Improving Quality With Outpatient Decision Support

Assesses physician compliance with paper-based and electronic guidelines, reminders, and alerts for outpatient settings. Target areas for the reminders and alerts are disease management, medication management, and interpretation of abnormal test results.

Study Overview

Detailed Description

The evidence base for practicing medicine continues to improve. However, abundant data show that gaps exist between best evidence and practice. Moreover, health care costs are climbing at an alarming rate. We propose to ask three related questions: 1) how effective are computer decision-support systems for improving compliance with evidence-based guidelines and costs in the ambulatory setting; 2) what is the impact on guideline compliance of applications that allow clinicians to track and follow-up test results; and 3) what are the main barriers to acceptance of guidelines delivered via real-time clinical decision-support systems.

Our work and that of others has shown that computerized decision-support in the form of alerts and reminders can improve outcomes and reduce costs in the inpatient setting. However, fewer data are available in the outpatient setting. An elegant series of studies from Regenstrief found that certain computer-based interventions, such as displaying charges for tests, prior test results, and the likelihood that a particular test would be abnormal, all reduced outpatient utilization, and that reminders to perform health maintenance procedures improved compliance. However, such systems are still not used broadly and the full potential of computer-based technology remains to be tested.

Also, there is ample evidence that physicians do not always act optimally on the results of patient studies and often are remiss at communicating satisfactorily with patients about the results of these studies. This situation may be exacerbated by increasing patient volumes in the face of managed care. The ability of the computer to assist in the tracking and follow-up of test results as well as communication with patients remains to be evaluated.

Even though some benefits of computer-based decision-support systems have been documented, such systems are slow to be adopted. Moreover, even when computerized guidelines have resulted in demonstrable improvements, often this improvement has been smaller than anticipated. This proposal aims to better understand the barriers to guideline acceptance so that the benefits of computer based decision-support can be realized.

Our organization, Brigham and Women's Hospital, is in a particularly good position to study these issues. We have in place a highly developed clinical information system including an outpatient electronic medical records (EMR) application that has been an active part of the clinical workflow since 1999. The EMR application currently is used by primary care physicians at one of our major medical centers to track their patients' problems, medications, allergies, and health maintenance data. We are developing a new EMR that will be used more broadly across our network, and that features a new interface with added functionality. The new EMR will allow us to evaluate the state of the patient at the time of the visit and generate reminders if the patient is out of compliance for certain guidelines. It also includes outpatient order entry that allows physicians to enter medication and laboratory orders directly into the computer. Decision-support in order entry will allow us to guide physician decision making at the most opportune time, and then evaluate the result of that guidance. For automated decision-support applications to be widely adopted, it is critical that their benefits be demonstrated in a wide variety of situations. We plan to implement several different types of interventions targeted at various phases of the clinical workflow to determine which strategies can achieve the greatest benefit.

Specific Aims:

  1. To evaluate the effectiveness of paper-based and interactive computer-based alerts and reminders for improving compliance with guidelines and reducing costs in the ambulatory setting.
  2. To evaluate the impact of computer-based tracking and follow-up reminder systems on guideline compliance.
  3. To identify and address patient, clinician, and system barriers to the effective use of computer-based clinical decision-support strategies in a diverse array of clinical settings.

Study Type

Interventional

Enrollment

3000

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

    • Massachusetts
      • Boston, Massachusetts, United States, 02472
        • Brigham and Women's Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • All physicians in on-site and satellite adult outpatient clinics with the Brigham and Women's Hospital and Massachusetts General Hospital.
  • All practices must have adopted our home-grown electronic health record system, the Longitudinal Medical Record, for at least 24 months prior to the start of each intervention trial.

Exclusion Criteria:

  • None

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Prevention
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

What is the study measuring?

Primary Outcome Measures

Outcome Measure
1) Compliance to guidelines regarding the outpatient laboratory monitoring of prescription medication regiments
2) Compliance to guidelines regarding the follow-up of abnormal test results, including critically abnormal test results, abnormal cholesterol, abnormal HbA1c, abnormal pap smears and abnormal mammogram
3) Compliance to guidelines regarding the management of hypertension in the general ambulatory population and amongst ethnic minority groups
4) Compliance to guidelines regarding the screening and management of osteoporosis

Secondary Outcome Measures

Outcome Measure
1) Patient satisfaction regarding communication with physicians
2) Physician satisfaction regarding follow-up of abnormal test results

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Principal Investigator: David W Bates, MD MSc, Brigham and Women's Hospital

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

September 1, 2000

Study Completion

December 1, 2006

Study Registration Dates

First Submitted

September 22, 2005

First Submitted That Met QC Criteria

September 23, 2005

First Posted (Estimate)

September 26, 2005

Study Record Updates

Last Update Posted (Estimate)

September 26, 2005

Last Update Submitted That Met QC Criteria

September 23, 2005

Last Verified

September 1, 2005

More Information

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

Clinical Trials on Coronary Artery Disease

Clinical Trials on Computerized Reminders Medications Monitoring

3
Subscribe