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DESIGN AND IMPLEMENTATION OF AN AUTOMATED EMAIL NOTIFICATION SYSTEM FOR RESULTS OF TESTS PENDING AT DISCHARGE Anuj K Dalal, MD, FHM, Jeffrey L Schnipper,

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Presentation on theme: "DESIGN AND IMPLEMENTATION OF AN AUTOMATED EMAIL NOTIFICATION SYSTEM FOR RESULTS OF TESTS PENDING AT DISCHARGE Anuj K Dalal, MD, FHM, Jeffrey L Schnipper,"— Presentation transcript:

1 DESIGN AND IMPLEMENTATION OF AN AUTOMATED NOTIFICATION SYSTEM FOR RESULTS OF TESTS PENDING AT DISCHARGE Anuj K Dalal, MD, FHM, Jeffrey L Schnipper, MD, MPH, Eric G Poon, MD, MPH, Kathleen Rossi-Roh, MEd, Allison Macleay, Deborah H Williams, MHA, Catherine L Liang, MPH, Nyryan V Nolido, MA, Jonas Budris, David W Bates, MD, MSc, Christopher L Roy, MD Brigham and Women’s Hospital Partners Healthcare, Inc. This project was supported by the Brigham and Women’s Healthcare Information Technology Innovation Program, and grant number R21HS from the Agency for Healthcare Research and Quality.

2 Case A 55 y/o F is hospitalized for an unprovoked DVT and PE A hypercoaguable work-up is sent by the inpatient medical team but is pending at discharge Results return a week later but are neither reviewed by the responsible inpatient attending nor communicated to the PCP

3 Background: Tests Pending At Discharge (TPADs) Physicians are aware of approximately 40% of the final results of TPADs † Few institutions have standardized systems to manage TPADs Automated systems using “push” notification may improve awareness of TPADs –Successful development and implementation requires integration with inpatient workflow, clinical information systems, and institutional culture † Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, Gandhi TK. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med Jul 19;143(2):121-8

4 Purpose: Automated Notification System Identify patients discharged with TPADs Notify responsible physicians of the finalized results of TPADs via secure, network –TO Discharging Inpatient Attending –CC Primary Care Physicians (network PCPs) 3 Notification Types: 1.Chemistry, Hematology 2.Radiology, Pathology 3.Microbiology (culture and non-culture)

5 Files TPADs in a queue Identifies providers from administrative databases Updates status of TPADs at 12:01 AM Any TPAD finalized ? Discharge time entered by unit clerk sent: TO Attending CC PCP (network) Triggers s until all non- suppressed TPADs finalized Limits one to provider per notification type per day Sends s to inpatient attendings and network PCPs YES Configurable rules to suppress certain TPADs Notification Types: 1.Chem/Heme 2.Rad/Path 3.Micro Excludes selected TPADs Design of System: A coordinated sequence of events

6 Design Considerations: Alert Fatigue Goal: Maximize utility of system by timely notification of relevant results Important Questions: 1.Should we notify providers on only abnormal results? 2.Should we notify providers on negative results, and if so which ones? 3.Should we exclude only commonly ordered inpatient results with fast turn-around (i.e., all basic metabolic panels, CBC’s, coags etc.)?

7 Design Considerations: Alert Fatigue Incorporated logic to suppress certain, inpatient-specific, non-essential TPADs, modifiable “on-the-fly” Kept to a minimum during pilot period to see what is coming thru (i.e., kept sensitivity high) –Chemistry: ABG, VBG –Hematology: RBC, MCV, MCH, MCHC, Diff Count –Radiology: Fluoroscopy use Uploaded outside hospital images (no reports generated) –Pathology/Microbiology: none Limited notification volume to no more than one per notification type per day, until all TPADs finalized. –Micro alerts: after initial notification, sent subsequent notifications only on abnormal results

