Management of test results in family medicine offices

Design and Evaluation of an Electronic Information Exchange System Connecting Laboratories and Physicians' Offices

Laboratory services are a crucial part of medical care and contribute to physicians' treatment-related decision-making. However, paper-based information exchanges between physicians' offices and laboratories waste physicians' time and prevent them from using outpatient test results in a timely and effective manner. To solve this problem, improve the safety and quality of patient care, and save patients' time and energy, the present study developed a web-based system for electronic information exchange between laboratories and offices in Microsoft Visual Studio with the ASP.net technology and the Microsoft SQL Server database. The developed web-based software met the needs of the users and stakeholders (physicians, laboratory personnel, and patients) in the laboratory service cycle. To evaluate the software, user satisfaction was assessed in terms of user interface, operational functionality, and system performance, indicating the acceptability of all the criteria from the viewpoint of the stakeholders. The developed web-based software enables electronic communication between offices and laboratories (two important healthcare bases), establishes information exchange (sending requests and receiving laboratory results) between these two bases, and also notifies the patients. The software gained the overall satisfaction of the users, and this highlights the need for electronic communications in the healthcare domain.

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.

The Effect of Information Technology on the Information Exchange between Laboratories and Ambulatory Care Centers: A Systematic Review

Laboratory services form an integral part of medical care in the decision-making of physicians, including those working at ambulatory care centers. Information exchange is essential between ambulatory care centers and laboratories. Inevitable errors have always existed in the exchange of such information on paper, which can be to some extent avoided by developing appropriate computer-based interfaces. Therefore, this review aimed to examine studies conducted to determine the effect of electronic communication between ambulatory care centers and laboratories. This systematic review was conducted on the basis of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were searched in the PubMed, Embase, Cochrane, and Web of Science, and those written in English and published between 2000 and February 2019 with full texts available were selected. From a total of 3898 papers retrieved from the studied databases, 24 papers were eligible for entering this study after removing similar and nonrelated studies. Electronic exchanges between ambulatory care centers and laboratories can have numerous benefits in terms of financial, organizational, and quality. This evidence for the value of electronic communications is an important factor contributing to its local investment and adoption.

Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians

IMPORTANCE

Current electronic health record (EHR) user interfaces are suboptimally designed and may be associated with excess cognitive workload and poor performance.

OBJECTIVE

To assess the association between the usability of an EHR system for the management of abnormal test results and physicians' cognitive workload and performance levels.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study was conducted in a simulated EHR environment. From April 1, 2016, to December 23, 2016, residents and fellows from a large academic institution were enrolled and allocated to use either a baseline EHR (n = 20) or an enhanced EHR (n = 18). Data analyses were conducted from January 9, 2017, to March 30, 2018.

INTERVENTIONS

The EHR with enhanced usability segregated in a dedicated folder previously identified critical test results for patients who did not appear for a scheduled follow-up evaluation and provided policy-based decision support instructions for next steps. The baseline EHR displayed all patients with abnormal or critical test results in a general folder and provided no decision support instructions for next steps.

MAIN OUTCOMES AND MEASURES

Cognitive workload was quantified subjectively using NASA-Task Load Index and physiologically using blink rates. Performance was quantified according to the percentage of appropriately managed abnormal test results.

RESULTS

Of the 38 participants, 25 (66%) were female. The 20 participants allocated to the baseline EHR compared with the 18 allocated to the enhanced EHR demonstrated statistically significantly higher cognitive workload as quantified by blink rate (mean [SD] blinks per minute, 16 [9] vs 24 [7]; blink rate, -8 [95% CI, -13 to -2]; P = .01). The baseline group showed statistically significantly poorer performance compared with the enhanced group who appropriately managed 16% more abnormal test results (mean [SD] performance, 68% [19%] vs 98% [18%]; performance rate, -30% [95% CI, -40% to -20%]; P < .001).

CONCLUSIONS AND RELEVANCE

Relatively basic usability enhancements to the EHR system appear to be associated with better physician cognitive workload and performance; this finding suggests that next-generation systems should strip away non-value-added EHR interactions, which may help physicians eliminate the need to develop their own suboptimal workflows.

Test Result Management Practices of Canadian Internal Medicine Physicians and Trainees

BACKGROUND

Missed test results are a cause of medical error. Few studies have explored test result management in the inpatient setting.

OBJECTIVE

To examine test result management practices of general internal medicine providers in the inpatient setting, examine satisfaction with practices, and quantify self-reported delays in result follow-up.

DESIGN

Cross-sectional survey.

PARTICIPANTS

General internal medicine attending physicians and trainees (residents and medical students) at three Canadian teaching hospitals.

MAIN MEASURES

Methods used to track test results; satisfaction with these methods; personal encounters with results respondents "wish they had known about sooner."

