Diabetes MellitusNCT00225628
Improving Quality With Outpatient Decision Support
A study testing Computerized Reminders Medications Monitoring, Computerized Test Results Management Application and Computerized Reminders Hypertension Management in people with Diabetes Mellitus and Coronary Artery Disease, run by Agency for Healthcare Research and Quality (AHRQ) at 1 site in United States.
Trial summary
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. Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Diabetes Mellitus, Coronary Artery Disease, Osteoporosis
- What is being tested?
- Computerized Reminders Medications Monitoring, Computerized Test Results Management Application and Computerized Reminders Hypertension Management
- Type of treatment
- Lifestyle or therapy programme
- How many people
- 3,000 participants
- Where
- 1 siteUnited States
- Study dates
- Sep 2000to Dec 2006
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- 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.
Who cannot join
- None
Trial locations and contacts
1 site in 1 country.
United States1 site
Brigham and Women's Hospital
Boston, Massachusetts, 02472
About this study
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.
Read the 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:
- 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.
- To evaluate the impact of computer-based tracking and follow-up reminder systems on guideline compliance.
- 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.
- Being tested
- Computerized Reminders Medications Monitoring, Computerized Test Results Management Application, Computerized Reminders Hypertension Management, Computerized Reminders Osteoporosis Screening and Mgt
- Keywords
- Computerized clinical decision support, Patient Safety, Quality of Care, Electronic Medical Records, Chronic Disease Management, Drug Monitoring, Guideline Adherence, Reminder Systems
- Medical subject headings
- Diabetes Mellitus, Coronary Artery Disease, Osteoporosis, Hypertension, Hyperlipidemias
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Computerized Reminders Medications MonitoringBehavioural
Computerized Test Results Management ApplicationBehavioural
Computerized Reminders Hypertension ManagementBehavioural
Computerized Reminders Osteoporosis Screening and MgtBehavioural
What is being measured
The primary outcome is the main question the study is designed to answer.
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 outcomes (2)
1) Patient satisfaction regarding communication with physicians
2) Physician satisfaction regarding follow-up of abnormal test results
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted26 Sep 2005 (estimated)
- Study startSep 2000
- Study completionDec 2006
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (9)Papers the sponsor has linked to this study.
- Other trials for Diabetes MellitusStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 3,000 participants
Sponsor and investigators
- Lead sponsor
- Agency for Healthcare Research and Quality (AHRQ)
- Sponsor type
- US federal agency
- Investigators
- David W Bates, MD MSc, Principal investigator, Brigham and Women's Hospital
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT00225628
- Sponsor's protocol ID
- 5U18HS011046
- Status last verified
- Sep 2005
- First submitted
- 22 Sep 2005
- Last updated
- 26 Sep 2005
- Results posted
- No
Publications
Poon EG, Haas JS, Louise Puopolo A, Gandhi TK, Burdick E, Bates DW, Brennan TA. Communication factors in the follow-up of abnormal mammograms. J Gen Intern Med. 2004 Apr;19(4):316-23. doi: 10.1111/j.1525-1497.2004.30357.x.
PubMed 15061740Hickner JM, Fernald DH, Harris DM, Poon EG, Elder NC, Mold JW. Issues and initiatives in the testing process in primary care physician offices. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):81-9. doi: 10.1016/s1553-7250(05)31012-9.
PubMed 15791767Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004 Nov 8;164(20):2223-8. doi: 10.1001/archinte.164.20.2223.
PubMed 15534158Poon EG, Wald J, Bates DW, Middleton B, Kuperman GJ, Gandhi TK. Supporting patient care beyond the clinical encounter: three informatics innovations from partners health care. AMIA Annu Symp Proc. 2003;2003:1072.
PubMed 14728575Gandhi TK, Sequist TD, Poon EG, Karson AS, Murff H, Fairchild DG, Kuperman GJ, Bates DW. Primary care clinician attitudes towards electronic clinical reminders and clinical practice guidelines. AMIA Annu Symp Proc. 2003;2003:848.
PubMed 14728353Poon EG, Wang SJ, Gandhi TK, Bates DW, Kuperman GJ. Design and implementation of a comprehensive outpatient Results Manager. J Biomed Inform. 2003 Feb-Apr;36(1-2):80-91. doi: 10.1016/s1532-0464(03)00061-3.
PubMed 14552849Murff HJ, Gandhi TK, Karson AK, Mort EA, Poon EG, Wang SJ, Fairchild DG, Bates DW. Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems. Int J Med Inform. 2003 Sep;71(2-3):137-49. doi: 10.1016/s1386-5056(03)00133-3.
PubMed 14519406Sequist TD, Gandhi TK, Karson AS, Fiskio JM, Bugbee D, Sperling M, Cook EF, Orav EJ, Fairchild DG, Bates DW. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005 Jul-Aug;12(4):431-7. doi: 10.1197/jamia.M1788. Epub 2005 Mar 31.
