Devi Sundaresan

Patient Portals: An Underused Resource for Improving Patient Engagement

The potential of patient portals to improve patient engagement and health outcomes has been discussed for more than a decade. The slow growth in patient portal adoption rates among patients and providers in the United States, despite external incentives, indicates that this is a complex issue. We examined evidence of patient portal use and effects with a focus on the pulmonary domain. We found a paucity of studies of patient portal use in pulmonary practice, and highlight gaps for future research. We also report on the experience of a pulmonary department using a patient portal to highlight the potential of these systems.

Improving Rates of Influenza Vaccination Through Electronic Health Record Portal Messages, Interactive Voice Recognition Calls and Patient-Enabled Electronic Health Record Updates: Protocol for a Randomized Controlled Trial

Background Clinical decision support (CDS), including computerized reminders for providers and patients, can improve health outcomes. CDS promoting influenza vaccination, delivered directly to patients via an electronic health record (EHR) patient portal and interactive voice recognition (IVR) calls, offers an innovative approach to improving patient care. Objective To test the effectiveness of an EHR patient portal and IVR outreach to improve rates of influenza vaccination in a large multispecialty group practice in central Massachusetts. Methods We describe a nonblinded, randomized controlled trial of EHR patient portal messages and IVR calls designed to promote influenza vaccination. In our preparatory phase, we conducted qualitative interviews with patients, providers, and staff to inform development of EHR portal messages with embedded questionnaires and IVR call scripts. We also provided practice-wide education on influenza vaccines to all physicians and staff members, including information on existing vaccine-specific EHR CDS. Outreach will target adult patients who remain unvaccinated for more than 2 months after the start of the influenza season. Using computer-generated randomization and a factorial design, we will assign 20,000 patients who are active users of electronic patient portals to one of the 4 study arms: (1) receipt of a portal message promoting influenza vaccines and offering online appointment scheduling; (2) receipt of an IVR call with similar content but without appointment facilitation; (3) both (1) and (2); or (4) neither (1) nor (2) (usual care). We will randomize patients without electronic portals (10,000 patients) to (1) receipt of IVR call or (2) usual care. Both portal messages and IVR calls promote influenza vaccine completion. Our primary outcome is percentage of eligible patients with influenza vaccines administered at our group practice during the 2014-15 influenza season. Both outreach methods also solicit patient self-report on influenza vaccinations completed outside the clinic or on barriers to influenza vaccination. Self-reported data from both outreach modes will be uploaded into the EHR to increase accuracy of existing provider-directed EHR CDS (vaccine alerts). Results With our proposed sample size and using a factorial design, power calculations using baseline vaccination rate estimates indicated that 4286 participants per arm would give 80% power to detect a 3% improvement in influenza vaccination rates between groups (α=.05; 2-sided). Intention-to-treat unadjusted chi-square analyses will be performed to assess the impact of portal messages, either alone or in combination with the IVR call, on influenza vaccination rates. The project was funded in January 2014. Patient enrollment for the project described here completed in December 2014. Data analysis is currently under way and first results are expected to be submitted for publication in 2016. Conclusions If successful, this study’s intervention may be adapted by other large health care organizations to increase vaccination rates among their eligible patients. ClinicalTrial ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277 (Archived by WebCite at http://www.webcitation.org/6fbLviHLH).

Association of Self-Monitoring of Blood Glucose Use on Glycated Hemoglobin and Weight in Newly Diagnosed, Insulin-Naïve Adult Patients with Type 2 Diabetes

Background: Clinical trials have shown that self-monitoring of blood glucose (SMBG) combined with patient education and medication titration can lead to improved glycated hemoglobin (HbA1c) and reduced weight in recently diagnosed non-insulin-treated type 2 diabetes mellitus (T2DM) patients. This retrospective matched cohort study assessed the association of SMBG with achieving long-term clinical outcomes in these patients in a real-world clinical setting. Methods: Using electronic medical records (2008–2011), we selected a population of adult patients recently diagnosed with T2DM not receiving insulin who were SMBG users and a population of non-SMBG controls with similar demographic and clinical characteristics using propensity score matching. The main study outcomes compared between the two groups were time to achieve (1) HbA1c <7% for patients with baseline HbA1c ≥7% and (2) a ≥5% reduction in weight from baseline. Results: Of the 589 patients identified in each group, 113 in each group had a baseline HbA1c ≥7% (mean, 8.2%). The SMBG users were more likely to achieve an HbA1c <7% (12 months: 58.4% versus 38.9%, p = .0037; 36 months: 84.0% versus 70.0%, p = .0013) and to do so faster (median, 6.5 versus 20.5 months; log-rank p = .0016). Self-monitoring of blood glucose was associated with faster weight reduction (median time to achieve a ≥5% reduction, 23.5 versus 35.9 months for SMBG and non-SMBG, respectively; log-rank p = .0005). Conclusions: In newly diagnosed T2DM insulin-naïve patients, SMBG users had an improved rate of achieving long-term glycemic control and weight loss in a real-world clinical setting.

