Abstract
To determine whether a clinical decision support system can favorably impact the delivery of emergency department and hospital services. Randomized clinical trial of three clinical decision support delivery modalities: email messages to care managers (email), printed reports to clinic administrators (report) and letters to patients (letter) conducted among 20,180 Medicaid beneficiaries in Durham County, North Carolina with follow-up through 9 months. Patients in the email group had fewer low-severity emergency department encounters vs. controls (8.1 vs. 10.6/100 enrollees, p < 0.001) with no increase in outpatient encounters or medical costs. Patients in the letter group had more outpatient encounters and greater outpatient and total medical costs. There were no treatment-related differences for patients in the reports group. Among patients <18 years, those in the email group had fewer low severity (7.6 vs. 10.6/100 enrollees, p < 0.001) and total emergency department encounters (18.3 vs. 23.5/100 enrollees, p < 0.001), and lower emergency department ($63 vs. $89, p = 0.002) and total medical costs ($1,736 vs. $2,207, p = 0.009). Patients who were ≥18 years in the letter group had greater outpatient medical costs. There were no intervention-related differences in patient-reported assessments of quality of life and medical care received. The effectiveness of clinical decision support messaging depended upon the delivery modality and patient age. Health IT interventions must be carefully evaluated to ensure that the resultant outcomes are aligned with expectations as interventions can have differing effects on clinical and economic outcomes.
Similar content being viewed by others
References
McGlynn, E. A., Asch, S. M., Adams, J., et al., The quality of health care delivered to adults in the United States. N. Engl. J. Med. 348:2635–2645, 2003.
Berwick, D. M., Nolan, T. W., and Whittington, J., The triple aim: Care, health, and cost. Health Aff. (Millwood) 27:759–769, 2008.
Lee, T. H., Bodenheimer, T., Goroll, A. H., Starfield, B., and Treadway, K., Perspective roundtable: Redesigning primary care. N. Engl. J. Med. 359:e24, 2008.
Rittenhouse, D. R., and Shortell, S. M., The patient-centered medical home: Will it stand the test of health reform? JAMA 301:2038–2040, 2009.
Coleman, K., Austin, B. T., Brach, C., and Wagner, E. H., Evidence on the chronic care model in the new millennium. Health Aff. (Millwood) 28:75–85, 2009.
Kindig, D. A., Understanding population health terminology. Milbank Q. 85:139–161, 2007.
Kindig, D. A., Asada, Y., and Booske, B., A population health framework for setting national and state health goals. JAMA 299:2081–2083, 2008.
Villagra, V. G., An obesity/cardiometabolic risk reduction disease management program: A population-based approach. Am. J. Med. 122:S33–S36, 2009.
Georgiou, A., Buchner, D. A., Ershoff, D. H., Blasko, K. M., Goodman, L. V., and Feigin, J., The impact of a large-scale population-based asthma management program on pediatric asthma patients and their caregivers. Ann. Allergy Asthma Immunol. 90:308–315, 2003.
Lynch, J. P., Forman, S. A., Graff, S., and Gunby, M. C., High-risk population health management–achieving improved patient outcomes and near-term financial results. Am. J. Manag. Care 6:781–791, 2000.
Mattke, S., Serxner, S. A., Zakowski, S. L., Jain, A. K., and Gold, D. B., Impact of 2 employer-sponsored population health management programs on medical care cost and utilization. Am. J. Manag. Care 15:113–120, 2009.
Loeppke, R., Nicholson, S., Taitel, M., Sweeney, M., Haufle, V., and Kessler, R. C., The impact of an integrated population health enhancement and disease management program on employee health risk, health conditions, and productivity. Popul. Health Manag. 11:287–296, 2008.
Cook, J., Michener, J. L., Lyn, M., Lobach, D., and Johnson, F., Practice profile. Community collaboration to improve care and reduce health disparities. Health Aff. (Millwood) 29:956–958, 2010.
Eisenstein, E. L., Ortiz, M., Anstrom, K. J., and Lobach, D. F., Health information technology economic evaluation. In: Kushniruk, A. W., and Borcycki, E. (Eds.), The Human and Social Side of Health Information Systems, 1st edition. Idea Group Publishing, Hershey, PA, pp. 240–258, 2008.
Lobach, D. F., Kawamoto, K., Kooy, K., et al., Proactive population health management in the context of a regional health information exchange using standards-based decision support. AMIA 2007 Annual Symposium Proceedings, Chicago, IL, November 2007. 2007.
Lobach, D. F., Low, R., Arbanas, J. A., Rabold, J. S., Tatum, J. L., Epstein, S. D, Defining and supporting the diverse information needs of community-based care using the web and hand-held devices. Proc. AMIA Symp. 398–402, 2001.
Kawamoto, K., and Lobach, D. F., Design, implementation, use, and preliminary evaluation of SEBASTIAN, a standards-based web service for clinical decision support. AMIA Symp. 2005:380–384, 2005.
EuroQol--a new facility for the measurement of health-related quality of life. The EuroQol Group. Health Policy. 16(3):199–208, 1990.
Goldstein, E., Cleary, P., Langwell, K., Zaslavsky, A., and Heller, A., Medicare managed care CAHPS®: A tool for performance improvement. Health Care Finance Rev. 22:101–107, 2001.
Steiner, B. D., Denham, A. C., Askin, E., Newton, W. P., Wroth, T., and Dobson, L. A., Community care of North Carolina: Improving care through community health networks (vol 6, pg 361, 2008). Ann. Fam. Med. 6:468, 2008.
