Michael Matheny, MD MS; Tejal Gandhi, MD MPH; John Orav, PhD; Zahra Ladak-Merchant, BDS MPH;

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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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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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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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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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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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MethodsMethodsResults Manager Summary ScreenResults Manager Summary Screen

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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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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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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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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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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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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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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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% % % %


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


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% % % %


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


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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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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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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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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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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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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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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

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Michael Matheny, MD MS; Tejal Gandhi, MD MPH; John Orav, PhD; Zahra Ladak-Merchant, BDS MPH;

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