Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record

Managing Critical Patient-Reported Outcome Measures in Oncology Settings: System Development and Retrospective Study

BACKGROUND

Remote monitoring programs based on the collection of patient-reported outcome (PRO) data are being increasingly adopted in oncology practices. Although PROs are a great source of patient data, the management of critical PRO data is not discussed in detail in the literature.

OBJECTIVE

This first-of-its-kind study aimed to design, describe, and evaluate a closed-loop alerting and communication system focused on managing PRO-related alerts in cancer care.

METHODS

We designed and developed a novel solution using an agile software development methodology by incrementally building new capabilities. We evaluated these new features using participatory design and the Fit between Individuals, Task, and Technology framework.

RESULTS

A total of 8 questionnaires were implemented using alerting features, resulting in an alert rate of 7.82% (36,838/470,841) with 13.28% (10,965/82,544) of the patients triggering at least one alert. Alerts were reviewed by 501 staff members spanning across 191 care teams. All the alerts were reviewed with a median response time of 1 hour (SD 185 hours) during standard business hours. The most severe (red) alerts were documented 56.83% (2592/4561) of the time, whereas unlabeled alerts were documented 27.68% (1298/4689) of the time, signaling clinician concordance with the alert thresholds.

CONCLUSIONS

A PRO-based alert and communication system has some initial benefits in reviewing clinically meaningful PRO data in a reasonable amount of time. We have discussed key system design considerations, workflow integration, and the mitigation of potential impact on the burden of care teams. The introduction of a PRO-based alert and communication system provides a reliable mechanism for care teams to review and respond to patient symptoms quickly. The system was standardized across many different oncology settings, demonstrating system flexibility. Future studies should focus on formally evaluating system usability through qualitative methods.

Improving Results Management Processes in an Acute Hospital Using a Multi-Faceted Approach

BACKGROUND

Radiological examinations and laboratory tests are routinely ordered by hospital physicians as part of the care plan to diagnose and treat patients. However, the failure to actively review and follow-up on these results pose a significant problem to patient safety. A study team was formed to mitigate the clinical risks of poor results management, which was identified as a top clinical risk in our organisation, in order to make improvements to the results management process and to ensure the timely review, acknowledgement, and follow-up of test results.

METHODS

The institutional expectations of results management were set and published as a hospital policy, which was communicated to all clinical departments for compliance. Improvements to the electronic medical records system were made to facilitate the results acknowledgement process, and physicians were engaged to educate them on the importance of results management.

RESULTS

The study team observed a decrease in unacknowledged results from approximately 16,000 in March 2017 to 2673 in December 2020. The compliance rate for acknowledgement results increased from a monthly average of 83.7% (from March to December 2017) to a monthly average of 99.3% (in 2020). The risk score for results management decreased from 16 to 6.5, and was excluded from the organisation's top clinical risks.

CONCLUSION

This study showed the importance of both system improvements and culture changes that are required to improve the process of results management, and provides a step forward for the hospital to safeguard patient safety and mitigate clinical risk.

Electronic Health Record Transition and Impact on Screening Test Follow-Up

INTRODUCTION

Nonurgent clinically significant test results (CSTRs) are a common cause of missed and delayed diagnoses. However, little is known about the impact of electronic health record (EHR) transitions on CSTR follow-up. This study examines follow-up rates for three CSTRs (incidental pulmonary nodules [IPNs]), prostate-specific antigen [PSA], and Pap smears) before and after EHR transition.

METHODS

This is a retrospective cohort study at an urban tertiary medical center using an interrupted time series (ITS) design to assess monthly changes in CSTR follow-up-defined as completion of computed tomography chest imaging 5 to 13 months after first mention of an IPN in a radiology report; completion of a follow-up PSA test, urology visit, or prostate biopsy within 6 months of the first reported PSA > 4; or completion of a colposcopy or gynecology visit within 6 months of a first reported abnormal Pap smear. Patients were included with first-onset abnormal CSTRs for IPN, PSAs > 4, or abnormal Pap smears occurring in the 24 months before and after the EHR transition.