KEY RESULTS

We received surveys from 33/51 attendings and 99/108 trainees (response rate 83%). Only 40.9% of respondents kept a record of all tests they order, and 50.0% had a system to ensure ordered tests were completed. Methods for tracking test results included typed team sign-out lists (40.7%), electronic health record (EHR) functionality (e.g., the electronic "inbox") (38.9%), and personal written or typed lists (14.8%). Almost all trainees (97.9%) and attendings (81.2%) reported encountering at least one test result they "wish they had known about sooner" in the past 2 months (p = 0.001). A higher percentage of attendings kept a record of tests pending at hospital discharge compared to trainees (75.0% vs. 35.7%, p < 0.001), used EHR functionality to track tests (71.4% vs. 27.5%, p = 0.004), and reported higher satisfaction with result management (42.4% vs. 12.1% satisfied or very satisfied, p < 0.001).

CONCLUSIONS

Canadian physicians report an array of problems managing test results in the inpatient setting. In the context of prior studies from the outpatient setting, our study suggests a need to develop interventions to prevent missed results and avoid potential patient harms.

Primary care provider perceptions of enablers and barriers to following guideline-recommended laboratory tests to confirm chronic kidney disease: a qualitative descriptive study

Background

Patients should receive follow-up serum creatinine tests after an initial abnormal result to diagnose chronic kidney disease. However, half of the time this fails to occur in primary care. We interviewed primary care providers to better understand their perceptions of enablers and barriers to following this guideline-recommended care.

Methods

We performed a qualitative descriptive study guided by the Theoretical Domains Framework (TDF), a framework for behavioural change. We used purposeful sampling to recruit primary care providers (physicians and nurse practitioners) based on provider and practice characteristics (rural, solo versus team practice, etc.) from Ontario, Canada. We completed one-on-one interviews with providers using a semi-structured and open-ended interview guide based on the 14 TDF domains. We alternated between data collection and analysis, where we used directed content analysis to identify frequent, important, and conflicting enablers and barriers.

Results

We completed 13 interviews with nine primary care physicians and four nurse practitioners. Nine themes related to the TDF emerged from the data: 1) environmental context and resources, 2) knowledge, 3) memory, attention, and decision processes, 4) beliefs about consequences, 5) goals, 6) social or professional role, 7) behavioural regulation, 8) skills, and 9) optimism. Within these themes, we identified 16 enablers and five barriers. Some enablers included, providers’ knowledge on appropriate testing, their motivation to order these tests, and their use of tools and resources to help order follow-up serum creatinine tests. However, providers perceived some barriers including that ordering confirmatory laboratory tests for chronic kidney disease was not always a priority in regards to other care they wish to provide. Providers also noted that a perceived barrier is patients not going to the laboratory to complete the test.

Conclusions

We identified novel enablers and barriers to primary care providers completing guideline recommended repeat testing for the diagnosis of chronic kidney disease. Similar research is needed to understand the views of patients. These research findings can be used to inform strategies to improve the quality of care.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0879-2) contains supplementary material, which is available to authorized users.

Test results management and distributed cognition in electronic health record-enabled primary care

Managing abnormal test results in primary care involves coordination across various settings. This study identifies how primary care teams manage test results in a large, computerized healthcare system in order to inform health information technology requirements for test results management and other distributed healthcare services. At five US Veterans Health Administration facilities, we interviewed 37 primary care team members, including 16 primary care providers, 12 registered nurses, and 9 licensed practical nurses. We performed content analysis using a distributed cognition approach, identifying patterns of information transmission across people and artifacts (e.g. electronic health records). Results illustrate challenges (e.g. information overload) as well as strategies used to overcome challenges. Various communication paths were used. Some team members served as intermediaries, processing information before relaying it. Artifacts were used as memory aids. Health information technology should address the risks of distributed work by supporting awareness of team and task status for reliable management of results.

Laboratory testing in primary care: A systematic review of health IT impacts

INTRODUCTION

Laboratory testing in primary care is a fundamental process that supports patient management and care. Any breakdown in the process may alter clinical information gathering and decision-making activities and can lead to medical errors and potential adverse outcomes for patients. Various information technologies are being used in primary care with the goal to support the process, maximize patient benefits and reduce medical errors. However, the overall impact of health information technologies on laboratory testing processes has not been evaluated.

OBJECTIVES

To synthesize the positive and negative impacts resulting from the use of health information technology in each phase of the laboratory 'total testing process' in primary care.

METHODS

We conducted a systematic review. Databases including Medline, PubMed, CINAHL, Web of Science and Google Scholar were searched. Studies eligible for inclusion reported empirical data on: 1) the use of a specific IT system, 2) the impacts of the systems to support the laboratory testing process, and were conducted in 3) primary care settings (including ambulatory care and primary care offices). Our final sample consisted of 22 empirical studies which were mapped to a framework that outlines the phases of the laboratory total testing process, focusing on phases where medical errors may occur.

RESULTS

Health information technology systems support several phases of the laboratory testing process, from ordering the test to following-up with patients. This is a growing field of research with most studies focusing on the use of information technology during the final phases of the laboratory total testing process. The findings were largely positive. Positive impacts included easier access to test results by primary care providers, reduced turnaround times, and increased prescribed tests based on best practice guidelines. Negative impacts were reported in several studies: paper-based processes employed in parallel to the electronic process increased the potential for medical errors due to clinicians' cognitive overload; systems deemed not reliable or user-friendly hampered clinicians' performance; and organizational issues arose when results tracking relied on the prescribers' memory.

