%)0.621 Self Pay6 (1.1%)4 (2.0%)0.297 Totals570200

© 2003 By Default! A Free sample background from Slide 19 Results Outcomes Pre/CPre/IPost/CPost/IOR (95% CI)p* %% Satisfied with Test Result Communication ( )0.012 Total Number *Interaction term of Post & Intervention

© 2003 By Default! A Free sample background from Slide 20 Results Outcomes Pre/CPre/IPost/CPost/IOR (95% CI)p* %% Satisfied with Test Result Communication ( )0.012 Expectation Met Regarding Test Result Communication Method ( )0.001 Satisfied with Information Given about Treatment & Condition ( )0.034 Total Number *Interaction term of Post & Intervention

© 2003 By Default! A Free sample background from Slide 21 Results Outcomes Pre/CPre/IPost/CPost/IOR (95% CI)p* %% Satisfied with Test Result Communication ( )0.012 Expectation Met Regarding Test Result Communication Method ( )0.001 Satisfied with Information Given about Treatment & Condition ( )0.034 Satisfied with PCP Listening Skills ( )0.501 Satisfied with General PCP Communication ( )0.367 Total Number *Interaction term of Post & Intervention

© 2003 By Default! A Free sample background from Slide 22 Discussion Patient Satisfaction with Overall Test Result CommutationOR ~4 Patient Satisfaction with Overall Test Result CommutationOR ~4 Patient Satisfaction with Diagnosis & Treatment Information OR ~4.5 Patient Satisfaction with Diagnosis & Treatment Information OR ~4.5 Meeting of Patient Expectations of Test Result Receipt MethodOR ~3 Meeting of Patient Expectations of Test Result Receipt MethodOR ~3

© 2003 By Default! A Free sample background from Slide 23 Discussion Intervention included a number of potential workflow improvements 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 letterCan imbed actual test results into letter Improve patient-friendly interpretations of resultsImprove patient-friendly interpretations of results –One-click patient contact information

© 2003 By Default! A Free sample background from Slide 24 Discussion Improvements in Secondary Outcomes suggested that they were significant factors in improving overall patient satisfaction 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

© 2003 By Default! A Free sample background from Slide 25 Discussion Limitations Generalizibility 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

© 2003 By Default! A Free sample background from Slide 26 Discussion Limitations Survey Response Rate Survey Response Rate –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

© 2003 By Default! A Free sample background from Slide 27 Conclusions An automated management system that provides centralized test result tracking and facilitates contact with patients improved overall patient satisfaction with communication of test results An automated management system that provides centralized test result tracking and facilitates contact with patients improved overall patient satisfaction with communication of test results 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 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

© 2003 By Default! A Free sample background from Slide 28 Acknowledgements Co-Authors Co-Authors –Tejal K. Gandhi, MD MPH –John Orav, PhD –Zahra Ladak-Merchant, BDS MPH –David W. Bates, MD MS –Gilad J. Kuperman, MD PhD –Eric G. Poon, MD MPH Funding Funding –AHRQ U18-HS –NLM T15-LM-07092

© 2003 By Default! A Free sample background from Slide 29 Michael Matheny, MD MS Brigham & Women’s Hospital Thorn Francis Street Boston, MA Michael Matheny, MD MS Brigham & Women’s Hospital Thorn Francis Street Boston, MA The End