The Impact of a Web-Based Point-of-Care Tool on Physician Behavior and Patient Health Outcomes
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1 The Impact of a Web-Based Point-of-Care Tool on Physician Behavior and Patient Health Outcomes J.B. Jones, PhD, MBA 1, Xiaowei (Sherry) Yan, PhD 1, Hannah Husby, MPH 1, Jake Delatorre-Reimer, BA 1, Farah Refai, MPH 1, Shruti Vaidya, MS 1, Ridhima Nerlekar, MS 1, Karen MacDonald, BA 2 1 Sutter Health Research, Development & Dissemination, Walnut Creek, CA; 2 AstraZeneca, Wilmington, DE HEALTH CARE SYSTEMS RESEARCH NETWORK CONFERENCE 2019, PORTLAND, OR APRIL 8, 2019
2 Research supported by AstraZeneca No other relationships to disclose Disclosures
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 5
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 Epic Maestro (Middleware) CM-SHARE 7
8 Why Was CM-SHARE Developed? 8
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 timeconsuming 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 9
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 More technology? More clicks? Longer encounter? % Usage of CM-SHARE 100% 90% 80% 70% 60% 50% 40% 30% Use of CM-SHARE Among Different Patient Populations 20% 10% 0% 6/18/2018 7/18/2018 8/18/2018 9/18/ /18/ /18/ /18/2018 All Patients CM Patients CM Primary Dx CM Dx Present 11
12 Methods
13 Evaluation Overview Areas of Focus for CM-SHARE Pilot FIDELITY Use How often and when is CM- SHARE used by clinicians? PROCESS Time Does CM-SHARE impact time and clicks in the EHR? Quality Does CM-SHARE impact lab orders? LONG-TERM OUTCOMES Clinical Outcomes CM-SHARE 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? Does CM-SHARE impact patient HbA1c values?
14 EHR and Audit Data: Pre-Post Parallel Matched Comparison Evaluation Design Intervention group (Pilot Clinicians) Pre-cohort: Similar patients, similar encounters Comparing similar patients pre- and post- to make sure that differences are due to intervention, not time or bias CM-SHARE is not used CM-SHARE is used Pre-intervention Post-intervention Parallel control group Parallel control: Similar patients/ encounters, no opportunity for CM- SHARE use Application Go-live (4/2016) Parallel control: Similar patients/ encounters, no opportunity for CM- SHARE use 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% CM-SHARE was launched for 11,772 of 34,955 encounters June 1, June 30, 2018 Encounters with Patients with a Cardiometabolic Condition 37% Patients with Diabetes-Focused Encounters 61% CM-SHARE was launched for 8,781 of 23,471 encounters 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% Patients can benefit from CM SHARE s easy-tounderstand health data visuals June 1, June 30, 2018 Encounters with Patients with a Cardiometabolic Condition 37% Patients with Diabetes-Focused Encounters 61% Why these People?
18 Efficiency: Same Visit Length, Less Provider Computer Time for Diabetes and Hypertension Encounters Front desk checks in patient Complete check-in process MA/Nurse rooming patient Complete rooming process Exam Room Physician entrance Physician exit Patient is discharged Time Total office visit time CM-SHARE Launch Effect Average time on computer in control group (min) Diabetes and hypertension encounters with CM-SHARE 54 No Change Total Office Visit Time Physician Exam Room Time Physician Computer Time Physician exam room time Physician computer time in the exam room 20 No Change % Less Time
19 Front desk checks in patient Complete check-in process MA/Nurse rooming patient Complete rooming process Fewer Clicks on the Computer for Diabetes and Hypertension Encounters Exam Room 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 Clicks Total Encounter Clicks Physician Total Encounter Clicks Physician Exam Room Clicks CM-SHARE Launch Effect Average # of clicks in encounters of control group Diabetes and hypertension encounters with CM-SHARE 366 No Change % Fewer % Fewer
20 FIRST OFFICE VISIT CM-SHARE Patients with Diabetes Have More Frequent HbA1c Lab Monitoring 6 MONTHS 12 MONTHS 18 MONTHS Control Patients CM-SHARE Patients *p-value: *p-value: No Difference Average Number of HbA1c Lab Orders
21 FIRST OFFICE VISIT After 18 Months the CM-SHARE Group Demonstrates Slightly Lower HbA1c Values 6 MONTHS 12 MONTHS 18 MONTHS Control Patients CM-SHARE Patients No Difference No Difference Average HbA1c Difference 0.1 lower *p-value: 0.02
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
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