An Automatic Notification System for Test Results Finalized after Discharge (Massachusetts)

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Summary:

When results of tests are finalized after a patient has been discharged from a hospital, they may not come to the attention of the provider. These finalized results of tests pending at discharge (TPADs) represent a significant patient safety concern. Lack of followup on these results can lead to delayed diagnosis, delayed treatment, redundant test ordering, and harm to patients.  

This project developed an automated email notification system of TPADs and conducted an evaluation of the tool’s impact on provider awareness of these tests. The system was implemented for patients who were discharged from the inpatient general medicine and cardiology services at Brigham and Women’s Hospital in Boston, Massachusetts.

The objectives of this project were to:

  • Create an automatic notification system to prompt physicians of test results finalized after discharge. 
  • Evaluate the impact of this system on physician awareness of test results finalized after discharge. 

A cluster-randomized controlled trial was conducted in which the inpatient attending physician as well as the primary care provider (PCP) were randomized to either receive an email notification or usual care for all patients discharged with TPADs over an 8-month period. The providers were surveyed regarding their awareness of any TPAD results, actionable TPAD results, and satisfaction with the tool. 

Providers who received the automated email had a statistically significant improvement in their awareness of TPADs than those who did not. Inpatient attendings were significantly more aware of actionable TPADs when receiving automated emails. Eight-nine percent of attendings and 70 percent of PCPs indicated satisfaction with the tool. The project team concluded that automated email notification of TPADs is an effective strategy for managing these results. Future areas of research include down-stream actions taken on results post-discharge, impact on readmissions, the relative effect on network versus non-network PCPs, and post-discharge health service utilization. 

An Automatic Notification System for Test Results Finalized After Discharge - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality Through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 018229
  • Project Period: 
    January 2010 – March 2012
  • AHRQ Funding Amount: 
    $294,052
  • PDF Version: 
    (PDF, 193.67 KB)

Summary: The transition to the ambulatory setting following hospital discharge is a vulnerable time for patients. One important patient safety concern is failure of responsible providers to followup on test results finalized after a patient is discharged. Such failure can lead to delays in diagnosis, missed treatment opportunities, redundant test orders, and subsequent patient harm. Automated systems that ensure timely notification of these test results to responsible providers have the potential to mitigate these well-documented problems and improve health care quality and safety. This project created an automated system to notify physicians of patients’ test results pending at discharge (TPADs) via secure email. The system was designed to facilitate communication and acknowledgement of test results by responsible inpatient and ambulatory physicians during care transitions. The study team evaluated the system’s impact on physicians’ awareness of test results.

In the first phase of this study, components of the system were developed to: 1) identify tests with results pending at the time of discharge; 2) obtain the identity and email addresses of the responsible inpatient and ambulatory providers; 3) exclude routinely-ordered tests to avoid provider alert fatigue; and 4) automate notification to providers by email once results are available. The intervention relied primarily upon the inpatient clinical information system; the admission, discharge, and transfer systems; and network email to orchestrate the series of events that lead to the automated notification of final test results after discharge.

In the second phase, a cluster-randomized, 8-month controlled trial measured the impact of this system on physicians’ awareness. The study participants were 441 patients who were discharged from the inpatient general medicine and cardiology services at Brigham and Women’s Hospital (BWH). Prior to the intervention, staff randomized both the responsible inpatient provider (attending physician at time of hospital discharge) and the responsible outpatient provider (the patient’s primary care physician [PCP]).
The study population included patients with TPADs discharged from these services if both their inpatient attending physician and PCP were randomized to the either intervention or usual care. Patients were excluded if their inpatient attending physician and PCP were in discordant arms, or if their inpatient attending and PCP was the same person.

The primary outcome was awareness of any TPAD result by the inpatient attending physician. Secondary outcomes included awareness of any TPAD result by the PCP, user satisfaction, awareness of actionable test results, and whether appropriate actions are taken in response to these results after electronic health record review. Physician awareness was measured by a survey sent to responsible providers 72 hours after the last finalized TPAD result was available. The study may inform future efforts to optimize this type of intervention at BWH and other institutions trying to minimize this patient safety problem.