8 Chemistry/Hematology Notification March 29, 2011 Dear Dr. HOSPITALIST, M.D.: DISCHARGED PATIENT (BWH# ), for whom you were the attending of record, was discharged from Brigham and Women's Hospital on 03/27/2011. Some tests from this hospitalization were still pending at the time of discharge. We have listed below 1) tests whose results have been finalized after discharge, and 2) tests whose results are still pending. Chemistry and Hematology test types are included in this service. Radiology, Pathology, and Microbiology test types are available in separate notifications The patient's PCP, NON-NETWORK PROVIDER, did not receive this notification because s/he does not have a Partners address listed. This is a new service we are piloting that we hope you will find to be helpful. Note: Any corrections or changes made after tests are finalized are not captured by this service but are reported per current lab protocol. Inpatient Attending: HOSPITALIST, M.D. Work Phone: Primary Care Physician: NON-NETWORK PROVIDER, M.D. Work Phone: Status: Results FINALIZED Hematology Test NameResultsNormal RangeDate Resulted ANTITHROMBIN III FUNCTIONAL76( %)03/28/ :29:00 APCR (FACTOR 5 LEIDEN)4.17;NEW REFERENCE RANGE EFFECTIVE 3/19/08; PREVIOUS REFERENCE RANGE ( )03/28/ :21:00 Status: Results PENDING Chemistry Test NameSpecimen Login Time ANTI-PROTHROMBIN03/25/ :04:00 CARDIOLIPIN IGG03/25/ :04:00 CARDIOLIPIN IGM03/25/ :04:00 Please the BWH Post-Discharge Results Notification Service for any questions, comments, and concerns related to this alert.BWH Post-Discharge Results Notification Service

9 Chemistry/Hematology Notification March 30, 2011 Dear Dr. HOSPITALIST, M.D.: DISCHARGED PATIENT (BWH# ), for whom you were the attending of record, was discharged from Brigham and Women's Hospital on 03/27/2011. Some tests from this hospitalization were still pending at the time of discharge. We have listed below 1) tests whose results have been finalized after discharge, and 2) tests whose results are still pending. Chemistry and Hematology test types are included in this service. Radiology, Pathology, and Microbiology test types are available in separate notifications The patient's PCP, NON-NETWORK PROVIDER, did not receive this notification because s/he does not have a Partners address listed. This is a new service we are piloting that we hope you will find to be helpful. Note: Any corrections or changes made after tests are finalized are not captured by this service but are reported per current lab protocol. Inpatient Attending: HOSPITALIST, M.D. Work Phone: Primary Care Physician: NON-NETWORK PROVIDER, M.D. Work Phone: Status: Results FINALIZED Chemistry Test NameResultsNormal RangeDate Resulted CARDIOLIPIN IGG16;METHODOLOGY CHANGE 8/23/99.;PRE CHANGE REFERENCE RANGE 0-22 GPL, POST CHANGE REFERENCE RANGE 0-15 GPL(0-15 GPL units)03/29/ :46:00 CARDIOLIPIN IGM14(0-15 MPL units)03/29/ :46:00 Hematology Test NameResultsNormal RangeDate Resulted ANTITHROMBIN III FUNCTIONAL76( %)03/28/ :29:00 APCR (FACTOR 5 LEIDEN)4.17;NEW REFERENCE RANGE EFFECTIVE 3/19/08; PREVIOUS REFERENCE RANGE ( )03/28/ :21:00 Status: Results PENDING Chemistry Test NameSpecimen Login Time ANTI-PROTHROMBIN03/25/ :04:00 Please the BWH Post-Discharge Results Notification Service for any questions, comments, and concerns related to this alert.BWH Post-Discharge Results Notification Service

10 Chemistry/Hematology Notification March 31, 2011 Dear Dr. HOSPITALIST, M.D.: DISCHARGED PATIENT (BWH# ), for whom you were the attending of record, was discharged from Brigham and Women's Hospital on 03/27/2011. Some tests from this hospitalization were still pending at the time of discharge. We have listed below 1) tests whose results have been finalized after discharge, and 2) tests whose results are still pending. Chemistry and Hematology test types are included in this service. Radiology, Pathology, and Microbiology test types are available in separate notifications The patient's PCP, NON-NETWORK PROVIDER, did not receive this notification because s/he does not have a Partners address listed. This is a new service we are piloting that we hope you will find to be helpful. Note: Any corrections or changes made after tests are finalized are not captured by this service but are reported per current lab protocol. Inpatient Attending: HOSPITALIST, M.D. Work Phone: Primary Care Physician: NON-NETWORK PROVIDER, M.D. Work Phone: Status: Results FINALIZED Chemistry Test NameResultsNormal RangeDate Resulted ANTI-PROTHROMBIN3(0-20 UNITS)03/30/ :23:00 CARDIOLIPIN IGG16;METHODOLOGY CHANGE 8/23/99.;PRE CHANGE REFERENCE RANGE 0-22 GPL, POST CHANGE REFERENCE RANGE 0-15 GPL.(0-15 GPL units)03/29/ :46:00 CARDIOLIPIN IGM14(0-15 MPL units)03/29/ :46:00 Hematology Test NameResultsNormal RangeDate Resulted ANTITHROMBIN III FUNCTIONAL76( %)03/28/ :29:00 APCR (FACTOR 5 LEIDEN)4.17;NEW REFERENCE RANGE EFFECTIVE 3/19/08; PREVIOUS REFERENCE RANGE ( )03/28/ :21:00 Status: Results PENDING Please the BWH Post-Discharge Results Notification Service for any questions, comments, and concerns related to this alert.BWH Post-Discharge Results Notification Service

