Background
Objective
What are the perceived barriers and facilitators to completeness of CDR forms and timely reporting of notifiable conditions to PHAs?How do perspectives on these barriers and facilitators differ among providers, those at the clinics responsible for reporting and PHA staff responsible for processing CDR forms?
Methods
Settings and site selection
Instrument development
Data collection
Data analysis
Surveys
Interviews
Synthesis
Results
Population characteristics
Clinic | Location | Provider Type: Number | Service | # patients/month | Mode: Lab Orders | Mode: CDR → PHA |
---|---|---|---|---|---|---|
1 | Urban | MD:9; NP:4 | Primary Care | 1000 | electronic | fax |
2 | Urban | MD:140; NP:5 | Primary Care | 6700 | electronic | fax out of EMR |
3 | Urban | MD:8 | Teen Clinic | 1000 | electronic | fax |
4 | Urban | MD:37; NP:1; PA:2 | Adult Medicine | 2860 | electronic | fax/mail |
5 | Urban | MD:10; NP:1 | Primary Care | 2600 | electronic | mail |
6 | Urban | MD:9 | Women’s Health | 1000 | paper, fax | fax |
7 | Rural | MD:2 | Primary Care | 1200 | paper | fax |
Provider surveys
Knowledge and experience with reporting
Yes N (%) | |
---|---|
Have you ever completed a notifiable condition report form? | 17 (61) |
In the past year, have you received any training about Indiana’s reportable conditions requirements? | 6 (21) |
Does your clinic or organization have specific protocols for reporting cases to public health or the health department? | 24 (86) |
In the past year, were you provided with a list of conditions to report to public health or the health department? | 8 (28) |
Are you familiar with the different time frames for reporting specific notifiable conditions to public health or the health department? | 5 (17) |
In the past year, did you receive any calls from public health or the health department regarding a reportable case? | 3 (11) |
In the past year, did you need to call public health or the health department regarding a reportable case? | 8 (29) |
Barriers to reporting
Clinic reporter and PHA staff interviews
Overview
Clinics n (%) | PHAs n (%) | ||
---|---|---|---|
Theme 1: Greater reporting knowledge and experience is associated with perceptions of a minimal reporting burden
| |||
Sub-themes:
| Notifiable condition reporting is not a burden or time-consuming activity or interruptive of daily workflow for regular reporters | 7 (63.6) | - |
Reporting requirements (who should report, which conditions are reportable, which forms to use, reporting timeframes for different conditions) are clear for regular reporters | 7 (63.6) | - | |
Clinic settings in which regular reporters work have a well-established flow of information and process for handling new positive cases of reportable conditions | 7 (63.6) | - | |
Infrequent reporters perceive notifiable condition reporting as burdensome and interruptive of their workflow | 4 (36.4) | - | |
Reporting requirements are not clear for infrequent reporters | 4 (36.4) | - | |
Infrequent reporters assume that labs report notifiable conditions | 4 (36.4) | - | |
Infrequent reporters express confusion about whether their organization requires notifiable condition reporting | 4 (36.4) | - | |
Theme 2: A positive laboratory report initiates the case reporting process in both clinic and PHA settings
| |||
Sub-themes:
| Reporting workflow in begins with receipt of a positive lab result in both clinics and PHAs | 11 (100) | 9 (100) |
PHA workers begin case processing activities with receipt of a positive lab result | - | 9 (100) | |
Other than treatment orders based on a lab report, physicians are not involved reporting workflow | 11 (100) | ||
Lab reports are missing critical information, such as clinic name, patient phone number, etc., so are insufficient alone for case reporting | - | 9 (100) | |
Delays in lab reporting contribute to delayed CDR form completion | 3 (27.3) | ||
Theme 3: Inaccurate or missing information interrupts and delays reporting which contributes to timeliness, data quality and completeness issues
| |||
Sub-themes: | PHA workers perceive the majority of CDR forms they receive as generally incomplete, missing crucial information and low in data quality | - | 9 (100) |
PHA workers report frequent communications with clinics to gather needed case information | - | 9 (100) | |
PHA workers perceive that communications with clinics around reporting can be unproductive and frustrating | - | 9 (100) | |
Clinics are perceived as infrequent reporters due to their assumption that labs report to PHAs | - | 9 (100) | |
Specific to communications around notifiable condition reporting, clinic reporters perceive frequency of contact from PHAs as rare | 8 (72.7) | - | |
Inaccurate or missing contact information prevents reaching patients regarding treatment | 6 (54.5) | 9 (100) | |
Clinic reporters assume labs report so do not regularly submit CDR forms | 4 (36.4) | - | |
Clinic reporters are unaware that they are required to submit CDR forms | 4 (36.4) | - | |
Clinic reporters knowingly submit CDR forms with missing information | 3 (27.3) | - | |
Clinic reporters only complete CDR form fields that they deem pertinent | 2 (18.2) | - | |
Theme 4: Searching for needed information interrupts and delays reporting and case investigation workflow
| |||