RESULTS

There were no significant differences in follow-up in the IPN or the Pap smear ITS models. In the PSA ITS model, follow-up was significantly decreasing (p = 0.0133) in the preintervention period, and there was a significant change in trend from intervention to postintervention (p = 0.0279).

CONCLUSION

EHR transition reversed a decreasing trend over time for PSA test follow-up, while IPN and Pap smear follow-up trends did not change significantly. Effects of EHR transition may differ by test studied.

The impact of health information technology on the management and follow-up of test results - a systematic review

OBJECTIVE

To investigate the impact of health information technology (IT) systems on clinicians' work practices and patient engagement in the management and follow-up of test results.

MATERIALS AND METHODS

A search for studies reporting health IT systems and clinician test results management was conducted in the following databases: MEDLINE, EMBASE, CINAHL, Web of Science, ScienceDirect, ProQuest, and Scopus from January 1999 to June 2018. Test results follow-up was defined as provider follow-up of results for tests that were sent to the laboratory and radiology services for processing or analysis.

RESULTS

There are some findings from controlled studies showing that health IT can improve the proportion of tests followed-up (15 percentage point change) and increase physician awareness of test results that require action (24-28 percentage point change). Taken as whole, however, the evidence of the impact of health IT on test result management and follow-up is not strong.

DISCUSSION

The development of safe and effective test results management IT systems should pivot on several axes. These axes include 1) patient-centerd engagement (involving shared, timely, and meaningful information); 2) diagnostic processes (that involve the integration of multiple people and different clinical settings across the health care spectrum); and 3) organizational communications (the myriad of multi- transactional processes requiring feedback, iteration, and confirmation) that contribute to the patient care process.

CONCLUSION

Existing evidence indicates that health IT in and of itself does not (and most likely cannot) provide a complete solution to issues related to test results management and follow-up.

Does health information technology improve acknowledgement of radiology results for discharged Emergency Department patients? A before and after study

BACKGROUND

The inadequate follow-up of test results is a key patient safety concern, carrying severe consequences for care outcomes. Patients discharged from the emergency department are at particular risk of having test results pending at discharge due to their short lengths of stay, with many hospitals acknowledging that they do not have reliable systems for managing such results. Health information technology hold the potential to reducing errors in the test result management process. This study aimed to measure changes in the proportion of acknowledged radiology reports pre and post introduction of an electronic result acknowledgement system and to determine the proportion of reports with abnormal results, including clinically significant abnormal results requiring follow-up action.

METHODS

A before and after study was conducted in the emergency department of a 450-bed metropolitan teaching hospital in Australia. All radiology reports for discharged patients for a one-month period before and after implementation of the electronic result acknowledgement system were reviewed to determine; i) those that reported abnormal results; ii) evidence of test result acknowledgement. All unacknowledged radiology results with an abnormal finding were assessed by an independent panel of two senior emergency physicians for clinical significance.

RESULTS

Of 1654 radiology reports in the pre-implementation period 70.6% (n = 1167) had documented evidence of acknowledgement by a clinician. For reports with abnormal results, 71.6% (n = 396) were acknowledged. Of 157 unacknowledged abnormal radiology reports reviewed by an independent emergency physician panel, 34.4% (n = 54) were identified as clinically significant and 50% of these (n = 27) were deemed to carry a moderate likelihood of patient morbidity if not followed up. Electronic acknowledgement occurred for all radiology reports in the post period (n = 1423), representing a 30.4% (95% CI: 28.1-32.6%) increase in acknowledgement rate, and an increase of 28.4% (95% CI: 24.6-32.2%) for abnormal radiology results.

CONCLUSIONS

The findings of this study demonstrate the potential of health information technology to improve the safety and effectiveness of the diagnostic process by increasing the rate of follow up of results pending at hospital discharge.