11 Measures Background Performance –What’s happening “under-the-hood”? TPAD processing: volume, % flagged abnormal, % suppressed by rules Reliability: discharge time, provider identification Notification Performance –What did physicians see? Volume of notifications by discharged patient, provider, and test type? User Satisfaction –Surveys to inpatient attending physicians receiving notifications

12 83 discharged patients (~ 1 month, general medicine, cardiology) 1 incorrect discharge time stamp Detected 405 chem/heme TPADs 4.9 per patient 264 chemistry (65%), 141 hematology (35%) 73 flagged abnormal (18%) Suppressed 19 (4.7%, 19/405), all hematology 136 s triggered ~1.7 alerts per discharged patient (136/82) 2 or more s on 34% (28/82) Files TPADs in a queue Identifies providers from administrative databases Updates status of TPADs at 12:01 AM Any TPAD finalized ? Discharge time entered by unit clerk sent: TO Attending CC PCP (network) YES Excludes selected TPADs Background Performance

13 One incorrectly entered discharge time stamp (1.2%, 1/83) –Unit clerk inadvertently “discharged” patient on Day 4 of 10-day hospitalization Detected 510 TPADs (249 chem, 261 heme)! –Triggered 9 s! –A rare event 3 responses from physicians (on 3 distinct patients) claiming sent to incorrect provider (3.6%, 3/83) –2 from Inpatient Attending –1 from PCP Background Performance

14 notifications sent to providers of 95 discharged patients with all TPADs finalized Non-network PCPs 1.6 alerts per discharged patient Notifications By Discharged Patient

15 notifications received by 35 distinct inpatient physicians from 3/15/11 thru 4/15/11 Hospitalists Cardiologists Traditional Internists Notifications By Inpatient Provider

16 User Satisfaction Inpatient physicians surveyed 3 days after receiving the final notification Asked to rate satisfaction on 5-point Likert scale 70 survey responses (29 physicians) –84% satisfied or very satisfied –6% neutral –10% dissatisfied or very dissatisfied

17 Selected Comments “I find this extremely useful, knowing the final results of tests, both test results that are positive as well as negative.” “Was unaware of this test even being ordered - had it not been for auto- notification, would never have known about test or result. No call to PCP as test is in normal range and will not affect management.” “The concept is great. All the notifications I have received are for negative results. Might be more worthwhile for blood tests if it was only for abnormal results.” “Test was not needed and was not ordered by me... “ “It is best to send these pathology results not just to the ordering physician but also the GI physician performing the biopsy.”

18 Conclusions Automated notification is a feasible and reliable strategy for managing results of TPADs, and compatible with inpatient workflow Successful implementation is dependent on accuracy and reliability of –Discharge time stamp –Provider identification “Garbage in, garbage out” phenomena

19 Conclusions The high volume of TPADs and notifications to providers are challenging to negotiate –Logic to limit volume and frequency of notifications to minimize alert fatigue –A user-configurable system to modify suppression rules is desirable Users are highly satisfied –Physicians vary with regard to type of results they wish to receive

20 Thank You! Questions? Comments?

21

22 Acknowledgements: TPAD Team BWH Information Systems Project Team –Kathleen Ross-Roh, MEd –Allison Macleay –Margo Daphnis –Eric Poon, MD, MPH BWH DGM Research Team –Catherine Liang, MPH –Nyryan V Nolido, MA –Deborah H Williams, MHA –Jonas Budris –Catherine Yoon, MSc –David Bates, MD, MSc –Christopher Roy, MD –Jeffrey Schnipper, MD, MPH

23 Funding Brigham and Women’s Healthcare Information Technology Innovation Program Agency for Healthcare Research and Quality, grant number R21HS018229