DISCUSSION

The potential of health information technology lies not only in the exchange of health information, but also in knowledge sharing among clinicians. This review has underscored the important role played by cognitive factors, which are critical in the clinician's decision-making, the selection of the most appropriate tests, correct interpretation of the results and efficient interventions.

CONCLUSIONS

By providing the right information, at the right time to the right clinician, many IT solutions adequately support the laboratory testing process and help primary care clinicians make better decisions. However, several technological and organizational barriers require more attention to fully support the highly fragmented and error-prone process of laboratory testing.

Communicating laboratory results through a Web site: Patients' priorities and viewpoints

BACKGROUND

Patients can access laboratory results using various technologies. The aim of this study was to integrate the laboratory results into the hospital Web site based on patients' viewpoints and priorities and to measure patients' satisfaction.

METHODS

This descriptive-analytical study was conducted in 2015. First, a questionnaire was distributed among 200 patients to assess patients' priorities to receive laboratory results through the Web site. Second, those who agreed (n = 95) to receive their laboratory results through the Web site were identified. Then, the required changes were made to the hospital Web site based on patients' viewpoints and priorities. Third, patients were divided into two groups. The first group received their laboratory results through the Web site on the date had been announced during their visit to the laboratory. The second group was informed by SMS once their results were shown on the Web site. After receiving laboratory results, patients' satisfaction was evaluated.

RESULTS

More than half of the participants (n = 53, 55.8%) were highly satisfied with receiving the results electronically. The higher number of people in SMS group (n = 9, 20.9%) reported that they were satisfied with time-saving compared to other group (n = 2, 3.8%) (P = .04). Participants after receiving the results through the Web site considered the functionalities of reprinting (P < .0001) and timeliness (P = .017) more important.

CONCLUSION

Integrating laboratory results into the hospital Web site based on the patients' viewpoints and priorities can improve patient satisfaction and lower the patients' concern regarding confidentiality of their results.

Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health Care

PURPOSE

We previously developed electronic triggers to automatically flag records for patients experiencing potential delays in diagnostic evaluation for certain cancers. Because of the unique clinical, logistic, and legal aspects of mammography, this study was conducted to evaluate the effectiveness of a trigger to flag delayed follow-up on mammography.

METHODS

An algorithm was developed to detect delays in follow-up of abnormal mammographic results (>60 days for BI-RADS^® 0, 4, and 5 and >7 months for BI-RADS 3) using clinical data in the electronic health record. Flagged records were then manually reviewed to determine the trigger's performance characteristics (positive and negative predictive value, sensitivity, and specificity). The frequency of delays and patient communication related to abnormal results, reasons for lack of follow-up, and whether patients were subsequently diagnosed with breast cancer were also assessed.

RESULTS

Of 365,686 patients seen between January 1, 2010, and May 31, 2015, the trigger identified 2,129 patients with abnormal findings on mammography, of whom it flagged 552 as having delays in follow-up. From these, review of 400 randomly selected records revealed 283 true delays (positive predictive value, 71%; 95% confidence interval, 66%-75%), including 280 records without any documented plan and three patients with plans that were not adhered to. Transcription and reporting inconsistencies were identified in 27% of externally performed mammographic reports. Only 335 records (84%) contained specific documentation that the patient was informed of the abnormal result.

CONCLUSIONS

Care delays appear to continue despite federal laws requiring patient notification of mammographic results within 30 days. Clinical application of mammography-related triggers could help detect these delays.

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.

Adaption, implementation and evaluation of collaborative service improvements in the testing and result communication process in primary care from patient and staff perspectives: a qualitative study

Background

Increasing numbers of blood tests are being ordered in primary care settings and the swift and accurate communication of test results is central to providing high quality care. The process of testing and result communication is complex and reliant on the coordinated actions of care providers, external groups in laboratory and hospital settings, and patients. This fragmentation leaves it vulnerable to error and the need to improve an apparently fallible system is apparent. However, primary care is complex and does not necessarily adopt change in a linear and prescribed manner influenced by a range of factors relating to practice staff, patients and organisational factors. To account for these competing perspectives, we worked in conjunction with both staff and patients to develop and implement strategies intended to improve patient satisfaction and increase efficiency of existing processes.

Methods

The study applied the principles of ‘experience-based co-design’ to identify key areas of weakness and source proposals for change from staff and patients. The study was undertaken within two primary practices situated in South Birmingham (UK) of contrasting size and socio-economic environment. Senior practice staff were involved in the refinement of the interventions for introduction. We conducted focus groups singly constituted of staff and patients at each practice to determine suitability, applicability and desirability alongside the practical implications of their introduction.