Improving Rates of Outpatient Influenza Vaccination Through EHR Portal Messages and Interactive Automated Calls: A Randomized Controlled Trial

BackgroundPatient reminders for influenza vaccination, delivered via electronic health record (EHR) patient portal messages and interactive voice response (IVR) calls, offer an innovative approach to improving patient care.ObjectiveTo test the effectiveness of portal and IVR outreach in improving rates of influenza vaccination.DesignRandomized controlled trial of EHR portal messages and IVR calls promoting influenza vaccination.ParticipantsAdults with no documented influenza vaccination 2 months after the start of influenza season (2014–2015).InterventionUsing a factorial design, we assigned 20,000 patients who were active portal users to one of four study arms: (a) receipt of a portal message promoting influenza vaccines, (b) receipt of IVR call with similar content, (c) both a and b, or (d) neither (usual care). We randomized 10,000 non-portal users to receipt of IVR call or usual care. In all intervention arms, information on pneumococcal vaccination was included if the targeted patient was overdue for pneumococcal vaccine.Main MeasuresEHR-documented influenza vaccination during the 2014–2015 influenza season, measured April 2015.Key ResultsAmong portal users, 14.0% (702) of those receiving both portal messages and calls, 13.4% (669) of message recipients, 12.8% (642) of call recipients, and 11.6% (582) of those with usual care received vaccines. On multivariable analysis of portal users, those receiving portal messages alone (OR 1.20, 95% CI 1.06–1.35) or IVR calls alone (OR 1.15 95% CI 1.02–1.30) were more likely than usual care recipients to be vaccinated. Those receiving both messages and calls were also more likely than the usual care group to be vaccinated (ad hoc analysis, using a Bonferroni correction: OR 1.29, 97.5% CI 1.13, 1.48). Among non-portal users, 8.5% of call recipients and 8.6% of usual care recipients received influenza vaccines (p = NS). Pneumococcal vaccination rates showed no significant improvement.ConclusionsOur outreach achieved a small but significant improvement in influenza vaccination rates.Registration: ClinicalTrials.gov Identifier NCT02266277 (https://clinicaltrials.gov/ct2/show/NCT02266277).

A retrospective study to assess clinical characteristics and time to initiation of open-triple therapy among patients with chronic obstructive pulmonary disease, newly established on long-acting mono- or combination therapy

Introduction An incremental approach using open-triple therapy may improve outcomes in patients with chronic obstructive pulmonary disease (COPD). However, there is little sufficient, real-world evidence available identifying time to open-triple initiation. Methods This retrospective study of patients with COPD, newly initiated on long-acting muscarinic antagonist (LAMA) monotherapy or inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) combination therapy, assessed baseline demographics, clinical characteristics, and exacerbations during 12 months prior to first LAMA or ICS/LABA use. Time to initiation of open-triple therapy was assessed for 12 months post-index date. Post hoc analyses were performed to assess the subsets of patients with pulmonary-function test (PFT) information and patients with and without comorbid asthma. Results Demographics and clinical characteristics were similar between cohorts in the pre-specified and post hoc analyses. In total, 283 (19.3%) and 160 (10.9%) patients had moderate and severe exacerbations at baseline, respectively, in the LAMA cohort, compared with 482 (21.3%) and 289 (12.8%) patients in the ICS/LABA cohort. Significantly more patients initiated open-triple therapy in the LAMA cohort compared with the ICS/LABA cohort (226 [15.4%] versus 174 [7.7%]; P<0.001); results were similar in the post hoc analyses. Mean (standard deviation) time to open-triple therapy was 79.8 (89.0) days in the LAMA cohort and 122.9 (105.4) days in the ICS/LABA cohort (P<0.001). This trend was also observed in the post hoc analyses, though the difference between cohorts was nonsignificant in the subset of patients with PFT information. Discussion In this population, patients with COPD are more likely to initiate open-triple therapy following LAMA therapy, compared with ICS/LABA therapy. Further research is required to identify factors associated with the need for treatment augmentation among patients with COPD.

PS2-6: Who Opens Alerts to Physicians? (And Who Doesn’t?)

Background/Aims With the increasing adoption of electronic medical records (EMR), there are many opportunities to implement systems of information flow, like alerts to providers. Tests of such systems have varied results. Methods Within a multispecialty group practice that uses Epic EMR, we conducted a trial of automated alerts to primary care physicians and their staff when older patients were discharged from hospital to home. We generated alerts for new medications, drug interactions, dose problems, or monitoring needs. Provider staff received alerts to schedule an office visit. Alerts appeared in the recipient’s Epic in-basket. Using EMR “digital crumbs”, we tracked the length of time before alerts were viewed. We analyzed the impact of physician age, gender, department, and employment status (full-time, part-time). We also analyzed the impact of patient conditions, including age, gender, comorbidity, and number of office visits in the previous year. Results Of 763 alerts to physicians, 616 (81%) were opened within one day. Characteristics associated with timely opening were age <50 (OR 1.7, 95% CI 1.1, 2.6) and full-time employment (OR 2.9, 95% CI 1.6, 5.2). Of 1928 alerts to staff, 1173 (61%) were opened within one day. Physician characteristics associated with staff opening of alerts were gender (staff of male physicians were more likely to open the alerts within one day [OR 1.8, 95% CI 1.4, 2.4]), and being a member of the Family Medicine department (OR 1.9, 95% CI 1.3, 2.6) or sub-specialty department (OR 16.6, 95% CI 2.3, 122.3). Staff of full-time physicians were less likely to open alerts within one day (OR 0.64, 95% CI 0.47, 0.87). Controlling for patient characteristics had no impact on results. Conclusions Special efforts may be required to reach physicians working part-time and older physicians. The characteristics related to staff opening of alerts are specific to this group practice, but the high level of variability across physician types and departments is likely to be an issue in many settings. Design of a system directed at reaching staff quickly may require in-depth assessment of work flow and communication patterns in clinical departments.