Oncology Patient Portal Enrollment at a Comprehensive Cancer Center: A Quality Improvement Initiative

PURPOSE

Patient portals (PPs) provide patients access to their electronic health record and may facilitate active engagement in their care. Because PP use has not been well studied among patients with cancer, we sought to: understand the willingness of patients with cancer to use the PP, identify barriers to PP use, and improve PP accessibility.

MATERIALS AND METHODS

As part of an institutional quality improvement initiative, we used a stakeholder-driven approach to examine PP use at the Dana-Farber Cancer Institute (Boston, MA). We conducted a survey across all ambulatory oncology practices as well as staff and patient focus groups in one ambulatory practice. We deployed three interventions to address barriers: staff education, staff-assisted enrollment support, and independent enrollment support.

RESULTS

In October 2015, 1,019 (87%) of 1,178 eligible patients completed the survey (PP enrolled, 57%; non-PP enrolled, 43%). PP-enrolled patients reported reviewing test results and appointment schedules. Non-PP-enrolled patients cited difficult PP enrollment, lack of computer access, and concern about sharing data electronically as barriers to PP enrollment. Focus groups (staff, n = 20; patient representatives, n = 5) also identified lack of awareness of PP benefits as a barrier. The interventions, deployed from November to December 2015, increased PP enrollment from 47% to 53% by January 2016.

CONCLUSION

Patients with cancer want to communicate with their team through the PP, but barriers to enrollment impede use. Straightforward system-level interventions may increase enrollment. Further work is necessary to ascertain the degree to which increased PP enrollment leads to greater engagement and better outcomes.

The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial

BACKGROUND

Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up.

KEY RESULTS

Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03).

CONCLUSIONS

Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern.

CLINICAL TRIALS IDENTIFIER

NCT01153451.

Time to Talk: Can Radiologists Improve Follow-Up of Abdominal Imaging Findings Indeterminate for Malignancy by Initiating Verbal Communication?

PURPOSE

The aims of this study were to examine the association between radiologist-initiated verbal communication for abdominal imaging findings indeterminate for malignancy and receipt of relevant outpatient follow-up imaging and to evaluate the proportion of findings that progress from indeterminate to suspicious for malignancy.

METHODS

Using a mandatory standardized assessment coding system, 727 eligible outpatient abdominal CT, MRI, and ultrasound studies performed between July 1, 2013, and January 31, 2014, were identified. Multivariate logistic regression was used to evaluate the association between radiologist-initiated verbal communication and receipt of relevant outpatient imaging follow-up, adjusted for patient, ordering physician, interpreting radiologist, and imaging variables.

RESULTS

Sixty-two percent of patients (451 of 727) with imaging findings indeterminate for malignancy received relevant outpatient imaging follow-up. Radiologist-initiated verbal communication occurred in 4.8% of cases (35 of 727). Radiologist-initiated verbal communication (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.02-5.87) and existing cancer diagnosis (OR, 3.00; 95% CI, 2.11-4.26) were associated with a higher likelihood of receiving relevant imaging follow-up. Compared with those whose imaging studies were ordered by clinicians in a medical specialty, patients with studies ordered by clinicians in surgical (OR, 0.70; 95% CI, 0.49-0.99) or other (OR, 0.44; 95% CI, 20.24-0.83) specialties were less likely to receive relevant imaging follow-up. Progression of findings from indeterminate to suspicious for malignancy occurred in 5.4% of cases and was not associated with radiologist-initiated verbal communication.

CONCLUSIONS

Radiologist-initiated verbal communication increases the likelihood that patients receive outpatient imaging follow-up for abdominal findings indeterminate for malignancy. Progression of these findings is relatively infrequent.