Specific Aims:

  • Create an automatic notification system to prompt physicians of test results finalized after discharge. (Achieved)
  • Evaluate the impact of this system on physician awareness of test results finalized after discharge. (Achieved)

2012 Activities: During this period the study team used a no-cost extension to complete the final analysis and develop manuscripts. As last self-reported in the AHRQ Research Reporting System, project progress was completely on tract and project spending was on target. The project ended in March 2012.

Impact and Findings: Four-hundred and forty-one patients assigned to either arm by randomized physician pair were analyzed. Surveys were sent to 441 attendings and 353 PCPs, and 275 and 152 responses were received from 80 attendings and 113 PCPs, respectively. Intervention attendings and PCPs were significantly more aware of TPAD results, while intervention attendings were more aware of actionable TPAD results. One-hundred and eighteen (85 percent) and 43 (63 percent) intervention attending and PCP survey respondents, respectively, were satisfied with this strategy. The project team concluded that automated email notification is a promising strategy to manage TPADs, potentially mitigating an unresolved patient safety concern. Future areas of research should include down-stream actions taken on TPAD results post-discharge, impact on readmissions, the relative effect on network versus non-network PCPs, and post-discharge health service utilization.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

An Automatic Notification System for Test Results Finalized after Discharge - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality Through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 018229
  • Project Period: 
    January 2010 - March 2012
  • AHRQ Funding Amount: 
    $294,052
  • PDF Version: 
    (PDF, 192.28 KB)

Summary: This project is creating an automated system to notify physicians, via secure email, patients' test results pending at discharge (TPADs). The system is designed to facilitate communication and acknowledgement of test results by responsible inpatient and ambulatory physicians during care transitions. The study team will evaluate the system's impact on physicians' awareness of test results.

In the first phase of this study, components of the system were developed to: 1) identify tests with results pending at the time of discharge; 2) obtain the identity and email addresses of the responsible inpatient and ambulatory providers; 3) exclude routinely-ordered tests to avoid provider alert fatigue; and 4) automate notification to providers by email once results are available. The intervention relies primarily upon the inpatient clinical information system; the admission, discharge, and transfer systems; and network email to orchestrate the series of events that lead to the automated notification of final test results after discharge.

In the second phase, a cluster-randomized, 6-month controlled trial measured the impact of this system on physicians' awareness. The study participants were 450 patients who were discharged from the inpatient general medicine and cardiology services at Brigham and Women's Hospital (BWH). Staff randomized both the responsible inpatient provider (attending physician at time of hospital discharge) and the responsible outpatient provider (the patient's primary care physician [PCP]) prior to the intervention. The study population included patients with TPADs discharged from these services if both their inpatient attending and primary care physician were randomized to the either intervention or usual care. Patients were excluded if their inpatient attending and PCP were in discordant arms or if their inpatient attending and PCP were the same person.

The primary outcome is awareness of any TPAD result by the inpatient attending. Secondary outcomes include awareness of any TPAD result by the PCP, user satisfaction, awareness of actionable test results, and whether appropriate actions are taken in response to these results after EHR review. Physician awareness is measured by a survey sent to responsible providers 72 hours after the last finalized TPAD result is available. The study will inform future efforts to optimize this type of intervention at BWH and other institutions trying to minimize this patient safety problem.

Specific Aims:

  • Create an automatic notification system to prompt physicians of test results finalized after discharge. (Achieved)
  • Evaluate the impact of this system on physician awareness of test results finalized after discharge. (Ongoing)

2011 Activities: Microbiology test types were activated. The randomized controlled trial (RCT) continued during this period, and the project achieved target enrollment of 450 subjects, thereby concluding the RCT at the end of May 2011. The research team began cleaning the final data set for analysis, compiling a list of patients for the exploratory analysis of downstream actions, and preparing preliminary drafts of manuscripts describing the innovation. The project team anticipates completing all aspects of the project by the end of the 9-month no-cost extension period.

As last self-reported in the AHRQ Research Reporting System, progress is completely on track and project budget spending is on target.

