Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial

Abstract

Background and objective: Physician awareness of the results of tests pending at discharge (TPADs) is poor. We developed an automated system that notifies responsible physicians of TPAD results via secure, network email. We sought to evaluate the impact of this system on self-reported awareness of TPAD results by responsible physicians, a necessary intermediary step to improve management of TPAD results.

Methods: We conducted a cluster-randomized controlled trial at a major hospital affiliated with an integrated healthcare delivery network in Boston, Massachusetts. Adult patients with TPADs who were discharged from inpatient general medicine and cardiology services were assigned to the intervention or usual care arm if their inpatient attending physician and primary care physician (PCP) were both randomized to the same study arm. Patients of physicians randomized to discordant study arms were excluded. We surveyed these physicians 72 h after all TPAD results were finalized. The primary outcome was awareness of TPAD results by attending physicians. Secondary outcomes included awareness of TPAD results by PCPs, awareness of actionable TPAD results, and provider satisfaction.

Results: We analyzed data on 441 patients. We sent 441 surveys to attending physicians and 353 surveys to PCPs and received 275 and 152 responses from 83 different attending physicians and 112 different PCPs, respectively (attending physician survey response rate of 63%). Intervention attending physicians and PCPs were significantly more aware of TPAD results (76% vs 38%, adjusted/clustered OR 6.30 (95% CI 3.02 to 13.16), p<0.001; 57% vs 33%, adjusted/clustered OR 3.08 (95% CI 1.43 to 6.66), p=0.004, respectively). Intervention attending physicians tended to be more aware of actionable TPAD results (59% vs 29%, adjusted/clustered OR 4.25 (0.65, 27.85), p=0.13). One hundred and eighteen (85%) and 43 (63%) intervention attending physician and PCP survey respondents, respectively, were satisfied with this intervention.

Conclusions: Automated email notification represents a promising strategy for managing TPAD results, potentially mitigating an unresolved patient safety concern.

Clinical trial registration: ClinicalTrials.gov (NCT01153451).

Keywords: Tests pending at discharge; automated email notification; care transitions.

Figure 1

Example of an automated email notification received by intervention physicians. A typical radiology/pathology email generated by the system. There were three notification types: one for chemistry/hematology, radiology/pathology, and microbiology results. In this example, there were no pending radiology results at discharge; therefore, only pathology results were detected and reported by the system. This patient may have had other types of tests pending at discharge (TPADs) (eg, microbiology or chemistry/hematology), which would have triggered separate emails to the responsible physicians. All emails included standard information (eg, subject heading, patient name, medical record number, discharge date, contact information for the inpatient attending physician and primary care physician (PCP)), and results of TPADs. Non-network PCPs did not receive emails, but their contact information was included in emails sent to inpatient attending physician physicians. Therefore, the discharging attending physician could contact non-network PCPs after reviewing TPAD results.

Figure 2

Randomization scheme. If we randomized by attending physician alone, then a primary care physician (PCP) of a patient in the usual care arm may also care for a patient in the intervention arm (ie, cared for by a different inpatient attending physician). Upon receiving notification of a test pending at discharge (TPAD) result of the intervention patient, the PCP could look up TPAD results of the usual care patient. Conversely, if we randomized by PCP alone, then an attending physician of a usual care patient may also care for a patient in the intervention arm (ie, cared for by a different PCP). Upon receiving notification of a TPAD result of the intervention patient, the attending physician could look up TPAD results of the usual care patient. Although the proposed schema reduced our sample size by 50%, it provided adequate statistical power to evaluate inpatient provider awareness while allowing for an unbiased analysis of PCP awareness.

Figure 3

Patient enrollment. Flow of patients identified by the automated email notification system during the study period. Patients with tests pending at discharge (TPADs) discharged from the general medicine and cardiology services were identified by the system. The system was configured to automatically exclude patients with discordant physician pairs and patients for whom the attending physician and primary care physician (PCP) were the same individual. Additionally, it automatically excluded every other patient with only microbiology TPADs. Finally, it excluded patients with TPADs whose PCP could not be identified (ie, missing the internal ID), or whose responsible physicians were not previously randomized (ie, when research staff were unavailable to manually randomize the PCP at time of discharge before the randomization process was automated).