Sub-themes: | Numerous and varied information resources are utilized to complete CDR forms, conduct investigations and/or close cases | 9 (81.8) | 9 (100) |
Clinic reporters spend time looking for, waiting for and compiling information from various sources (EHRs, different reporting and/or clinical systems, chart notes, lab reports, online searches, etc.) | 7 (63.6) | - | |
PHA workers spend a majority of their time looking for and compiling information from various sources to conduct case processing | - | 9 (100) | |
Theme 5: PHAs cannot be certain that the clinical advisories, updates and information they send are reaching their target audience
| |||
Sub-themes: | Clinic reporters do not have a clear idea about how information such as CDR form data is used by PHAs | 8 (72.7) | - |
Announcements and information sent by PHAs (fax, email) are not routinely distributed throughout the clinic | 5 (45.5) | - | |
Some clinics report they never receive announcements or information from PHAs | 4 (36.4) | - | |
Only PHA information deemed relevant is disseminated but how that determination is made is unclear to recipients | 3 (27.3) | - |
Theme: A positive laboratory report initiates the case reporting process in both clinic and PHA settings
“We have the [CDR] form that we fax, we put that form in the person’s medical record chart, put information in the computer, put our notes in there, and then they’re printing [the CDR form] and putting it in the chart. So there’s a lot of double-duty.” [Clinic 3, Respondent 1]
“It’s rare to get a complete lab report. But typically when I get things from a lab they don’t have all of the history or anything like that…” [PHA 3, Respondent 1]“Sometimes we only receive the patient’s name and test result on the [lab] report. And then the doctor’s office will say they gave all the information to the lab and wonder why we’re bothering them.” [PHA 1, Respondent 1]
“When we get the labs, whether it’s fax or in the mail or electronically, it’s all there so when we get it, we just look at it to see who it’s from, print off whatever information, and start our investigation. And then the lab might come through, it might not, so we already begin—so we have duplicates with the lab coming in and the provider but we, sometimes we already call the provider before we get it and we might have to go back and ask them to get the information. Or I just look into the computer to get it, because we have to look everyone up anyway.[..] It’s just a lot of paper work that we’re getting, duplicates.” [PHA 1, Respondent 3]
Theme: Inaccurate or missing information interrupts and delays reporting contributing to timeliness, data quality and completeness issues
“It might take you a month to get a hold of some of our patients.” [Clinic 2, Respondent 2]
“I know those conditions are getting reported and it must be by the lab.” [Clinic 4, Respondent 1]“I think that the vast majority of our providers and nurses, you know, think that the lab takes care of all of that.” [Clinic 5, Respondent 1]“We don’t fill out all of [the form]. We fill out the things that are pertinent.” [Clinic 3, Respondent 1]“…some patients, we can’t get a hold of so we go ahead and fax [the incomplete CDR form] to the health department and let them manage it.” [Clinic 2, Respondent 1]
“[reporters] leave out a lot of fields, whether it’s their treatment, or symptoms, or titer.” [PHA 2, Respondent 4]“It’s unusual … to have detailed info on a report…” [PHA 1, Respondent 2]
Theme: Searching for needed information interrupts and delays reporting and case investigation workflow
“[We look] in the chart…the EMR, but because the notes aren’t always in there, we may have to cobble that together. And all the demographics come from a different system.” [Clinic 1, Respondent 1]“A lot of [our] patients don’t have up-to-date contact numbers, so we may have to call their emergency contact or the pharmacy and ask if they’ve got an updated phone number for them.” [Clinic 6, Respondent 1]
“We look in InSight [local PHA database of labs, CDRs and case investigations], CareWeb [Web-based viewer of integrated EHRs]…the medical records section…we use Facebook, peoplesearch.com, 411, any kind of resource… Google the person’s name and a lot of the time we can find information on them.” [PHA 2, Respondent 4]“And we look up [Department of Corrections] records. Because the state forms ask us, was the person incarcerated?” [PHA 1, Respondent 3]“We have a rolodex to find the doctor’s information. Google—Google is my best friend if I don’t have something, I will Google immediately so that’s the big thing that I use. Or I use Healthgrades and WebMD. [..] sometimes the number on the lab won’t match, or we’ll get the lab electronically and there’ll be the name of the provider but not the phone number or there’ll be the name of the provider and the address but no phone number so I’ll do a Google search on the address or on the doctor to get the phone number so that I can call for information.” [PHA 2, Respondent 3]
“I spend approximately two hours on my phone every day [to clinics for CDR form information].” [PHA 1, Respondent 3]“The phone calls back and forth are typically the biggest [delay].” [PHA 1, Respondent 5]“I’ve never had anyone from the health department call me and say that they have questions, or unable to get ahold of the patient, or anything.” [Clinic 6, Respondent 1]