Critique date: Tue, 01/17/2012 - 10:39pm
Article Citation
Citation:
Loo ST, et al. Electronic Medical Record Reminders and Panel Management to Improve Primary Care of Elderly Patients. Arch Intern Med 2011; 171 (17): 1552-1558.
Clinical Bottom Lines
EMR reminders alone were effective to improve the rate of influenza vaccination and pneumococcal vaccination. However, more time and effort consuming practice guidelines, such as designation of health care proxy (HCP) or bone density screening required follow up contact by a panel manager in addition to EMR reminder, to achieve practice improvement.
Disclaimer:
This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.
Methods
Study Design:
Randomized, controlled clinical trial
Setting:
Primary care office in urban academic medical center
Patient Population:
Fifty-four faculty primary care physicians (PCP) practicing in 2 separate office locations within an urban academic medical center in Boston, MA were recruited. Physician characteristics were similar.
4640 patients (1930 in control arm, 1336 in EMR reminder arm, and 1394 in EMR reminder plus panel manager arm).
Inclusion criteria
65 years or older at the start of the study
Having a designated faculty PCP at the start of the study
Complete at least 1 visit to the practice in 18 months before the study start
Intervention/Exposure:
Fifty-four PCPs were divided into 3 arms: EMR reminder, EMR reminder plus panel manager, and usual care (control). Thirty four PCPs were located in office A and were provided with the new EMR reminder, and half of this group (n=17) were randomly assigned to also have a panel manager to assist them with the 4 targeted practice behaviors. The 20 remaining faculties in office B were assigned to the control arm.
Intervention
EMR reminder arm
New EMR reminders were activated. They were displayed in each patient's EMR available at the point of care and also in summary form in the provider's panel list for patients who are 65 years or older
The EMR reminders included advance directives, aspirin chemoprevention, Beers medication alerts, fall screening, osteoporosis screening, and vaccinations for influenza and pneumococcus
Reminders were displayed by a "geriatric alerts" link on the patient’s profile, the first screen visualized when opening a record. Clicking on this link would bring the user to a new screen, a geriatrics sheet status for each reminder. Each reminder displayed was an active link, allowing the user to respond to the reminder by processing or declining the suggested action.
Viewing or responding to a reminder was voluntary and completely at the discretion of the user.
EMR reminder plus panel manager arm
The panel manager is an administrative assistant without any specific clinical training who spent half of his time working on this study. He assisted physicians and patients in completing 4 targeted practice behaviors
The panel manager reviewed EMR’s geriatrics patient list for each assigned provider. That lists displays which patients had no HCP, or due for osteoporosis screening or pneumococcal or influenza vaccination.
After obtaining consent from the PCP, the panel manager attempted to contact the patient with phone up to 3 times. If not reached, letter with the same content was sent.
Two cycles of contact were attempted, one during first 6-month period, and then another during the last 6-month period.
On reaching the patient, the panel manager first verified the patient completed the care due or not. If not, the panel manager described the care due and stated explicitly that their PCP recommended the care. The panel manager also facilitated completion by mailing form, placing an order, scheduling a test.
Control arm
PCPs continue to use the existing EMR without the new reminders
Outcome Measures:
Designation of health care proxy, which was defined as a verified proxy documented in the EMR's health care proxy field
Initial bone density scan, which was defined as having a bone density scan ordered or completed
Administration of influenza vaccine, which was defined as vaccination documented as given at any location
Administration of pneumococcal vaccine, which was defined as vaccination documented as given at any location
Results
Results:
There were no significant differences across the arms in performances of 4 quality measures in the year before study or in the percentage of patients who already had completed the recommended care before the start of the study.
Among patients without a HCP, HCP was designated in 6.5% in control arm, 8.8% in EMR reminder arm (OR 1.45, 95%CI 0.95-2.22), and 19.7% in EMR reminder plus panel manager arm (OR 3.40, 95%CI 2.33-4.97). EMR reminder plus panel manager arm achieved higher rates than EMR reminder alone (OR 2.34, 95%CI 1.64-3.33)
Among patients without bone density screening, a test was completed in 17.7% in control arm, 19.7% in EMR reminder arm (OR1.10, 95%CI 0.70-1.72), and 30.5% in EMR reminder plus panel manager arm (OR 1.97, 95%CI 1.28-3.04). EMR reminder plus panel manager arm achieved higher rates than EMR reminder alone (OR1.80, 95% CI 1.18-2.73)
Influenza vaccine was given to 46.8% in control arm, 56.5% in EMR reminder arm (OR 1.44, 95%CI 1.18-1.76), and 59.7% in EMR reminder plus panel manager arm (OR 1.68, 95% CI 1.34-2.10). The difference between EMR reminder arm and EMR reminder plus panel manager arm was not statistically significant (OR 1.16, 95% CI 0.93-1.45).
Among patients who had not received pneumococcal vaccine, vaccine was given to 13.1% in control arm, 19.5% in EMR reminder arm (OR 1.47, 95% CI 1.02-2-11), and 25.6% in EMR reminder plus panel manager arm (OR 2.05, 95%CI 1.31-3.23). The difference between EMR reminder arm and EMR reminder plus panel manager arm was not statistically significant (OR 1.40, 95% CI 0.88-2.21).
Methodological Issues…
Methodological Issues and Applicability to Older Adults:
It is not clear about the definition of “bone density scan”, which was defined as “ordered or completed”. Order of the test by PCPs does not guarantee actual completion of the test. By combining “ordered” and “completed”, the effect of intervention would be overestimated.
It is not clear how long after the end of intervention outcomes were obtained. For patients seen toward the end of intervention, effect of panel management may not be accurately reflected.
Other Information
Funding Source and Role:
Donald W. Reynolds Foundation
Created By:
Shunichi Nakagawa, MD. Second Year Fellow. Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine
Disclaimer: This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.
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