Results

At each practice four of the six proposals for change were implemented these were increased access to phlebotomy, improved receptionist training, proactive communication of results, and increased patient awareness of the tests ordered and the means of their communication. All were received favourably by both patients and staff. The remaining issues around the management of telephone calls and the introduction of electronic alerts for missing results were not addressed due to constraints of time and available resources.

Conclusions

Approaches to tackling the same area of weakness differed at practices and was determined by individual staff attitudes and by organisational and patient characteristics. The long-term impact of the changes requires further quantitative evaluation.

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice

BACKGROUND

The handling of laboratory, imaging and other test results in UK general practice is a high-volume organisational routine that is both complex and high risk. Previous research in this area has focused on errors and harm, but a complementary approach is to better understand how safety is achieved in everyday practice. This paper ethnographically examines the role of informal dimensions of test results handling routines in the achievement of safety in UK general practice and how these findings can best be developed for wider application by policymakers and practitioners.

METHODS

Non-participant observation was conducted of high-volume organisational routines across eight UK general practices with diverse organisational characteristics. Sixty-two semi-structured interviews were also conducted with the key practice staff alongside the analysis of relevant documents.

RESULTS

While formal results handling routines were described similarly across the eight study practices, the everyday structure of how the routine should be enacted in practice was informally understood. Results handling safety took a range of local forms depending on how different aspects of safety were prioritised, with practices varying in terms of how they balanced thoroughness (i.e. ensuring the high-quality management of results by the most appropriate clinician) and efficiency (i.e. timely management of results) depending on a range of factors (e.g. practice history, team composition). Each approach adopted created its own potential risks, with demands for thoroughness reducing productivity and demands for efficiency reducing handling quality. Irrespective of the practice-level approach adopted, staff also regularly varied what they did for individual patients depending on the specific context (e.g. type of result, patient circumstances).

CONCLUSIONS

General practices variably prioritised a legitimate range of results handling safety processes and outcomes, each with differing strengths and trade-offs. Future safety improvement interventions should focus on how to maximise practice-level knowledge and understanding of the range of context-specific approaches available and the safeties and risks inherent in each within the context of wider complex system conditions and interactions. This in turn has the potential to inform new kinds of proactive, contextually appropriate approaches to intervention development and implementation focusing on the enhanced deliberation of the safety of existing high-volume routines.

Towards a new paradigm in laboratory medicine: the five rights

A body of evidence collected in the last few decades demonstrates that the pre- and post-analytical phases of the testing cycle are more error-prone than the analytical phase. However, the paradigm of errors and quality in laboratory medicine has been questioned, analytical mistakes continuing to be a major cause of adverse clinical outcomes and patient harm. Although the brain-to-brain concept is widely recognized in the community of laboratory professionals, there is lack of clarity concerning the inter-relationship between the different phases of the cycle, interdependence between the pre-analytical phase and analytical quality, and the effect of the post-analytical steps on the quality of ultimate laboratory information. Analytical quality remains the "core business" of clinical laboratories, but laboratory professionals and clinicians alike should never lose sight of the fact that pre-analytical variables are often responsible for erroneous test results and that quality biospecimens are pre-requisites for a reliable analytical phase. In addition, the pressure for expert advice on test selection and interpretation of results has increased hand in hand with the ever-increasing complexity of tests and diagnostic fields. Finally, the data on diagnostic errors and inappropriate clinical decisions made due to delay or misinterpretation of laboratory data underscore the current need for greater collaboration at the clinical-laboratory interface.

Patient perspectives on test result communication in primary care: a qualitative study

BACKGROUND

Although the number of blood tests ordered in primary care continues to increase, efficient systems for the communication of blood test results to patients are lacking. This is a concern in terms of both patient safety and patient satisfaction.

AIM

To gain an understanding of patient perspectives on organisational and technological aspects of current and prospective systems for communicating laboratory test results in primary care, and the influences that impact patients' preferred methods for receiving results.

DESIGN AND SETTING

Qualitative study using patient focus groups in four primary care practices in Birmingham, UK.

METHOD

The primary care practices were purposively selected to ensure they varied in size, socioeconomic environment, and the default pathways they used to communicate test results. A total of 26 patients from the four practices who had had a recent blood test were recruited. Over a 6 month period in 2011, six, 1-hour focus groups were conducted at the four practices involved in the study.

RESULTS

Patients expressed a preference for receiving results from the ordering GP or a clinically qualified member of staff. Suggestions for refining current systems included improved access to phlebotomy appointments, better management of patient telephone calls, and a clear, accessible protocol for the communication of results.

CONCLUSION

Despite the testing and result communication process being a core activity in primary care, it was found that practices could improve their service in a number of areas. Patients described frequent delays and inconsistency in both the level of information and the method of communication, as well as dissatisfaction with non-clinical staff relaying results. Patient preferences for result communication based on their experience of current systems have produced practical suggestions to improve processes.

Workarounds and Test Results Follow-up in Electronic Health Record-Based Primary Care

BACKGROUND

Electronic health records (EHRs) have potential to facilitate reliable communication and follow-up of test results. However, limitations in EHR functionality remain, leading practitioners to use workarounds while managing test results. Workarounds can lead to patient safety concerns and signify indications as to how to build better EHR systems that meet provider needs.

