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PPT - Implementation of an Electronic Test Result Management ...

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  • I’d like to thank Innovations in Practice Management group for inviting us to share with you the journey we at Partners Healthcare have been taking for the past few years implementing an electronic test result management system and some of the lessons we’ve learned along the way.
  • I think many of you who practice medicine in today’s challenging environment would agree that follow-up of test results in the primary care is by no means an easy task. First, there is a high volume of testing done. Our prior studies shows that a full time primary care physician on weekly basis, might have to review up to 800 chemistry and hematology data points, 12 pathology reports and 40 radiology reports. In most cases, these results arrive at various time points after the clinical encounter, when the patient is no longer physically in the practice and the physicians’ mind is focused on other patients’. While some practices have developed systems and processes to handle this steady stream of patient data, research done by various group suggest that many physicians do not have reliable systems in place to efficiently manage all the tasks associated with test result follow-up.
    This lack of a coherent strategy for this important task in outpatient medicine often leads to dissatisfaction from both patients and providers alike. Further more, delays in the review and follow-up of test results might lead to adverse clinical outcomes and compromise patient safety.
  • It was in this context that our various stakeholders, including clinicians, risk manager and health services researchers, came together to leverage the available information technology infrastructure to address this quality and patient safety issue.
  • The literature also offers a few examples of the extent of the problem.
    In the Ambulatory Quality Improvement Project, Dr. Haas documented that 31% of women with abnormal mammograms do not receive care consistent with established guidelines.
    In another study, 39% of patients with abnormal TSH at the Brigham do not get the appropriate follow-up within 60 days. National data also shows that about 1/3 of patients with abnormal pap smear are lost to follow-up.
    While there may be several reasons why follow-up of these results many not 100%, the significant quality gap documented by these studies does show that there is a problem to be addressed
  • And just in case anybody is not convinced why we need to improve on the result management systems, we tried to measure the level of pain experienced by clinicians as they manage results.
    Looking at a cohort of patients whose PCPs are in several BWH clinics, we determined that in a typical week….
    Perhaps Explains why physicians have to spend more than 1 hour a day after seeing patients to review test results
    Unreimbursed time
    ? Cutting corners
    In any case, physicians know that they are not happy with their systems of result management. In the survey we administered to assess delays in result management, we also asked provders about their satisfaction level with the way they manage test results. 57% of them said that they were not even somewhat satisfied.
  • Transcript

