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Nudging Physicians and Patients With Autopend Clinical Decision Support to Improve Diabetes Management
Laura Panattoni, PhD; Albert Chan, MD, MS; Yan Yang, PhD; Cliff Olson, MBA; and Ming Tai-Seale, PhD, MPH
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Michael L. Barnett, MD, MS; Zirui Song, MD, PhD; Asaf Bitton, MD, MPH; Sherri Rose, PhD; and Bruce E. Landon, MD, MBA, MSc

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

Laura Panattoni, PhD; Albert Chan, MD, MS; Yan Yang, PhD; Cliff Olson, MBA; and Ming Tai-Seale, PhD, MPH
Incorporating an autopend functionality into clinical decision support improved glycated hemoglobin laboratory test completion by between 21.1% and 33.9% for reminder messages read within 57 days.
DISCUSSION

We evaluated the impact of incorporating a novel autopend functionality into the CDS on routine A1C laboratory test completion. We found that for HMT reminders read within 57 days, reminders sent in the postautopend period were associated with a 21.1% (HR, 1.211; P = .050) to 33.9% (HR, 1.339; P = .003) increase in the likelihood of laboratory test completion. This result included 68% of the HMT reminders. However, the likelihood of laboratory test completion decreased the longer it took the patient to read the reminder. Among unread reminders, we found no statistical difference in A1C laboratory test completion in the postautopend period.

The autopend design was guided by the behavioral economics principle of nudging people to do the right thing. Autopend allowed the majority of patients to skip checking an additional website and potentially contacting their provider to check the laboratory test’s authorization status. Relocating provider triggers from the patient’s chart to a separate electronic folder for providers to approve, as well as coordinating the timing and content of the patient reminders with the provider authorization, may have minimized alert fatigue,16 the electronic task demand (eg, clicks, data entry, and time), and the downstream actions required by both parties. This in turn may have reduced providers’ workflow interruption and cognitive burden, improving job performance and satisfaction.17,18 However, the effects of these design features were associated with diminishing improvements for patients who took longer to read their reminders.

Although 87.0% of the postautopend period HMT reminders had autopend content, caution should be exercised before concluding that laboratory test completion rates could have been higher had all patients received autopend content. Patient and provider characteristics associated with the usual-content HMT reminders, and not the actual reminder content, may have contributed to the lower rates. Future research should explore these factors and the CDS designs that address them.

Stage II of the Meaningful Use criteria established expectations of using CDS to engage patients and improve population health.19 Although technology such as autopend may have an important role in helping health systems realize the potential of EHRs, physicians spend significant time meeting the demands of “desktop medicine.”20-22 Requiring physicians to approve autopend orders for regulatory compliance, rather than allowing them to go directly to patients or to the inboxes of other care team members, may have unintended consequences on physicians’ workflow. The functionality may need to be modified to enable other care team members to approve these orders.

Limitations

This study has some limitations. The observational pre-post study design limits our ability to rule out confounding factors. However, we did statistically control for time trends through the use of quarter fixed effects. Secondly, this study took place in a single multispecialty delivery organization, which was an early adopter of EHRs, and autopend was added onto an existing EpicCare-specific HMT reminder system. Furthermore, this study included only patients with an active patient portal, limiting generalizability to other settings and patient populations. However, these principles of CDS design could be applied to other EHR systems.

CONCLUSIONS

Our study results suggest that incorporating an autopend functionality into a CDS system was associated with improvements in A1C laboratory test completion among patients with diabetes who read their HMT reminders in a timely fashion. This multifaceted functionality was designed to simplify workflow, remove barriers, and coordinate the actions of patients and clinicians. Such a CDS tool can improve the care of chronically ill patients in the spirit of the Quadruple Aim.23

Author Affiliations: Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center (LP), Seattle, WA; Sutter Health Office of Patient Experience (AC), Sacramento, CA; Palo Alto Medical Foundation Research Institute (AC, YY, CO), Palo Alto, CA; University of California San Diego School of Medicine (MT-S), San Diego, CA.

Source of Funding: Agency for Healthcare Research and Quality R18 HS 019167.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (LP, AC, YY, CO, MT-S); acquisition of data (CO, MT-S); analysis and interpretation of data (LP, AC, YY, CO); drafting of the manuscript (LP, AC); critical revision of the manuscript for important intellectual content (LP, AC, YY, MT-S); statistical analysis (YY); provision of patients or study materials (MT-S); obtaining funding (MT-S); administrative, technical, or logistic support (AC); and supervision (MT-S).

Address Correspondence to: Laura Panattoni, PhD, Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109. Email: lpanatto@fredhutch.org.
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