OBJECTIVE

To understand why primary care practitioners (PCPs) use workarounds to manage test results by analyzing data from a previously conducted national cross-sectional survey on test result management.

METHODS

We conducted a secondary data analysis of quantitative and qualitative data from a national survey of PCPs practicing in the Department of Veterans Affairs (VA) and explored the use of workarounds in test results management. We used multivariate logistic regression analysis to examine the association between key sociotechnical factors that could affect test results follow-up (e.g., both technology-related and those unrelated to technology, such as organizational support for patient notification) and workaround use. We conducted a qualitative content analysis of free text survey data to examine reasons for use of workarounds.

RESULTS

Of 2554 survey respondents, 1104 (43%) reported using workarounds related to test results management. Of these 1028 (93%) described the type of workaround they were using; 719 (70%) reported paper-based methods, while 230 (22%) used a combination of paper- and computer-based workarounds. Primary care practitioners who self-reported limited administrative support to help them notify patients of test results or described an instance where they personally (or a colleague) missed results, were more likely to use workarounds (p=0.02 and p=0.001, respectively). Qualitative analysis identified three main reasons for workaround use: 1) as a memory aid, 2) for improved efficiency and 3) for facilitating internal and external care coordination.

CONCLUSION

Workarounds to manage EHR-based test results are common, and their use results from unmet provider information management needs. Future EHRs and the respective work systems around them need to evolve to meet these needs.

System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model

OBJECTIVES

To analyse a medical protection organisation's database to identify hazards related to general practice systems for ordering laboratory tests, managing test results and communicating test result outcomes to patients. To integrate these data with other published evidence sources to inform design of a systems-based conceptual model of related hazards.

DESIGN

A retrospective database analysis.

SETTING

General practices in the UK and Ireland.

PARTICIPANTS

778 UK and Ireland general practices participating in a medical protection organisation's clinical risk self-assessment (CRSA) programme from January 2008 to December 2014.

MAIN OUTCOME MEASURES

Proportion of practices with system risks; categorisation of identified hazards; most frequently occurring hazards; development of a conceptual model of hazards; and potential impacts on health, well-being and organisational performance.

RESULTS

CRSA visits were undertaken to 778 UK and Ireland general practices of which a range of systems hazards were recorded across the laboratory test ordering and results management systems in 647 practices (83.2%). A total of 45 discrete hazard categories were identified with a mean of 3.6 per practice (SD=1.94). The most frequently occurring hazard was the inadequate process for matching test requests and results received (n=350, 54.1%). Of the 1604 instances where hazards were recorded, the most frequent was at the 'postanalytical test stage' (n=702, 43.8%), followed closely by 'communication outcomes issues' (n=628, 39.1%).

CONCLUSIONS

Based on arguably the largest data set currently available on the subject matter, our study findings shed new light on the scale and nature of hazards related to test results handling systems, which can inform future efforts to research and improve the design and reliability of these systems.

Good practice statements on safe laboratory testing: A mixed methods study by the LINNEAUS collaboration on patient safety in primary care

BACKGROUND

The systems-based management of laboratory test ordering and results handling is a known source of error in primary care settings worldwide. The consequences are wide-ranging for patients (e.g. avoidable harm or poor care experience), general practitioners (e.g. delayed clinical decision making and potential medico-legal implications) and the primary care organization (e.g. increased allocation of resources to problem-solve and dealing with complaints). Guidance is required to assist care teams to minimize associated risks and improve patient safety.

OBJECTIVE

To identify, develop and build expert consensus on 'good practice' guidance statements to inform the implementation of safe systems for ordering laboratory tests and managing results in European primary care settings.

METHODS

Mixed methods studies were undertaken in the UK and Ireland, and the findings were triangulated to develop 'good practice' statements. Expert consensus was then sought on the findings at the wider European level via a Delphi group meeting during 2013.

RESULTS

We based consensus on 10 safety domains and developed 77 related 'good practice' statements (≥ 80% agreement levels) judged to be essential to creating safety and minimizing risks in laboratory test ordering and subsequent results handling systems in international primary care.

CONCLUSION

Guidance was developed for improving patient safety in this important area of primary care practice. We need to consider how this guidance can be made accessible to frontline care teams, utilized by clinical educators and improvement advisers, implemented by decision makers and evaluated to determine acceptability, feasibility and impacts on patient safety.

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives

BACKGROUND

The testing and result communication process in primary care is complex. Its successful completion relies on the coordinated efforts of a range of staff in primary care and external settings working together with patients. Despite the importance of diagnostic testing in provision of care, this complexity renders the process vulnerable in the face of increasing demand, stretched resources and a lack of supporting guidance.

METHODS

We conducted a series of focus groups with patients and staff across four primary care practices using process-improvement strategies to identify and understand areas where either unnecessary delay is introduced, or the process may fail entirely. We then worked with both patients and staff to arrive at practical strategies to improve the current system.

