Nudging Physicians and Patients With Autopend Clinical Decision Support to Improve Diabetes Management

ABSTRACT

Objectives: To determine the impact on routine glycated hemoglobin (A1C) laboratory test completion of incorporating an autopend laboratory order functionality into clinical decision support, which (1) routed provider alerts to a separate electronic folder, (2) automatically populated preauthorization forms, and (3) linked the timing and content of electronic patient health maintenance topic (HMT) reminders to the provider authorization.

Study Design: Observational pre-post study from November 2011 (1 year before autopend) through June 2014 (1.5 years after).

Methods: The study included HMT reminders concerning an A1C test for patients with type 1 or type 2 diabetes (N = 15,630 HMT reminders; 8792 patients) in a large multispecialty ambulatory healthcare system. A Cox proportional hazard model, adjusted for patient and provider demographics, estimated the likelihood of laboratory test completion based on 3 HMT reminder characteristics: preautopend versus postautopend period, read versus unread, and the patient’s time to reading.

Results: In the postautopend period, the median time for patients to read reminders decreased (1 vs 3 days; P <.001) and the median time to complete laboratory tests decreased (40 vs 48 days; P <.001). Comparing preautopend HMT reminders with a similar time to reading, the likelihood of A1C laboratory test completion increased after autopend by between 21.1% (hazard ratio [HR], 1.211; P = .050), when time to reading was 57 days, and 33.9% (HR, 1.339; P = .003), when time to reading was 0 days. This result included 68% of the reminders. There was no statistical difference in A1C laboratory test completion for unread reminders in the preautopend versus postautopend period.

Conclusions: Automated patient-centered decision support can improve guideline-concordant monitoring of A1C among patients with diabetes, particularly among patients who read reminders in a timely fashion.

Am J Manag Care. 2018;24(10):479-483Takeaway Points

• Incorporating an autopend functionality into clinical decision support coordinates and streamlines the process of completing routine preventive diabetes care.
• Autopend routed provider alerts to a separate electronic folder for batch completion, automatically populated preauthorization forms, and linked the timing and content of the patient reminder messages to the authorization.
• Among patient reminder messages read within 57 days, the likelihood of glycated hemoglobin laboratory test completion increased by between 21.1% (P = .050) and 33.9% (P = .003) after autopend. This result included 68% of the reminders.
• Autopend can improve guideline-concordant monitoring of chronically ill patients in the spirit of the Quadruple Aim.

The timely completion of routine preventive care is critical for diabetes management, yet only 39.5% of US patients diagnosed with diabetes have received all guideline-recommended services.^1,2 Stage II of the Meaningful Use legislation, Medicare’s Electronic Health Record (EHR) Incentive Program, requires the use of clinical decision support (CDS) to remind patients about preventive care. However, Medicare states that there is no definitive or comprehensive list of what constitutes CDS, partly to encourage the creation of novel and innovative CDS tools.³

Various CDS systems have been developed to improve the completion of routine preventive diabetes care. The use of electronic reminders to providers, often in the patient’s chart, prompts limited improvement,^4-6 partly because providers respond 30% to 40% of the time.^7,8 Study results have shown that electronic reminders sent directly to patients improve diabetes management.^9,10 However, a randomized controlled trial involving electronic alerts to both patients and providers had mixed findings.¹¹ This suggests that the interaction between patient and clinician interventions within CDS may be critical, especially if these systems developed independently.

The provider–patient interface can inadvertently generate barriers to preventive care. Providers are required to review and authorize each laboratory order, even if they occur routinely. Providers and patients may fail to perform required tasks (eg, authorization or laboratory test completion) without prompting.¹² However, locating provider alerts in the patient’s chart contributes to alert fatigue and creates challenges for patient management between visits.⁸ When patient alerts are triggered independently of the clinician authorization, patients may need to complete additional burdensome steps to confirm the laboratory order’s authorization, such as checking with the provider’s office, the laboratory, or additional websites.

Health information technology leaders at Sutter Health, a large nonprofit integrated healthcare delivery system headquartered in Sacramento, California, designed and incorporated an autopend functionality into the CDS. Autopend aimed to nudge providers and patients by simplifying workflow, removing barriers, and coordinating actions to improve preventive care. We examined whether incorporating an autopend functionality improved the likelihood of routine glycated hemoglobin (A1C) laboratory test completion for patients with diabetes.

RESEARCH DESIGN AND METHODS

Study Setting

The study was conducted at the Palo Alto Medical Foundation (PAMF), an affiliate of Sutter Health. PAMF is an ambulatory healthcare system serving more than 1 million patients in northern California. It has used a fully integrated EpicCare EHR with electronic health maintenance topic (HMT) patient reminders since 1999. The autopend functionality was activated on November 13, 2012.

Study Design

We conducted an observational pre-post study at the HMT reminder level and tracked associated A1C laboratory test completion. We compared HMT reminders sent in the year before autopend (November 1, 2011-November 13, 2012) with those in the 1.5 years after (November 13, 2012-June 30, 2014). Our data recorded laboratory test completion for an additional 6 months (through December 2014). We included all HMT reminders sent to patients eligible for autopend, who were defined as those with a problem list diagnosis of diabetes mellitus (International Classification of Diseases, Ninth Revision codes 250.xx, 401.xx, 790.xx, 272.xx, 791.xx, 790.29), a designated primary care provider (PCP), and an activated patient portal (MyHealthOnline). A total of 8792 patients received 15,630 HMT reminders.

Autopend Functionality and the HMT System

Preautopend. HMT reminders were sent to patients independently of providers’ authorization. All HMT reminders included “usual” content, which stated “you are due for” an A1C test and instructed patients to check a website to see if their laboratory tests had been ordered. If not, patients had to contact their provider. The CDS included provider alerts only in the patient’s chart. Providers learned about upcoming laboratory tests either when contacted by a patient or if they opened the patient’s chart, perhaps during an office visit. The provider then reviewed the order, filled out the authorization form, and contacted the patient.

Postautopend. Autopend (1) routed upcoming laboratory test notifications to a separate electronic folder, in addition to including an alert in the patient’s chart; (2) automatically populated or “pended” preauthorization forms in the electronic folder; and (3) linked the timing and content of the patient HMT reminders to the provider authorization. If the provider approved the order, an HMT reminder with autopend content was sent to patients stating “your clinician has ordered” an A1C test and they could proceed directly to the laboratory. In this case, the patient could skip checking the website and potentially following up with their provider. If the provider declined or ignored the notification, an HMT reminder with usual content was sent and patients had to complete the additional steps (eAppendices A, B, and C [eAppendices available at ajmc.com] provide further description).