Clinician Perspectives on the Management of Abnormal Subcritical Tests in an Urban Academic Safety-Net Health Care System

BACKGROUND

Missed or delayed follow-up of abnormal subcritical tests (tests that do not require immediate medical attention) can lead to poor patient outcomes. Safety-net health systems with limited resources and socially complex patients are vulnerable to safety gaps resulting from delayed management. Clinician perspectives to identify system challenges, vulnerable situations, and potential solutions were sought in focus groups.

METHODS

Five semistructured focus groups were conducted in 2015 with purposefully sampled clinicians from radiology, hospital medicine, emergency medicine, risk management, and ambulatory care from an urban, academic, integrated, safety-net health system. Thematic analysis identified challenges of current management of abnormal subcritical tests, vulnerable situations, and solution characteristics. A total of 43 clinicians participated.

RESULTS

Clinicians cited challenges in assigning responsibility for follow-up and identified tests pending at discharge and tests requiring delayed follow-up as vulnerable situations. The lack of tracking systems and missing contact information for patients and providers exacerbated these challenges. Proposed solution characteristics involved protocols to aid in assigning responsibility, reliable paths of communication, and systems to track the status of tests. Clinicians noted a strong desire for integration of the work flow and technology solutions into existing structures.

CONCLUSION

In an urban safety-net setting, clinicians recommended outlining clear chains of responsibility and communication in the management of subcritical test results, and employing simple, integrated technological solutions that allow for tracking and management of tests. Existing test management solutions should be adapted to work within safety-net systems, which often have fewer resources and more complex patients and may function in the absence of integrated technology systems.

Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project

OBJECTIVE

Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas.

STUDY SETTING

In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts.

STUDY DESIGN

Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools.

DATA COLLECTION METHODS

Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites.

PRINCIPAL FINDINGS

Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all P<0.001). Mean days between laboratory test date and evidence of completed action/treatment plan decreased by 19.4 days (P<0.001). Staff surveys showed modest but nonsignificant improvement for intervention practices relative to controls overall and for the 3 high-risk domains that were the focus of PROMISES.

CONCLUSIONS

A consortium of stakeholders, quality improvement tools, coaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.

Does integrating nonurgent, clinically significant radiology alerts within the electronic health record impact closed-loop communication and follow-up?

OBJECTIVE

To assess whether integrating critical result management software--Alert Notification of Critical Results (ANCR)--with an electronic health record (EHR)-based results management application impacts closed-loop communication and follow-up of nonurgent, clinically significant radiology results by primary care providers (PCPs).

MATERIALS AND METHODS

This institutional review board-approved study was conducted at a large academic medical center. Postintervention, PCPs could acknowledge nonurgent, clinically significant ANCR-generated alerts ("alerts") within ANCR or the EHR. Primary outcome was the proportion of alerts acknowledged via EHR over a 24-month postintervention. Chart abstractions for a random sample of alerts 12 months preintervention and 24 months postintervention were reviewed, and the follow-up rate of actionable alerts (eg, performing follow-up imaging, administering antibiotics) was estimated. Pre- and postintervention rates were compared using the Fisher exact test. Postintervention follow-up rate was compared for EHR-acknowledged alerts vs ANCR.

RESULTS

Five thousand nine hundred and thirty-one alerts were acknowledged by 171 PCPs, with 100% acknowledgement (consistent with expected ANCR functionality). PCPs acknowledged 16% (688 of 4428) of postintervention alerts in the EHR, with the remaining in ANCR. Follow-up was documented for 85 of 90 (94%; 95% CI, 88%-98%) preintervention and 79 of 84 (94%; 95% CI, 87%-97%) postintervention alerts (P > .99). Postintervention, 11 of 14 (79%; 95% CI, 52%-92%) alerts were acknowledged via EHR and 68 of 70 (97%; 95% CI, 90%-99%) in ANCR had follow-up (P = .03).

CONCLUSIONS

Integrating ANCR and EHR provides an additional workflow for acknowledging nonurgent, clinically significant results without significant change in rates of closed-loop communication or follow-up of alerts.