Dealing with abnormal test results was one of the main misery points during my years in practice. It was too easy for things to fall through the cracks. When clinicians receive an abnormal result, the usual steps are: review the patient’s chart, decide what to do, and take action. Proper management may require additional tests, a referral, or a return visit. Of course, any of these actions may trigger a new round of tests, which could restart the process. The problem for any clinician is how to keep track of every decision for each patient.
I ran into tracking issues in my first job at a community health center. My attempts at using computers to address this problem started there as well. The facility had a DEC PDP-11 mini-computer with MUMPS and FileMan, which I used to create a list of patients along with their abnormal labs. This worked well. However, computer time was limited, and I was not able to use the system as often as I would have liked. Frequently, I had to keep paper notes until computer time was available, which brought me back to square-one.
The first tracking system that I used on a regular basis was a spreadsheet-based setup I created in the mid-’90s. While this system worked as intended, it simply managed paper reports. However, I had always dreamed of a completely electronic system that tracked outgoing orders and provided alerts for abnormal or missing results (i.e., ordered tests for which no results were received). Modern EHR systems with bi-directional lab interfaces offer this capability. Curiosity led me to investigate how well clinicians are faring in addressing this problem with EHRs.
Using MEDLINE, I looked for research studies that focused on results management in EHR environments. Here are two that capture the essence of the issues involved.
In Unintended Errors with EHR-Based Result Management: A Case Series (1), the authors looked at instances in which errors occurred in results delivery using a commercial EHR system. They noted:
While the advantages of instantaneous delivery and comprehensive tracking are significant, several examples of unexpected result management errors occurred while using an electronic result communication system. The reasons for the errors were varied and included problems with routing logic, provider records, system settings, and maintenance. A lack of understanding of the complex interplay between systems, lack of adequate testing, failure to follow procedures, and human error contributed to these mistakes. In the cases where errors occurred, there was inadequate redundancy built into the process to tolerate faults, and manual testing had a limited ability to find configuration and data integrity issues prior to their occurrence.
They offered four recommendations to others using electronic systems:
1. Develop fault-tolerant systems that automatically report delivery failures.
2. Use robust testing to find rare errors that occur both within and between systems.
3. Implement tracking mechanisms for critical tests, such as cancer screening and diagnostics.
4. Deliver results directly to patients.
These findings indicate that using an EHR does not automatically guarantee that results management will become a no-brainer. In fact, they indicate the need for additional processes to monitor EHR configurations as well as the actual test results.
A look at this issue in a VA setting appears in Understanding the Management of Electronic Test Result Notifications in the Outpatient Setting, by Hysong et al. (2). This paper describes the authors’ attempts to understand factors that determine how providers respond to abnormal test alerts. This study was initiated because of puzzling findings from the authors’ earlier studies. They commented:
We recently examined providers’ responses and follow-up actions on over 2500 alerts of abnormal test results in CPRS. Of these, we found providers did not acknowledge (i.e., did not read) 18.1% of alerts pertaining to abnormal imaging results and 10.2% of abnormal laboratory alerts. Furthermore, approximately 8% of abnormal imaging and 7% of abnormal laboratory results lacked timely follow-up at 30 days. We also found that there was no significant relationship between acknowledging an alert and timely follow-up.
Thus, despite delivery of test results directly to a clinician’s View Alert window, abnormal results did not always receive timely follow-up. Clinicians do not optimally utilize all of the functions in the EHR; for instance, we found that about half (46%) of clinicians did not use the specific features of the View Alert window that facilitate better processing of electronic alerts. Instead, providers often used handwritten notes or external systems (e.g., ticklers on their calendar) to help process their alerts.
In order to determine the reasons behind these findings, the authors conducted focus groups at two VA centers. Participants offered the following as reasons for results management issues:
- The number of alerts received
- Unnecessary and/or redundant alerts
- Providers’ lack of knowledge regarding features of the alert system
- Lack of a mechanism to manage and track alerts
Clearly, EHR systems can help with results management; however, they create new issues that healthcare organizations and providers must address. It appears that whether practices use paper or an EHR, there remains a need to create formal processes for managing results. In either case, managing test results remains a potential misery point, and better EHR system designs would likely improve matters.
From my personal perspective of sleepless nights spent worrying if anything had fallen through the cracks, results management is a prime example of the adage, “the more things change the more they stay the same.”
- Yackel TR, Embi PJ. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010 Jan-Feb;17(1):104-7.
- Hysong SJ, Sawhney MK, Wilson L, Sittig DF, Esquivel A, Singh S, Singh H. Understanding the management of electronic test result notifications in the outpatient setting. BMC Med Inform Decis Mak. 2011 Apr 12;11:22.