O’Connor, P. J., Sperl-Hillen, J., Johnson, P. E., Rush, W. A., and Crain, A. L., Customized feedback to patients and providers failed to improve safety or quality of diabetes care: A randomized trial. Diabetes Care 32:1158–1163, 2009.
Prochaska, J. O., Decision making in the transtheoretical model of behavior change. Med. Decis. Making 28:845–849, 2008.
Andriole, K. P., Avrin, D. E., Weber, E., Luth, D. M., and Bazzill, T. M., Automated examination notification of emergency department images in a picture archiving and communication system. J. Digit. Imaging 14:143–144, 2001.
Kuperman, G. J., Teich, J. M., Tanasijevic, M. J., et al., Improving response to critical laboratory results with automation: Results of a randomized controlled trial. J. Am. Med. Inform. Assoc. 6:512–522, 1999.
Rind, D. M., Safran, C., Phillips, R. S., et al., Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch. Intern. Med. 154:1511–1517, 1994.
White, K. S., Lindsay, A., Pryor, T. A., Brown, W. F., and Walsh, K., Application of a computerized medical decision-making process to the problem of digoxin intoxication. J. Am. Coll. Cardiol. 4:571–576, 1984.
Lobach, D. F., Electronically distributed, computer-generated, individualized feedback enhances the use of a computerized practice guideline. Proc. AMIA Annu. Fall Symp. 493–497, 1996.
Rascati, K. L., Okano, G. J., and Burch, C., Evaluation of physician intervention letters. Med. Care 34:760–766, 1996.
Tierney, W. M., Hui, S. L., and McDonald, C. J., Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. Med. Care 24:659–666, 1986.
Balas, E. A., Austin, S. M., Mitchell, J. A., Ewigman, B. G., Bopp, K. D., and Brown, G. D., The clinical value of computerized information services. A review of 98 randomized clinical trials. Arch. Fam. Med. 5:271–278, 1996.
Becker, D. M., Gomez, E. B., Kaiser, D. L., Yoshihasi, A., and Hodge, R. H., Jr., Improving preventive care at a medical clinic: How can the patient help? Am. J. Prev. Med. 5:353–359, 1989.
Szilagyi, P. G., Bordley, C., Vann, J. C., et al., Effect of patient reminder/recall interventions on immunization rates: A review. JAMA 284:1820–1827, 2000.
Tseng, D. S., Cox, E., Plane, M. B., and Hla, K. M., Efficacy of patient letter reminders on cervical cancer screening: A meta-analysis. J. Gen. Intern. Med. 16:563–568, 2001.
Chen, C., Garrido, T., Chock, D., Okawa, G., and Liang, L., The Kaiser permanente electronic health record: Transforming and streamlining modalities of care. Health Aff. (Millwood). 28:323–333, 2009.
Eisenstein, E. L., Anstrom, K. J., Arbanas, J. A., et al., Assessing the potential economic value of health information technology interventions in a community-based health network. AMIA Annu. Symp. Proc. 2005:221–225, 2005.
Eisenstein, E. L., Anstrom, K. J., Marci, J. M., Crosslin, D. R., Johnson, F. S., Kawamoto, K., and Lobach, D. F., Developing a framework for conducting economic evaluations of community-based health information technology interventions. 2005. Washington, D.C.: AMIA Conference. 10-25-2005. Ref Type: Conference Proceeding, 2005.
Committee on Data Standards for Patient Safety; Board on Health Care Services. Patient Safety: Achieving a New Standard for Care. Philip Aspden, Janet M. Corrigan, Julie Wolcott, and Shari M. Erickson, Editors. The National Academies Press, Washington, D.C. 2004.
Heavy, S. R., House approves health data technology bill. http://newsyahoocom/s/nm/20060728/hl_nm/congress_health_technology_dc;_ylt=AvSsT8if7qSlqjVQ0HMehLwQ3QA;_ylu=X3oDMTA5aHJvMDdwBHNlYwN5bmNhdA-- . -Accessed 08-01/2006, 2006.
Sidorov, J., It ain’t necessarily so: The electronic health record and the unlikely prospect of reducing health care costs. Health Aff. (Millwood) 25:1079–1085, 2006.
Chaudhry, B., Wang, J., Wu, S., et al., Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Ann. Intern. Med. 144:742–752, 2006.
Eisenstein, E. L., Collins, R., Cracknell, B. S., et al., Sensible approaches for reducing clinical trial costs. Clin. Trials 5:75–84, 2008.
Acknowledgments
The authors would like to thank Allyn Meredith, MA, for her expert editorial assistance. Funding for this study was provided by grant R01HS015057 from the U.S. Agency for Healthcare Research and Quality, Rockville, MD. DFL and KK are part owners of Clinica Software, Inc., which holds the intellectual property rights, including a pending patent application, to a clinical decision support engine known as SEBASTIAN [17] that was used by the population health management interventions to identify patient care needs. Clinica is creating an open-source version of this CDS engine that has served as the basis of the Health Level 7 Decision Support Service standard. DFL is also a director of Clinica. ELE is an unpaid board member for QCIII, a software and services company specializing in information support and program development for cardiology service lines.
Trial Registration: http://clinicaltrials.gov/ct2/show/NCT00365885
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lobach, D.F., Kawamoto, K., Anstrom, K.J. et al. A Randomized Trial of Population-Based Clinical Decision Support to Manage Health and Resource Use for Medicaid Beneficiaries. J Med Syst 37, 9922 (2013). https://doi.org/10.1007/s10916-012-9922-3
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s10916-012-9922-3