RESULTS

A total of six areas across the process were identified where improvements could be introduced. These were: (1) delay in phlebotomy, (2) lack of a fail-safe to ensure blood tests are returned to practices and patients, (3) difficulties in accessing results by telephone, (4) role of non-clinical staff in communicating results, (5) routine communication of normal results and (6) lack of a protocol for result communication.

CONCLUSIONS

A number of potential failures in testing and communicating results to patients were identified, and some specific ideas for improving existing systems emerged. These included same-day phlebotomy sessions, use of modern technology methods to proactively communicate routine results and targeted training for receptionists handling sensitive data. There remains an urgent need for further work to test these and other potential solutions.

Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

Objective

Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.

Method

Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.

Results

Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.

Conclusion

Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.

Test result communication in primary care: a survey of current practice

Background

The number of blood tests ordered in primary care continues to increase and the timely and appropriate communication of results remains essential. However, the testing and result communication process includes a number of participants in a variety of settings and is both complicated to manage and vulnerable to human error. In the UK, guidelines for the process are absent and research in this area is surprisingly scarce; so before we can begin to address potential areas of weakness there is a need to more precisely understand the strengths and weaknesses of current systems used by general practices and testing facilities.

Methods

We conducted a telephone survey of practices across England to determine the methods of managing the testing and result communication process. In order to gain insight into the perspectives from staff at a large hospital laboratory we conducted paired interviews with senior managers, which we used to inform a service blueprint demonstrating the interaction between practices and laboratories and identifying potential sources of delay and failure.

Results

Staff at 80% of practices reported that the default method for communicating normal results required patients to telephone the practice and 40% of practices required that patients also call for abnormal results. Over 80% had no fail-safe system for ensuring that results had been returned to the practice from laboratories; practices would otherwise only be aware that results were missing or delayed when patients requested results. Persistent sources of missing results were identified by laboratory staff and included sample handling, misidentification of samples and the inefficient system for collating and resending misdirected results.

Conclusions

The success of the current system relies on patients both to retrieve results and in so doing alert staff to missing and delayed results. Practices appear slow to adopt available technological solutions despite their potential for reducing the impact of recurring errors in the handling of samples and the reporting of results. Our findings will inform our continuing work with patients and staff to develop, implement and evaluate improvements to existing systems of managing the testing and result communication process.

Developing a preliminary 'never event' list for general practice using consensus-building methods

BACKGROUND

The 'never event' concept has been implemented in many acute hospital settings to help prevent serious patient safety incidents. Benefits include increasing awareness of highly important patient safety risks among the healthcare workforce, promoting proactive implementation of preventive measures, and facilitating incident reporting.

AIM

To develop a preliminary list of never events for general practice.

DESIGN AND SETTING

Application of a range of consensus-building methods in Scottish and UK general practices.

METHOD

A total of 345 general practice team members suggested potential never events. Next, 'informed' staff (n =15) developed criteria for defining never events and applied the criteria to create a list of candidate never events. Finally, UK primary care patient safety 'experts' (n = 17) reviewed, refined, and validated a preliminary list via a modified Delphi group and by completing a content validity index exercise.

RESULTS

There were 721 written suggestions received as potential never events. Thematic categorisation reduced this to 38. Five criteria specific to general practice were developed and applied to produce 11 candidate never events. The expert group endorsed a preliminary list of 10 items with a content validity index (CVI) score of >80%.

CONCLUSION

A preliminary list of never events was developed for general practice through practitioner experience and consensus-building methods. This is an important first step to determine the potential value of the never event concept in this setting. It is now intended to undertake further testing of this preliminary list to assess its acceptability, feasibility, and potential usefulness as a safety improvement intervention.

The Impact for Patient Outcomes of Failure to Follow Up on Test Results. How Can We Do Better?

BACKGROUND

The World Health Organization-World Alliance for Patient Safety has identified test result management as a priority area. Poor test result follow-up can have major consequences for the quality of care, including missed diagnoses and suboptimal patient outcomes. Over the last three decades there has been considerable growth in the number of requests for pathology and radiology services which has added to the complexity of how patient care is delivered and test results are managed. This can contribute to a lack of clarity about where and with whom responsibility for test follow-up should reside: a problem that is compounded by a lack of clear definitions about what are critical, unexpected or significantly abnormal results.

AIM OF THIS PAPER

This paper will present a narrative review highlighting key issues related to the problem of failure to follow up laboratory test results, and outline potential solutions.

CONCLUSIONS

Information technology (IT) has the potential to enhance the performance and safety of test result management processes. Effective solutions must engage all stakeholders, including consumers, in arriving at decisions about who needs to receive results, how and when they are communicated, and how they are acknowledged and acted upon and the documentation of these actions.

Test result communication in primary care: clinical and office staff perspectives

OBJECTIVE

To understand how the results of laboratory tests are communicated to patients in primary care and perceptions on how the process may be improved.

DESIGN

Qualitative study employing staff focus groups.

SETTING

Four UK primary care practices.

PARTICIPANTS

Staff involved in the communication of test results.

