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No News Is Not Always Good News

Let's improve patient notification about test results.

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The ordering and management of test results in a primary care setting is time consuming and involves a series of steps. Anywhere along this continuum, the process can break down and delay patient care or compromise patient safety. Accurate and timely communication of test results by the provider to the patient is essential to ensure good patient outcomes and patient satisfaction.

In the outpatient setting, between 8% and 25% of abnormal test results are followed up in a timely manner.1,2

Poor test result communication can be associated with delays in treatment and missed opportunities for follow-up.3 Failure to document that patients have been informed is also common.1,4 Ineffective communication about test results can also increase the risk of malpractice liability.5 Failures or delays in diagnosis constitute the fastest growing area of malpractice claims, with about one-fourth attributable to avoidable failures related to follow-up communication.6 Healthcare providers are and should be concerned that current test result management processes are unsatisfactory.3,7,8

The Diagnostic Testing Process

Patient notification processes vary across health clinics.9 However, the series of decisions and actions involved in the testing process itself are generally consistent.10 Methods used for test result communication are the most variable. A survey of 262 physicians found that approximately 17% to 32% had no reliable method of ensuring test results were received by patients.7 One-third did not always notify patients of abnormal test results, and physicians often depended on follow-up visits to inform patients of results.7

Some providers call patients to convey abnormal results or have a nurse or medical assistant give the results.9 Other clinics automatically schedule a patient for a follow-up visit for certain test results.9 Common reasons for not notifying patients of abnormal test results include: trivial results; follow-up is expected to be in clinic; patient unavailable; forgetfulness by provider; and lack of time by provider.7

Limited data are available about a reasonable standard of care for test result management. The aim of this article is to identify the components of a standardized approach to the management of test results in a primary care setting.     

EHR for Test Reporting

The use of the electronic health record (EHR) in primary care is rapidly expanding.11 Studies of settings in which test results were managed with an EHR showed that results were more likely to have interpretation by a clinician, documentation of patient notification, and documentation of a follow-up plan.12 EHR shows great potential to assist practices in test result management, but in areas involving clinician thought and input, such as follow-up on an abnormal test result, the EHR is not being utilized to its fullest potential.12

Some clinical settings using an EHR with automated test result notification showed lack of timely test result follow-up despite use of a test result alert system.2 Standardization of alert-management strategies, including improving provider knowledge of appropriate tools in the EHR to manage alerts, could reduce the lack of timely follow-up on abnormal diagnostic test results.13 Automated test result management systems that provide centralized test result tracking and facilitate contact with patients improved patient satisfaction with test result communication.5 However, despite the use of an EHR to facilitate communication of test results, follow-up remains a significant safety challenge.5,13

Impact on Patient

It is important that all test results be provided to patients in an efficient manner that is convenient to both patients and healthcare providers. A survey found that patients do not typically discuss their preference for test result communication.14 Studies that have examined patient notification have found that the majority of patients want to be notified of both normal and abnormal results.7,14,15 They prefer multiple methods of notification, including postal mail,9,16 email17 or direct phone contact.9,14,16 However, with the use of technologies such as a webpage or short message services, patients have expressed concern about information security.17

The Agency for Healthcare Research and Quality published a patient fact sheet, "Five Steps to Safer Health Care," to help ensure safer healthcare.18 Step three encourages the patient to ask the healthcare provider when and how test results will be provided and not to assume they are normal if not communicated.18 Encouraging patients to call their provider for test results is one way to help ensure that all patients receive test results. This can be burdensome for staff in a clinical setting.

The notification strategies utilized by providers can have a great impact on patient care because if an abnormal result is lost in a clinic, a "no news is good news" policy may provide false reassurance that everything is normal.19

Should the patient have a role in obtaining test results or should it be the sole responsibility of the clinician? In September 2011 the Department of Health and Human Services partnered with the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention and the Office of Civil Rights to propose a rule allowing patients access to their test results directly from the laboratory.20 The proposal states that direct patient access to laboratory test results would decrease provider workload, reduce the number of patients not receiving notification of test results, and reduce the risk of loss of follow-up.20 Even if this practice were implemented, the need for some intervention by clinicians to interpret the results for the patient would remain.

Strategies for Clinicians

Although the use of EHR in results management has shown promise in result reporting, EHR may not always query for an interpretation or follow-up plan.12 (And, many practices have not transitioned to EHR.) One study proposed the use of an algorithm for result reporting that could enhance patient satisfaction, but implementation was not evaluated.9 Settings that had some standardization in the process had better results reporting than those that did not.13 The implementation of the following strategies may assist clinicians to efficiently manage test results and ensure timely and accurate test result reporting to patients:

1. Familiarize yourself with the EHR functions that involve diagnostic test ordering and results reporting. Some systems have alerts for test results and overdue orders. Systems can generate result letters that can serve as the paper trail for documentation of reporting a result.