PubMed 15802479Matheny ME, Gandhi TK, Orav EJ, Ladak-Merchant Z, Bates DW, Kuperman GJ, Poon EG. Impact of an automated test results management system on patients' satisfaction about test result communication. Arch Intern Med. 2007 Nov 12;167(20):2233-9. doi: 10.1001/archinte.167.20.2233.
PubMed 17998497
Study at a glance
From the registry record, last updated by the sponsor on 26 Sep 2005. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Improving Quality With Outpatient Decision Support
- ClinicalTrials.gov ID
- NCT00225628
- Acronym / sponsor ID
- 5U18HS011046
- Keywords
- Computerized clinical decision support, Patient Safety, Quality of Care, Electronic Medical Records, Chronic Disease Management, Drug Monitoring, Guideline Adherence, Reminder Systems
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 3,000 participants
- Lead sponsor
- Agency for Healthcare Research and Quality (AHRQ)US federal agency
- Study start
- Sep 2000
- Study completion
- Dec 2006
- First posted
- 26 Sep 2005 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
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.
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:
- 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.
- To evaluate the impact of computer-based tracking and follow-up reminder systems on guideline compliance.
- 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 design
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (2 listed)
- 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.
Key exclusion criteria (1 listed)
- None
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Computerized Reminders Medications Monitoring | Behavioural | – |
| Computerized Test Results Management Application | Behavioural | – |
| Computerized Reminders Hypertension Management | Behavioural | – |
| Computerized Reminders Osteoporosis Screening and Mgt | Behavioural | – |
Primary outcome
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
2 secondary outcomes
1) Patient satisfaction regarding communication with physicians
2) Physician satisfaction regarding follow-up of abnormal test results
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 26 Sep 2005.
- Background: PubMed 15061740Poon EG, Haas JS, Louise Puopolo A, Gandhi TK, Burdick E, Bates DW, Brennan TA. Communication factors in the follow-up of abnormal mammograms. J Gen Intern Med. 2004 Apr;19(4):316-23. doi: 10.1111/j.1525-1497.2004.30357.x.
- Results publication: PubMed 15791767Hickner JM, Fernald DH, Harris DM, Poon EG, Elder NC, Mold JW. Issues and initiatives in the testing process in primary care physician offices. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):81-9. doi: 10.1016/s1553-7250(05)31012-9.
- Results publication: PubMed 15534158Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004 Nov 8;164(20):2223-8. doi: 10.1001/archinte.164.20.2223.
- Results publication: PubMed 14728575Poon EG, Wald J, Bates DW, Middleton B, Kuperman GJ, Gandhi TK. Supporting patient care beyond the clinical encounter: three informatics innovations from partners health care. AMIA Annu Symp Proc. 2003;2003:1072.
- Results publication: PubMed 14728353Gandhi TK, Sequist TD, Poon EG, Karson AS, Murff H, Fairchild DG, Kuperman GJ, Bates DW. Primary care clinician attitudes towards electronic clinical reminders and clinical practice guidelines. AMIA Annu Symp Proc. 2003;2003:848.
- Results publication: PubMed 14552849Poon EG, Wang SJ, Gandhi TK, Bates DW, Kuperman GJ. Design and implementation of a comprehensive outpatient Results Manager. J Biomed Inform. 2003 Feb-Apr;36(1-2):80-91. doi: 10.1016/s1532-0464(03)00061-3.
- Results publication: PubMed 14519406Murff HJ, Gandhi TK, Karson AK, Mort EA, Poon EG, Wang SJ, Fairchild DG, Bates DW. Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems. Int J Med Inform. 2003 Sep;71(2-3):137-49. doi: 10.1016/s1386-5056(03)00133-3.
- Results publication: PubMed 15802479Sequist TD, Gandhi TK, Karson AS, Fiskio JM, Bugbee D, Sperling M, Cook EF, Orav EJ, Fairchild DG, Bates DW. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005 Jul-Aug;12(4):431-7. doi: 10.1197/jamia.M1788. Epub 2005 Mar 31.
- Derived from this study: PubMed 17998497Matheny ME, Gandhi TK, Orav EJ, Ladak-Merchant Z, Bates DW, Kuperman GJ, Poon EG. Impact of an automated test results management system on patients' satisfaction about test result communication. Arch Intern Med. 2007 Nov 12;167(20):2233-9. doi: 10.1001/archinte.167.20.2233.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
David W Bates, MD MSc principal investigator
Brigham and Women's Hospital
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Computerized Reminders Medications Monitoring, Computerized Test Results Management Application and Computerized Reminders Hypertension Management in people with Diabetes Mellitus and Coronary Artery Disease, run by Agency for Healthcare Research and Quality (AHRQ) at 1 site in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 2 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 26 Sep 2005. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
1) Compliance to guidelines regarding the outpatient laboratory monitoring of prescription medication regiments. The study lists 4 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT00225628, which also lists 9 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 26 Sep 2005.