Preliminary Impact and Findings: An interim analysis of the data showed promising results. Inpatient attending and PCP satisfaction with the new automated email notification system was high. Those physicians receiving usual care reported lower satisfaction with existing systems of managing TPADs. Both inpatient attending and primary care physicians reported higher awareness of test results finalized after discharge: 72 percent and 56 percent, respectively. The inpatient attending and PCP in the control group both reported lower awareness, at 34 percent each.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient- centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

An Automatic Notification System for Test Results Finalized after Discharge - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality Through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 018229
  • Project Period: 
    January 2010 – June 2011
  • AHRQ Funding Amount: 
    $294,052
  • PDF Version: 
    (PDF, 359.85 KB)


Target Population: General

Summary: This project will create an automatic system that notifies physicians when laboratory test results are finalized after discharge and documents these results in patients’ electronic health record (EHR). The system was designed to facilitate communication and to create a collaborative plan of care for in- and outpatient providers during patients’ transition to the ambulatory setting. The impact of this system on physician awareness of test results will be evaluated.

In the first phase of this study, components of the system were developed to: 1) identify laboratory tests with results pending at the time of discharge; 2) obtain the identity and e-mail addresses of appropriate inpatient and ambulatory providers; 3) exclude routinely-ordered tests to avoid provider alert-fatigue; 4) automate final-test notification to providers as they become available by e-mail; and 5) document these results in the ambulatory EHR. The intervention primarily relies upon the inpatient test results system and the admission, discharge, and transfer system to orchestrate the series of events leading to automated notification of test results finalized post discharge.

In the second phase, a cluster randomized six-month controlled trial is being conducted to measure the impact of this system on physicians’ awareness. The study participants are 450 patients who were discharged from the inpatient general medicine and cardiology services at Brigham and Women's Hospital (BWH). Staff randomized both the responsible inpatient provider (attending physician at the time of hospital discharge) and responsible outpatient provider (the patient’s primary care physician prior to the intervention). Participating physicians’ patients who were discharged from these services and had tests pending during the study period constitute the study population. Patients for whom the physician was both the inpatient and outpatient provider were excluded.

The primary outcome will be awareness of all post-discharge test results among responsible providers. Secondary outcomes will include user satisfaction, awareness of actionable test results as judged by providers, and whether appropriate actions are taken in response to these results after EHR review. Physician awareness will be measured by a survey that will be sent to providers 72 hours after the first finalized test result is available. The results of this study will inform future efforts to optimize this type of intervention at BWH and other institutions trying to minimize this patient safety problem.

Specific Aims:
  • Create an automatic notification system to prompt physicians of test results finalized after discharge. (Ongoing)
  • Evaluate the impact of this system on physician awareness of test results finalized after discharge. (Ongoing)

2010 Activities: The study team completed Phase 1 of the intervention which included building the notification service for chemistry and hematology test types. Between May and June 2010, the service was pilot tested in a "pseudo-live" environment in which the service ran, but e-mail notifications were suppressed. During this time the team was able to ascertain that the service was functioning according to the research requirements and randomization scheme. The notification service became operational in August 2010.

Phase 2 analysis and development, including pathology and radiology test types, were delayed in order to devote additional resources to developing Phase 1 test types, which took the team more time than anticipated. Phase 2 development was completed in early December 2010 and was briefly tested over a 2-week period. The service was activated for physicians after it was ascertained to be functioning according to specifications.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The randomized controlled trial (RCT) was initiated and the project is focusing on collection of data. The project is meeting most of its aims and budget spending is roughly on target.

Preliminary Impact and Findings: Over a two-week pilot period in which e-mail notifications were suppressed, the system automatically identified 2,992 tests pending from 233 discharges, including 1,159 chemistry and 1,833 hematology results. These figures are somewhat higher than the team expected. The higher amount is likely due to additional tests being incorporated from issues related to the discharge time stamp and code bugs related to ambulatory test results.

A baseline awareness survey was conducted to determine optimal timing for sending study surveys during the trial period. The survey response rate was 62 percent and overall physician awareness of pending chemistry and hematology tests was 22 percent. Preliminary data from the study pilot and the RCT show a trend toward increased awareness for the intervention group as compared with the control group, but these data are crude and the total responses to date are limited.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

An Automatic Notification System for Test Results Finalized after Discharge - Final Report

Citation:
Dalal A. An Automatic Notification System for Test Results Finalized after Discharge - Final Report. (Prepared by Brigham and Women's Hospital under Grant No. R21 HS018229). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 195.47 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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