24 Configurable System: Lab Selection

25 Microbiology Notification April 17, 2011 Dear Dr. HOSPITALIST, M.D.: DISCHARGED PATIENT (BWH# ), for whom you were the attending of record, was discharged from Brigham and Women's Hospital on 03/27/2011. Some tests from this hospitalization were still pending at the time of discharge. We have listed below 1) tests whose results have been finalized after discharge, and 2) tests whose results are still pending. Chemistry and Hematology test types are included in this service. Radiology, Pathology, and Microbiology test types are available in separate notifications The patient's PCP, NON-NETWORK PROVIDER, did not receive this notification because s/he does not have a Partners address listed. This is a new service we are piloting that we hope you will find to be helpful. Note: Any corrections or changes made after tests are finalized are not captured by this service but are reported per current lab protocol. Inpatient Attending: HOSPITALIST, M.D. Work Phone: Primary Care Physician: NON-NETWORK PROVIDER, M.D. Work Phone: Microbology Results FINALIZED SpecimenTest ResultDate CollectedDate Resulted B BLOODBLOOD CULTURENO GROWTH04/10/201104/16/2011 B BLOODBLOOD CULTURENO GROWTH04/10/201104/16/2011 B BLOODBLOOD CULTUREKLEBSIELLA PNEUMONIAE04/09/201104/15/2011 B BLOODBLOOD CULTUREKLEBSIELLA PNEUMONIAE04/09/201104/15/2011 Please the BWH Post-Discharge Results Notification Service for any questions, comments, and concerns related to this alert.BWH Post-Discharge Results Notification Service

26 Radiology/Pathology Notification March 21, 2011 Dear Dr. HOSPITALIST, M.D.: DISCHARGED PATIENT (BWH# ), for whom you were the attending of record, was discharged from Brigham and Women's Hospital on 03/27/2011. Some tests from this hospitalization were still pending at the time of discharge. We have listed below 1) tests whose results have been finalized after discharge, and 2) tests whose results are still pending. Chemistry and Hematology test types are included in this service. Radiology, Pathology, and Microbiology test types are available in separate notifications The patient's PCP, NON-NETWORK PROVIDER, did not receive this notification because s/he does not have a Partners address listed. This is a new service we are piloting that we hope you will find to be helpful. Note: Any corrections or changes made after tests are finalized are not captured by this service but are reported per current lab protocol. Inpatient Attending: HOSPITALIST, M.D. Work Phone: Primary Care Physician: NON-NETWORK PROVIDER, M.D. Work Phone: Pathology Results FINALIZED Specimen: SURG,Gastric biopsyDate Resulted: 03/20/2011 PATHOLOGIC DIAGNOSIS: A. DUODENUM: Mild chronic active duodenitis. B. GASTRIC ANTRUM: Antral mucosa with moderate chronic active gastritis. HELICOBACTER PYLORI ARE SEEN ON H&E STAIN. No intestinal metaplasia identified. C. GASTRIC BODY: Corpus mucosa with mild chronic active gastritis. NUMEROUS HELICOBACTER PYLORI ARE SEEN ON H&E STAIN. No intestinal metaplasia identified. D. DISTAL ESOPHAGUS: Squamous mucosa with active esophagitis with erosion. A PAS-D stain is negative for fungal forms. Please the BWH Post-Discharge Results Notification Service for any questions, comments, and concerns related to this alert.BWH Post-Discharge Results Notification Service

27 What’s in the s? ChemistryHematologyRadiologyPathologyMicrobiology Infectious Serologies: Coxsackie B Ab, Lyme Ab, HIV Ab, HBsAb, HBcAb, HCV Ab, TP-IgG (RPR) Hemoglobin A1cMRI: cardiac, knee Biopsies:gastric, intestine, pancreas, liver, cardiac, kidney, lymph node, bone marrow, skin Bacterial cultures/stains: blood, urine, sputum, csf, stool, AFB Proteins: SPEP, UPEP, C-peptide Malaria/Babesia Smear Chest X-ray Cytology: bile duct, pancreatic mass, peritoneal Fungal cultures/stains Rheum Serologies: ANA, ANCA, Anti-DS DNA WBC, Hgb, HCT, Platelets Vascular Line Removal/Placement SPEP, UPEPViral cultures Immunologic Tests: IgG, IgA, Complements PT/INRCT Angiography Factor 2 Gene Analysis (Prothrombin Mutation) Infectious Serologies: CMV, EBV, H.Pylori Vitamins & Elements: Zinc, Vit A, 25(OH) Vit D, Vit B- 12, Folate Factor V Leiden (APC Resistance) Exercise Stress TestFlow CytometryViral load: HIV, HCV Enzymes & Hormones: Plasma Renin, Aldosterone, ACE, ACTH UrinalysisCT Abd/Pelvis Surgical Specimens: skin Other: C.Diff,  -D-glucan

28 Limitations Single institution within an large integrated healthcare network A robust culture of utilization by inpatient physicians Variable reliability of processes to enter discharge time and maintain administrative databases by clinical service and institution → limit adoption

29 Implications “Push” notification is an acceptable strategy to manage results of TPADs Future studies –Evaluate impact on physician awareness –Analyze downstream actions taken –Elucidate desired features to maximize utility for physicians


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