1. Health Care Systems Research Network Conference 2019, Portland, OR
The Impact of a Web-Based Point-of-Care Tool on Physician Behavior and Patient Health Outcomes
J.B. Jones, PhD, MBA1, Xiaowei (Sherry) Yan, PhD1, Hannah Husby, MPH 1, Jake Delatorre-Reimer, BA1, Farah Refai, MPH1, Shruti Vaidya, MS1, Ridhima Nerlekar, MS1, Karen MacDonald, BA2
1Sutter Health Research, Development & Dissemination, Walnut Creek, CA; 2AstraZeneca, Wilmington, DE
Health Care Systems Research Network Conference 2019, Portland, OR
APRIL 8, 2019

2. Disclosures Research supported by AstraZeneca
No other relationships to disclose

3. Overview
Background
Methods
Results
Conclusions and Limitations

4. Background

5. Sutter Health 12,000+ doctors 24 acute care hospitals 53,000 employees
$12 billion in revenues (2017)
36 Outpatient surgery centers
5,000 Volunteers
Home health and hospice services throughout Northern California
Medical research and medical education/training
3,000,000+ patients cared for

6. Cardiometabolic Program
Sutter Health and AstraZeneca formed a research collaboration to transform care for diabetes and other cardiometabolic (CM) conditions in 2015 by bringing together researchers, physicians, technologists, and patients.
Diabetes | Hypertension | Dyslipidemia

7. What Is CM-SHARE? CardioMetabolic Sutter Health Advanced Re-engineered Encounter
Maestro
(Middleware)
Epic

8. Why Was CM-SHARE Developed?

9. What Problems Does CM-SHARE Solve?
Saves time: efficient access to data
Looking for all patient data needed within the EHR for the care encounter is time- consuming
Improves quality of care: actionable data and alerts
Medication adherence data are not interpretable in the EHR
Lack of tools to view/close quality gaps
Allows better engagement with patients: patient-friendly graphs and data
Few easy-to-use visual tools to share information with patients
Patients lack motivation and guidance

10. Developing and Piloting CM-SHARE with Physicians and Patients
Use is completely voluntary
Decision when to use is up to the clinician
No incentives for use of application
Elmer Fudd

11. Digital Health Solutions: Evaluation Concerns
Use of CM-SHARE Among Different Patient Populations
More technology?
More clicks?
Longer encounter?
% Usage of CM-SHARE

12. Methods

13. Areas of Focus for CM-SHARE Pilot
Evaluation Overview
Areas of Focus for CM-SHARE Pilot
PROCESS
FIDELITY
Time
Does CM-SHARE impact time and clicks in the EHR?
Quality
Does CM-SHARE impact lab orders?
Use
How often and when is CM-SHARE used by clinicians?
LONG-TERM OUTCOMES
CM-SHARE
Clinical Outcomes
Does CM-SHARE impact patient HbA1c values?
Context
Does CM-SHARE help clinicians and patients share information with each other, do their jobs more easily, and is it easy to use?
EXPERIENCE
Does use of CM-SHARE impact patients’ understanding?
Does use of CM-SHARE impact patient-provider communication?

14. EHR and Audit Data: Pre-Post Parallel Matched Comparison Evaluation Design
Comparing similar patients pre- and post- to make sure that differences are due to intervention, not time or bias
Intervention group
(Pilot Clinicians)
Pre-cohort: Similar patients, similar encounters
CM-SHARE is not used
CM-SHARE is used
Pre-intervention
Post-intervention
Application Go-live
(4/2016)
Parallel control: Similar patients/ encounters, no opportunity for CM-SHARE use
Parallel control group
Adding comparisons to an external control provides the strongest evidence that differences are due to the intervention, not selection bias, time, patients, or physicians

15. Results

16. CM-SHARE Launch Rates Indicate Higher Usage for Patients with Diabetes
All Patient Encounters
34%
Encounters with Patients with a Cardiometabolic Condition
37%
CM-SHARE was launched for 11,772 of 34,955 encounters
CM-SHARE was launched for 8,781 of 23,471 encounters
June 1, June 30, 2018
Patients with Diabetes-Focused Encounters
61%
CM-SHARE was launched for 1,607 of 2,651 encounters

17. Physicians Report CM-SHARE Use Is Prioritized for Patients with High Morbidity and Need
All Patient Encounters
34%
Encounters with Patients with a Cardiometabolic Condition
37%
Patients can benefit from CM–SHARE’s easy-to-understand health data visuals
June 1, June 30, 2018
Why these People?
Patients with Diabetes-Focused Encounters
61%

18. Efficiency: Same Visit Length, Less Provider Computer Time for Diabetes and Hypertension Encounters
Exam Room
CM-SHARE Launch Effect
Time
Average time on computer in control group (min)
Diabetes and hypertension encounters with CM-SHARE
Total office visit time 54
No Change
Physician exam room time 20
Physician computer time in the exam room 15
25-30% Less Time
Front desk checks in patient
Complete
check-in process
MA/Nurse
rooming
patient
Complete
rooming
process
Physician entrance
Physician
exit
Patient is discharged
Total Office Visit Time
Physician Exam Room Time
Physician Computer Time

19. Fewer Clicks on the Computer for Diabetes and Hypertension Encounters
Exam Room
CM-SHARE Launch Effect
Clicks
Average # of clicks in encounters of control group
Diabetes and hypertension encounters with CM-SHARE
Total Encounter Clicks
366
No Change
Physician Total Encounter Clicks
218
22% Fewer
Physician Exam Room Clicks 85
11-20% Fewer
Front desk checks in patient
Complete
check-in process
MA/Nurse
rooming
patient
Complete
rooming
process
Physician entrance
Physician
exit
Patient is discharged
Total Encounter Clicks, including Clinical Staff
Physician Total Encounter Clicks (including Pre and Post)
Physician Exam Room Clicks

20. CM-SHARE Patients with Diabetes Have More Frequent HbA1c Lab Monitoring
6 MONTHS
12 MONTHS
FIRST OFFICE VISIT
18 MONTHS
Control Patients
1.28
1.11
No Difference
*p-value:
*p-value:
CM-SHARE Patients
1.43
1.24
Average Number of HbA1c Lab Orders

21. No Difference No Difference 0.1 lower
After 18 Months the CM-SHARE Group Demonstrates Slightly Lower HbA1c Values
FIRST OFFICE VISIT
6 MONTHS
12 MONTHS
18 MONTHS
Control Patients
No Difference
No Difference
CM-SHARE Patients
0.1 lower
*p-value: 0.02
Average HbA1c Difference

22. Conclusions and Limitations

23. Conclusions and Limitations
Consistency of use over time suggests CM-SHARE meets physicians’ need for a patient engagement tool
Uncontrolled diabetes appears to be the primary use case
Early results indicate positive trends in both reduction of EHR burden and improvement of disease monitoring
CM-SHARE is more likely to impact mediators of HbA1c. Patient clinical outcomes tend to a take longer time to see an effect.
HbA1c changes were not clinically significant but they are encouraging as we think about conducting a larger and longer evaluation
More work is needed to understand how CM-SHARE mediates patient outcomes and physician behavior change
Limitations include:
Pilot study with small sample size
Intensity of CM-SHARE use was not adjusted for in the analysis

24. Questions?
Thank you For more information, contact JB Jones at or Hannah Husby at