    • 1. 11 Implementation of an ElectronicImplementation of an Electronic Test Result ManagementTest Result Management System to Improve the QualitySystem to Improve the Quality of Abnormal Test Resultof Abnormal Test Result FollowupFollowup Eric Poon, MD MPH; Bates, David, MD MSc;Eric Poon, MD MPH; Bates, David, MD MSc; Gilad Kuperman, MD PhD; Qi Li, MD MBA;Gilad Kuperman, MD PhD; Qi Li, MD MBA; Pat Carchidi, RN; Sam Wang, MD PhD;Pat Carchidi, RN; Sam Wang, MD PhD; Blackford Middleton, MD MSc; Tejal Gandhi, MD MPHBlackford Middleton, MD MSc; Tejal Gandhi, MD MPH Brigham and Women’s Hospital, Boston, MA Partners Information Systems, Boston, MA
    • 2. 2 BackgroundBackground  Follow-up of test results in the primary careFollow-up of test results in the primary care setting often a challenge:setting often a challenge: – High volume of test resultsHigh volume of test results – Test results arrive when physician not focusedTest results arrive when physician not focused on the patienton the patient – Lack of systems to ensure reliability andLack of systems to ensure reliability and efficiencyefficiency  Room for improvement:Room for improvement: – Patient and provider satisfactionPatient and provider satisfaction – Clinical outcomes and patient safetyClinical outcomes and patient safety
    • 3. 3 Objectives of InformationObjectives of Information Technology-BasedTechnology-Based InterventionIntervention  Improve efficiency and reliability of testImprove efficiency and reliability of test result follow-up in the outpatientresult follow-up in the outpatient setting.setting.  Improve adherence to establishedImprove adherence to established guidelines for the management ofguidelines for the management of abnormal test results.abnormal test results.  Improve patient satisfaction regardingImprove patient satisfaction regarding communication of test results.communication of test results.
    • 4. 4 Description of Intervention:Description of Intervention: Results Manager (RM)Results Manager (RM)  Electronic test results ‘inbox’ embedded intoElectronic test results ‘inbox’ embedded into the home-grown electronic medical record.the home-grown electronic medical record.  Key Features:Key Features: – Prioritizes degree of test result abnormalityPrioritizes degree of test result abnormality – Facilitates review of test results in context ofFacilitates review of test results in context of patient’s historypatient’s history – Embeds guidelines to assist with decisionEmbeds guidelines to assist with decision makingmaking – Generates test result lettersGenerates test result letters – Allows clinicians to set reminders for futureAllows clinicians to set reminders for future testing.testing.
    • 5. 5 Results Manager ‘Inbox’Results Manager ‘Inbox’
    • 6. 6
    • 7. 7
    • 8. 8
    • 9. 9
    • 10. 10 Implementation ofImplementation of Results ManagerResults Manager  Staggered rolloutStaggered rollout – Spring 2003 -> Spring 2004Spring 2003 -> Spring 2004 – 20 adult primary care practices affiliated20 adult primary care practices affiliated with 2 academic medical centerswith 2 academic medical centers  2 Training models explored:2 Training models explored: – Group demos + limited follow-upGroup demos + limited follow-up – Train the trainer (practice champions)Train the trainer (practice champions) with intensive follow-upwith intensive follow-up
    • 11. 11 Usage of ResultsUsage of Results ManagerManager
    • 12. 12 Results ManagerResults Manager Satisfaction SurveySatisfaction Survey How Strongly do you agree with the following statements? (1= strong agree, 5=strongly disagree) Mean Standard Deviation RM improves care quality 1.8 0.9 RM decreases malpractice risk 2.1 0.9 RM2 is easy to use 2.3 1.1 RM2 is useful to me 1.9 0.9 RM2 takes more time than before 3.2 1.4 N=59, Response rate = 51%
    • 13. 13 Key Lessons Learned (1)Key Lessons Learned (1)  Use of systems such as RM has significantUse of systems such as RM has significant potential to improve quality and safetypotential to improve quality and safety  Primary care physicians are in generalPrimary care physicians are in general receptive to the features offered by RM:receptive to the features offered by RM: – Active notification of test resultsActive notification of test results – ‘‘One stop shopping’ for test results managementOne stop shopping’ for test results management  Review results in contextReview results in context  Write result lettersWrite result letters  Document communication/actionsDocument communication/actions
    • 14. 14 Key Lessons Learned (2)Key Lessons Learned (2)  Success factors for rapid adoptionSuccess factors for rapid adoption – Presence of physician championsPresence of physician champions – Practice ownership of adoption processPractice ownership of adoption process – Physicians’ dissatisfaction with baselinePhysicians’ dissatisfaction with baseline paper-based processespaper-based processes
    • 15. 15 KeyKey LessonsLessons Learned (3)Learned (3)  Successful training strategiesSuccessful training strategies – Demonstrate how new intervention fits with localDemonstrate how new intervention fits with local workflow needsworkflow needs – Hands-on training works better than didacticHands-on training works better than didactic sessionssessions – Don’t underestimate physicians’ need for trainingDon’t underestimate physicians’ need for training  Understand that introduction of newUnderstand that introduction of new systems creates opportunities for new errorssystems creates opportunities for new errors – Understand the limitations of the application andUnderstand the limitations of the application and create fail-safe mechanismscreate fail-safe mechanisms
    • 16. 16 Thank you!Thank you! Eric Poon, MD MPHEric Poon, MD MPH Division of General Medicine and Primary CareDivision of General Medicine and Primary Care Brigham and Women’s Hospital, Boston MABrigham and Women’s Hospital, Boston MA Clinical Informatics Research and DevelopmentClinical Informatics Research and Development Partners Information Systems, Wellesley, MAPartners Information Systems, Wellesley, MA epoon@partners.orgepoon@partners.org
    • 17. 1717 Extra SlidesExtra Slides
    • 18. 18 AA Tragic Case of DelayedTragic Case of Delayed DiagnosisDiagnosis  JM presented in 1996 to a practice with aJM presented in 1996 to a practice with a positive HIV test resultpositive HIV test result  Repeat HIV test was done.Repeat HIV test was done.  HIV result was negative, but result was neverHIV result was negative, but result was never communicated to the patient.communicated to the patient.  Patient’s subsequent CD4 count were normalPatient’s subsequent CD4 count were normal and viral loads were undetectable.and viral loads were undetectable.  Patient was never put on anti-retroviralPatient was never put on anti-retroviral medications, but claims to have sufferedmedications, but claims to have suffered significant emotional traumasignificant emotional trauma  Mistake was discovered 8 years later.Mistake was discovered 8 years later. Associated Press Aug 30th 2004
    • 19. 19 Quality of Abnormal Test ResultQuality of Abnormal Test Result Follow-up: Room for ImprovementFollow-up: Room for Improvement  31% of women with abnormal31% of women with abnormal mammograms do not receive caremammograms do not receive care consistent with established guidelinesconsistent with established guidelines (Haas, 2000)(Haas, 2000)  39% of abnormal TSH at BWH not39% of abnormal TSH at BWH not followed up within 60 days (Solomon,followed up within 60 days (Solomon, 1996)1996)  36% of abnormal pap smear are ‘lost’36% of abnormal pap smear are ‘lost’ to follow-up (Marcus 1998)to follow-up (Marcus 1998)
    • 20. 20 More Ammunition: Burden ofMore Ammunition: Burden of Outpatient Test Result ManagementOutpatient Test Result Management  Per week, full-time PCP needs toPer week, full-time PCP needs to reviewreview:: – 360 chemistry results (SMA7 = 7)360 chemistry results (SMA7 = 7) – 460 hematology results460 hematology results – 12 pathology reports12 pathology reports – 40 radiology reports40 radiology reports  57% of attending physicians surveyed57% of attending physicians surveyed report beingreport being notnot satisfied with the waysatisfied with the way they manage test resultsthey manage test results

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