2. Develop an agreed upon practice guideline for test result management.

    a. Select a method for normal test result notification (letter, phone call).

    b. Select a method for abnormal test result notification (phone call, office visit).

    c. Select a method for tracking tests until completed (use function in EHR, determine a tracking method for practice, or develop your own tracking file).

    d. Select a method for patient communication about uncompleted ordered tests (a single reminder letter; phone call for more concerning outstanding orders).

3. When ordering tests:

    a. Inform patient about reason for ordered test.

    b. Inform patient about anticipated time frame for test result notification.

    c. Inform patient about method of communication for test result notification.

    d. Instruct patient to call for test results if test results are not communicated in the aforementioned time frame.

    e. Inform patient he or she will be informed of both abnormal and normal test results.

4. Document response to test result, follow-up plan and communication of test result to the patient in the EHR (a letter generated from EHR will log communication, new entry into EHR).

5. Track uncompleted tests (activate EHR overdue order alert function at time of test ordering; if no EHR, determine practice tracking method).

6. Track every test until follow-up recommendations are completed, or document patient's decline of the needed follow-up.

7. Breathe easy knowing you have completed the diagnostic test management process for your patient's ordered tests.

Your Responsibility

Patients who have diagnostic tests are entitled to have all test results reported to them in a timely manner. It is the responsibility of the ordering provider to ensure that all completed tests are reviewed, follow-up care is determined, and results are documented and communicated to the patient. Whether or not the patient has a responsibility in the diagnostic test management process requires further exploration. In the meantime, standardization of the process by use of guidelines can help clinicians efficiently and accurately notify patients about test results and positively impact outcomes and satisfaction.

References

1. Casalino LP, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med. 2009;169(12):1123-1129.

2. Singh H, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med. 2010;123(3):238-244.

3. Poon EG, et al. "I wish I had seen this test result earlier!" Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164(20):2223-2228.

4. Chen ET, et al. Crossing the finish line: follow-up of abnormal test results in a multisite community health center. J Natl Med Assoc. 2010;102(8):720-725.

5. Matheny ME, et al. Impact of an automated test results management system on patients' satisfaction about test result communication. Arch Intern Med. 2007;167(20):2233-2239.

6. Phillips RL Jr., et al. Learning from malpractice claims about negligent, adverse events in primary care in the United States Qual Saf Health Care. 2004;13(2):121-126.

7. Boohaker EA, et al. Patient notification and follow-up of abnormal test results. A physician survey. Arch Intern Med. 1996;156(3):327-331.

8. Murff HJ, et al. Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems. Int J Med Inform. 2003;71(2-3):137-149.

9. Hickner JM, et al. Issues and initiatives in the testing process in primary care physician offices. Jt Comm J Qual Saf. 2005;31(2):81-89.

10. Elder NC, Barney K. But what does it mean for me?" Primary care patients' communication preferences for test results notification. Jt Comm J Qual Patient Saf. 2012;38(4):168-176.

11. Edsall RL, Adler KG. User satisfaction with EHRs: Report of a survey of 422 family physicians. Fam Pract Manag. 2008;15(2):25-32.

12. Elder NC, et al. The management of test results in primary care: does an electronic medical record make a difference? Fam Med. 2010;42(5):327-33.

13. Hysong SJ, et al. Provider management strategies of abnormal test result alerts: a cognitive task analysis. J Am Med Inform Assoc. 2010;17(1):71-77.

14. Baldwin, DM et al. Patient preferences for notification of normal laboratory test results: A report from the ASIPS Collaborative. BMC Fam Pract. 2005,6(1):11.

15. Meza JP, Webster DS. Patient preferences for laboratory test results notification. Am J Manag Care. 2000;6(12):297-300.

16. Grimes GC, et al. Patient preferences and physician practices for laboratory test results notification. J Am Board Fam Med. 2009;22(6):670-667.

17. Grayston J, et al. Using new technologies to deliver test results in primary care: structured interview study of patients' views. Primary Health Care Research & Development. 2010;11(2):142-154.

18. Agency for Healthcare Research and Quality. Five steps to safer health care. Patient fact sheet. http://www.ahrq.gov/patients-consumers/care-planning/errors/5steps/index.html

19. Hallock ML, et al. A macro-ergonomic work system analysis of the diagnostic testing process in an outpatient health care facility for process improvement and patient safety. Ergonomics. 2006;49(5-6):544-566.

20. Davis TG, Singh H. Should patients get direct access to their laboratory test results? An answer with many questions. JAMA. 2011; 306(22):2502-2503.

Caroline Sullivan is an adult nurse practitioner at Columbia Advanced Practice Nurse Associates in New York City.




     

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