FINDINGS

Five main themes emerged from the data: (i) the default method for communicating results differed between practices; (ii) clinical impact of results and patient characteristics such as anxiety level or health literacy influenced methods by which patients received their test result; (iii) which staff member had responsibility for the task was frequently unclear; (iv) barriers to communicating results existed, including there being no system or failsafe in place to determine whether results were returned to a practice or patient; (v) staff envisaged problems with a variety of test result communication methods discussed, including use of modern technologies, such as SMS messaging or online access.

CONCLUSIONS

Communication of test results is a complex yet core primary care activity necessitating flexibility by both patients and staff. Dealing with the results from increasing numbers of tests is resource intensive and pressure on practice staff can be eased by greater utilization of electronic communication. Current systems appear vulnerable with no routine method of tracing delayed or missing results. Instead, practices only become aware of missing results following queries from patients. The creation of a test communication protocol for dissemination among patients and staff would help ensure both groups are aware of their roles and responsibilities.

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice

OBJECTIVE

To explore experiences and perceptions of frontline administrators involved in the systems-based management of laboratory test ordering and results handling in general medical practice.

DESIGN

Qualitative using focus group interviews.

SETTING

West of Scotland general medical practices in three National Health Service (NHS) territorial board areas.

PARTICIPANTS

Convenience samples of administrators (receptionists, healthcare assistants and phlebotomists).

METHODS

Transcript data were subjected to content analysis.

RESULTS

A total of 40 administrative staff were recruited. Four key themes emerged: (1) system variations and weaknesses (eg, lack of a tracking process is a known risk that needs to be addressed). (2) Doctor to administrator communication (eg, unclear information can lead to emotional impacts and additional workload). (3) Informing patients of test results (eg, levels of anxiety and uncertainty are experienced by administrators influenced by experience and test result outcome) and (4) patient follow-up and confidentiality (eg, maintaining confidentiality in a busy reception area can be challenging). The key findings were explained in terms of sociotechnical systems theory.

CONCLUSIONS

The study further confirms the safety-related problems associated with results handling systems and adds to our knowledge of the communication and psychosocial issues that can affect the health and well-being of staff and patients alike. However, opportunities exist for practices to identify barriers to safe care, and plan and implement system improvements to accommodate or mitigate the potential for human error in this complex area.

Evaluating the Connections Between Primary Care Practice and Clinical Laboratory Testing: A Review of the Literature and Call for Laboratory Involvement in the Solutions

Context.—Growing evidence has demonstrated a high frequency of quality gaps in laboratory medicine, with recent studies estimating that 15% to 54% of primary care medical errors reported by primary care physicians and staff are related to the testing process. However, there is lack of evidence-based performance metrics in the preanalytic and postanalytic phases of the testing pathway for primary care practices.

Objective.—To use results of the literature review to assist in the development of quality indicators that could improve preanalytic and postanalytic processes in primary care–based laboratory medicine.

Data Sources.—Literature in Ovid/MEDLINE from 2001 through 2011 was searched as a primary source of information. Ninety-five peer-reviewed and non–peer-reviewed publications were retrieved following title and abstract review and 10 articles were reviewed in their entirety by the authors. A systematic review of the literature was conducted regarding the connections between clinical laboratories and primary care offices and the resulting errors. Root causes of errors were categorized into 7 major themes: process failures, delays, communication gaps, errors in judgment and cognition, influence of minorities/language, practice culture, and lack of patient centeredness. Selected articles were evaluated for evidence quality using the Systematic Evidence Review and Evaluation Methods for Quality Improvement grading scale developed by the Centers for Disease Control and Prevention.

Conclusions.—The focused literature review documented 7 key error themes in the laboratory medicine/primary care testing process. Performance metrics related to these themes are proposed that deserve future study for evidence-based improvement.

Failure to follow-up test results for ambulatory patients: a systematic review

BACKGROUND

Serious lapses in patient care result from failure to follow-up test results.

OBJECTIVE

To systematically review evidence quantifying the extent of failure to follow-up test results and the impact for ambulatory patients.

DATA SOURCES

Medline, CINAHL, Embase, Inspec and the Cochrane Database were searched for English-language literature from 1995 to 2010.

STUDY SELECTION

Studies which provided documented quantitative evidence of the number of tests not followed up for patients attending ambulatory settings including: outpatient clinics, academic medical or community health centres, or primary care practices.

DATA EXTRACTION

Four reviewers independently screened 768 articles.

RESULTS

Nineteen studies met the inclusion criteria and reported wide variation in the extent of tests not followed-up: 6.8% (79/1163) to 62% (125/202) for laboratory tests; 1.0% (4/395) to 35.7% (45/126) for radiology. The impact on patient outcomes included missed cancer diagnoses. Test management practices varied between settings with many individuals involved in the process. There were few guidelines regarding responsibility for patient notification and follow-up. Quantitative evidence of the effectiveness of electronic test management systems was limited although there was a general trend towards improved test follow-up when electronic systems were used.

