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Implementation of an Implementation of an Electronic Test Result Electronic Test Result Management System to Management System to Improve the Quality of Improve the Quality of Abnormal Test Result 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 Blackford Middleton, MD MSc; Tejal Gandhi, MD MPHMPH

Brigham and Women’s Hospital, Boston, MA

Partners Information Systems, Boston, MA

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BackgroundBackground

Follow-up of test results in the primary Follow-up of test results in the primary care setting often a challenge:care setting often a challenge:– High volume of test resultsHigh volume of test results– Test results arrive when physician not Test results arrive when physician not

focused on the patientfocused on the patient– Lack of systems to ensure reliability and Lack 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

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Objectives of Information Objectives of Information Technology-Based Technology-Based InterventionIntervention Improve efficiency and reliability Improve efficiency and reliability

of test result follow-up in the of test result follow-up in the outpatient setting.outpatient setting.

Improve adherence to established Improve adherence to established guidelines for the management of guidelines for the management of abnormal test results.abnormal test results.

Improve patient satisfaction Improve patient satisfaction regarding communication of test regarding communication of test results.results.

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Description of Description of Intervention:Intervention:Results Manager (RM)Results Manager (RM) Electronic test results ‘inbox’ embedded Electronic test results ‘inbox’ embedded

into the home-grown electronic medical into the home-grown electronic medical record.record.

Key Features:Key Features:– Prioritizes degree of test result abnormalityPrioritizes degree of test result abnormality– Facilitates review of test results in context of Facilitates review of test results in context of

patient’s historypatient’s history– Embeds guidelines to assist with decision Embeds guidelines to assist with decision

makingmaking– Generates test result lettersGenerates test result letters– Allows clinicians to set reminders for future Allows clinicians to set reminders for future

testing.testing.

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Results Manager Results Manager ‘Inbox’‘Inbox’

66

77

88

99

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Implementation of Implementation of Results ManagerResults Manager Staggered rolloutStaggered rollout

– Spring 2003 -> Spring 2004Spring 2003 -> Spring 2004– 20 adult primary care practices 20 adult primary care practices

affiliated with 2 academic medical affiliated with 2 academic medical centerscenters

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

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Usage of Results Usage of Results ManagerManager

Number of Result Letters Generated Using RM2 Per Month (BWH + MGH)

01000200030004000500060007000

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Results Manager Results 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%

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Key Lessons Learned (1)Key Lessons Learned (1)

Use of systems such as RM has significant Use of systems such as RM has significant potential to improve quality and safetypotential to improve quality and safety

Primary care physicians are in general Primary 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 One stop shopping’ for test results

managementmanagement Review results in contextReview results in context Write result lettersWrite result letters Document communication/actionsDocument communication/actions

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Key Lessons Learned (2)Key Lessons Learned (2)

Success factors for rapid adoptionSuccess factors for rapid adoption– Presence of physician champions Presence of physician champions – Practice ownership of adoption Practice ownership of adoption

processprocess– Physicians’ dissatisfaction with Physicians’ dissatisfaction with

baseline paper-based processesbaseline paper-based processes

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Key Key LessonsLessons Learned Learned (3)(3) Successful training strategiesSuccessful training strategies

– Demonstrate how new intervention fits with Demonstrate how new intervention fits with local workflow needslocal workflow needs

– Hands-on training works better than didactic Hands-on training works better than didactic sessionssessions

– Don’t underestimate physicians’ need for Don’t underestimate physicians’ need for training training

Understand that introduction of new Understand that introduction of new systems creates opportunities for new systems creates opportunities for new errorserrors– Understand the limitations of the application Understand the limitations of the application

and create fail-safe mechanismsand create fail-safe mechanisms

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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

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Extra SlidesExtra Slides

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A A Tragic Case of Delayed Tragic Case of Delayed DiagnosisDiagnosis

JM presented in 1996 to a practice with a JM 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 HIV result was negative, but result was

never communicated to the patient.never communicated to the patient. Patient’s subsequent CD4 count were Patient’s subsequent CD4 count were

normal and viral loads were normal and viral loads were undetectable. undetectable.

Patient was never put on anti-retroviral Patient was never put on anti-retroviral medications, but claims to have suffered medications, but claims to have suffered significant emotional trauma significant emotional trauma

Mistake was discovered 8 years later.Mistake was discovered 8 years later.Associated Press Aug 30th 2004

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Quality of Abnormal Test Result Quality of Abnormal Test Result Follow-up: Room for Follow-up: Room for ImprovementImprovement

31% of women with abnormal 31% of women with abnormal mammograms do not receive mammograms do not receive care consistent with established care consistent with established guidelines (Haas, 2000)guidelines (Haas, 2000)

39% of abnormal TSH at BWH not 39% of abnormal TSH at BWH not followed up within 60 days followed up within 60 days (Solomon, 1996)(Solomon, 1996)

36% of abnormal pap smear are 36% of abnormal pap smear are ‘lost’ to follow-up (Marcus 1998)‘lost’ to follow-up (Marcus 1998)

2020

More Ammunition: Burden of More Ammunition: Burden of Outpatient Test Result Outpatient Test Result ManagementManagement Per week, full-time PCP needs to Per 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 57% of attending physicians surveyed report being surveyed report being notnot satisfied satisfied with the way they manage test with the way they manage test resultsresults