Improving Test Result Follow-up through Electronic Health Records Requires More than Just an Alert

Abstract

A recent American Medical Association report highlighted failures in communication of abnormal test results as an important but understudied facet of improving safety in ambulatory care. 1 Because many outpatient test results are not life-threatening and don't require verbal communication, health information technology (IT) has potential to reliably transmit result information in the fragmented outpatient setting. Thus, few will disagree that communication of abnormal test results is an obvious context where advantages of health IT will be observed.In this issue of JGIM, Callen et al. report the results of a timely systematic review of 19 studies that documented quantitative evidence of test results not followed up in ambulatory settings. 2 They found wide variation in abnormal results lacking follow-up: 7 % to 62 % for laboratory, and 1 % to 36 % for imaging tests. Although evidence of the effectiveness of electronic test management systems was limited, there was a general trend towards improved followup in electronic systems.In another article in this issue, El-Kareh et al. discuss the results of a randomized controlled trial that put electronic communication to the test. The authors studied the effectiveness of sending microbiology test result alerts via a secure, internal e-mail system to clinicians when results were finalized post-discharge. 3 They found better documented evidence of appropriate follow-up within 3 days in the intervention group (28 % vs. 13 % in controls). Neither group's laboratory follow-up rate was particularly encouraging.On the bright side, both studies used distinctly different research approaches to reach similar conclusions, i.e., application of information and communication technologies, such as electronic health records (EHRs) with alerting capability, can increase the likelihood of appropriate test result follow-up. In paper-based systems, evaluating evidence of follow-up is itself challenging. On the other hand, both articles remind us that using EHR-based technology by itself does not entirely solve the problem of failure to follow up test results. Callen et al., as well as others, have made a strong case for addressing these failures based on safety implications. Additionally, Stage 2 meaningful EHR use (slated for implementation in 2014) includes laboratory test result reporting criteria. Time is now ripe for novel approaches to understand and improve this complex problem.The use of technology in the complex healthcare system must take into context the social environment where technology is embedded. For example, Callen et al. found lack of clear policies and procedures in relation to test result follow-up. We previously identified ambiguity of responsibility for test result follow-up to be a key factor in failure to follow up abnormal results. 4 Several EHRs now use asynchronous alert notifications to transmit results, but providers often receive many other types of notifications in their electronic in-box. We found that primary care providers (PCPs) receive a mean of 57 ale...

Communication breakdowns and diagnostic errors: a radiology perspective

“…Although the result is entered into the patient’s electronic record, the ordering physician is not alerted and does not view the result until the patient’s follow up visit several weeks later. In this instance, the lack of a direct computerized provider order entry (COPE) system created the opportunity for transcription errors, and the absence of a two-way system-to-system interface for ordering tests prevented the results from being routed to the ordering provider once it became available [35]. …”

Implementation Science Workshop: Implementation of an Electronic Referral System in a Large Academic Medical Center

“…Evaluation dimensions can often be anticipated by addressing the eight dimensions of the model. 33,34 Experience with several studies 31,[35][36][37] has revealed that consideration of all eight dimensions of the sociotechnical model is essential to an understanding of successful implementation, use and evaluation of health IT-related interventions. Many of these dimensions were addressed in the case study, as detailed below.…”

“…Similarly, external factors such as reimbursement systems, legal considerations, national quality measurement initiatives, accreditation and other policy and regulatory requirements all have influence on the success of health IT-based communication interventions. 33 The case study recognized these external rules and regulations by considering referral rates and their possible impact on health systems participating in global payment or shared savings contracts.…”

Visible but Unseen?

“…In continuation of this finding, systems that rely on clinicians to "pull" information from the system are not sufficient [11], partly because critical results are overlooked and partly because clinicians waste time accessing the system in vain before the results are available. The alternative approach of "pushing" information to physicians by means of alerts does, however, not ensure consistent follow-up on test results [25]. Physicians who receive a large number of alerts may, for example, experience alert fatigue and stop reacting promptly to alerts [24].…”