LIMITATIONS

Most studies used medical record reviews; hence evidence of follow-up action relied upon documentation in the medical record. All studies were conducted in the US so care should be taken in generalising findings to other countries.

CONCLUSIONS

Failure to follow-up test results is an important safety concern which requires urgent attention. Solutions should be multifaceted and include: policies relating to responsibility, timing and process of notification; integrated information and communication technologies facilitating communication; and consideration of the multidisciplinary nature of the process and the role of the patient. It is essential that evaluations of interventions are undertaken and solutions integrated into the work and context of ambulatory care delivery.

Effects of laboratory data exchange in the care of patients with HIV

BACKGROUND

Electronic health record (EHR) systems are often modified through the addition of new features over time. Few studies have examined the specific effects of such changes. We examined whether implementation of a bidirectional laboratory interface for order entry and data reporting within an existing ambulatory EHR would result in more prompt responses to laboratory indications for antiretroviral therapy (ART) changes or in improved communication with HIV+ patients about relevant laboratory results.

METHODS

We conducted a single-arm intervention study comparing the timeliness of ART regimen changes, HIV viral load (VL) outcomes and patient-reported assessments of care before and after implementation of a laboratory data exchange interface within an existing EHR, without changing the EHR ordering or results reporting user interface. Patient data was extracted from the EHR covering the period from 1 year before to 2 years after the intervention for a cohort of 1181 patients who had received care during the baseline year. The timeliness of ART changes was represented by the days from a laboratory-result "signal" (CD4 dropping below 350 or 200 or VL increasing by a half-log or to a value over 100,000) to an ART-change "response". Patient assessments of care were collected by interviewing 100 anonymous patients at baseline and another 125 at 2 years post-intervention.

RESULTS

A total of 171 laboratory "signal" events were followed within 80 days by a change in ART therapy. The mean time from signal to therapy change (adjusted for clustering by patient) initially increased, from 37.7 days during the pre-intervention year to 48.2 days during the quarter immediately following activation of the lab intervention. It then declined to a mean of 31.4 days over the remaining 21 months of observation (P=0.03 for the 6-day improvement from the pre-period). A majority of patients (65%) achieved undetectable VL values by the end of the observation period; faster signal-response times were not associated with greater achievement of undetectable VL. Patients rated communication about laboratory tests more highly after implementation of the interface (91 vs. 83 on a 100-point scale, P=0.01); ratings were not higher for other aspects of care.

CONCLUSIONS

Adding laboratory data exchange interfaces within existing EHRs holds promise for improving HIV care, both in the timeliness of responses to important laboratory results and in the quality of provider communication about lab tests. However, the benefits from this incremental change may be modest unless more extensive redesign of laboratory follow-up workflows is undertaken, with support from enhanced user interfaces that take advantage of the laboratory information delivered. Providers should also consider increased staffing to compensate for dips in follow-up performance during the initial post-implementation months.

"But what does it mean for me?" Primary care patients' communication preferences for test results notification

BACKGROUND

The best ways to communicate test results in primary care to achieve patient satisfaction and assist patients to incorporate results into their personal health decision making are unknown. A study was conducted to determine the factors that patients believe are important in achieving those goals.

METHODS

Semistructured interviews were conducted with a convenience sample of 12 adults, at least half with a chronic disease requiring regular testing, who shared experiences about receiving test results from physicians' offices and how they used them in their health decision making. In addition, "think aloud" interviewing techniques were used to assess participants' satisfaction and stated understanding with six different formats for receiving a hypothetical test result (a mildly elevated lipid profile). The interviews were analyzed using the editing technique to determine important factors in test results notification.

FINDINGS

Three themes were found to be important in satisfaction with and stated understanding and use of test results: (1) the information shared (test result, clinician interpretation and guidance), (2) significance of the results (testing purpose, abnormal or normal result) and (3) personal preferences for communication (timeliness, interpersonal connection, and hard copy). Participants' stated understanding was highest, among several potential formats, for actual values with desired/normal values, a low-literacy description of the test's purpose, and a simple graph.

CONCLUSIONS

A results notification algorithm includes (1) communication elements (the purpose of the test, the actual results with desired values, clinician guidance, and a graphical representation) and (2) appropriate choice of notification technique (phone/visit for diagnostic tests and all significantly abnormal results and mail/e-mail/Web for all others).

Reducing missed laboratory results: defining temporal responsibility, generating user interfaces for test process tracking, and retrospective analyses to identify problems

Researchers have conducted numerous case studies reporting the details on how laboratory test results of patients were missed by the ordering medical providers. Given the importance of timely test results in an outpatient setting, there is limited discussion of electronic versions of test result management tools to help clinicians and medical staff with this complex process. This paper presents three ideas to reduce missed results with a system that facilitates tracking laboratory tests from order to completion as well as during follow-up: (1) define a workflow management model that clarifies responsible agents and associated time frame, (2) generate a user interface for tracking that could eventually be integrated into current electronic health record (EHR) systems, (3) help identify common problems in past orders through retrospective analyses.