Identifying Diagnostic Stewardship Mechanisms in the Electronic Test Result Management Process - Preliminary Findings from a Scoping Review

Digital health can play a key role in diagnostic stewardship, which refers to the coordinated guidance and interventions to ensure the appropriate utilisation of diagnostic tests for therapeutic decision-making. Outcomes of test result management and the impacts of digital health are a result of the interaction between dimensions of a complex environment. This poster will present preliminary findings from a scoping review which identifies the stewardship mechanisms that facilitate safe and effective electronic management of test results.

Diagnostic Informatics-The Role of Digital Health in Diagnostic Stewardship and the Achievement of Excellence, Safety, and Value

Diagnostic investigations (pathology laboratory and medical imaging) aim to: increase certainty of the presence or absence of disease by supporting the process of differential diagnosis; support clinical management; and monitor a patient's trajectory (e. g., disease progression or response to treatment). Digital health can be defined as the collection, storage, retrieval, transmission, and utilization of data, information, and knowledge to support healthcare. Digital health has become an essential component of the diagnostic process, helping to facilitate the accuracy and timeliness of information transfer and enhance the effectiveness of decision-making processes. Digital health is also important to diagnostic stewardship, which involves coordinated guidance and interventions to ensure the appropriate utilization of diagnostic tests for therapeutic decision-making. Diagnostic stewardship and informatics are thus important in efforts to establish shared decision-making. This is because they contribute to the establishment of shared information platforms (enabling patients to read, comment on, and share in decisions about their care) based on timely and meaningful communication. This paper will outline key diagnostic informatics and stewardship initiatives across three interrelated fields: (1) diagnostic error and the establishment of outcomes-based diagnostic research; (2) the safety and effectiveness of test result management and follow-up; and (3) digitally enhanced decision support systems.

Variation in electronic test results management and its implications for patient safety: A multisite investigation

Objective

The management and follow-up of diagnostic test results is a major patient safety concern. The aim of this qualitative study was to explore how clinicians manage test results on an everyday basis (work-as-done) in a health information technology–enabled emergency department setting. The objectives were to identify (1) variations in work-as-done in test results management and (2) the strategies clinicians use to ensure optimal management of diagnostic test results.

Materials and Methods

Qualitative interviews (n = 26) and field observations were conducted across 3 Australian emergency departments. Interview data coded for results management (ie, tracking, acknowledgment, and follow-up), and artifacts, were reviewed to identify variations in descriptions of work-as-done. Thematic analysis was performed to identify common themes.

Results

Despite using the same test result management application, there were variations in how the system was used. We identified 5 themes relating to electronic test results management: (1) tracking test results, (2) use and understanding of system functionality, (3) visibility of result actions and acknowledgment, (4) results inbox use, and (5) challenges associated with the absence of an inbox for results notifications for advanced practice nurses.

Discussion

Our findings highlight that variations in work-as-done can function to overcome perceived impediments to managing test results in a HIT-enabled environment and thus identify potential risks in the process. By illuminating work-as-done, we identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.

Conclusions

Test results tracking and follow-up is a priority area in need of health information technology development and training to improve team-based collaboration/communication of results follow-up and diagnostic safety.

Factors influencing digital review of pathology test results in an inpatient setting: a cross-sectional study

BACKGROUND

Delay or failure to view test results in a hospital setting can lead to delayed diagnosis, risk of patient harm, and represents inefficiency. Factors influencing this were investigated to identify how timeliness and completeness of test review could be improved through an evidence-based redesign of the use of clinical test review software.

METHODS

A cross-section of all abnormal hematology and biochemistry results which were published on a digital test review platform over a 3-year period were investigated. The time it took for clinicians to view these results, and the results that were not viewed within 30 days, were analyzed relative to time of the week, the detailed type of test, and an indicator of patient record data quality.

RESULTS

The majority of results were viewed within 90 min, and 93.9% of these results viewed on the digital platform within 30 days. There was significant variation in results review throughout the week, shown to be due to an interplay between technical and clinical workflow factors. Routine results were less likely to be reviewed, as were those with patient record data quality issues.

CONCLUSION

The evidence suggests that test result review would be improved by stream-lining access to the result platform, differentiating between urgent and routine results, improving handover of responsibility for result review, and improving search for temporary patient records. Altering the timing of phlebotomy rounds and a review of the appropriateness of routine test requests at the weekend may also improve result review rates.

Patient groups, clinicians and healthcare professionals agree - all test results need to be seen, understood and followed up

Background Diagnostic testing provides integral information for the prevention, diagnosis, treatment and management of disease. Inadequate test result reporting and follow-up is a major risk to patient safety. Factors contributing to failure to follow-up test results include unclear delineation of responsibility about who is meant to act on a test result; poor coordination across different levels of care; and the absence of integrated health information systems for the efficient information communication. Methods A 2016 Australian Stakeholder Forum brought together over 30 representatives from 14 different consumer, clinical and management stakeholder organisations to discuss safe and effective test result communication, management and follow-up. Thematic analysis was conducted drawing on multimodal data collected in the form of observational fieldnotes and document artefacts produced by participants. Results The forum identified major challenges which pose immediate risks to patient safety. Participants recommended priorities for addressing issues relating to: (i) the governance of test result management processes; (ii) integration of health care processes through the utilisation of effective digital health solutions; and (iii) involving patients as key partners in the decision-making and care process. Conclusions Stakeholder groups diverged slightly in their priorities. Consumers highlighted the lack of patient involvement in the test result management process but were less concerned about standardisation of reports and critical result thresholds than pathologists. The forum foregrounded the need for a systems approach, capable of identifying and addressing interconnections and multiple factors that contribute to poor test result follow-up, with a strong emphasis on enhancing the contribution of patients.

Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism

BACKGROUND

Delays in following up abnormal test results are a common problem in outpatient settings. Surveillance systems that use trigger tools to identify delayed follow-up can help reduce missed opportunities in care.

OBJECTIVE

To develop and test an electronic health record (EHR)-based trigger algorithm to identify instances of delayed follow-up of abnormal thyroid-stimulating hormone (TSH) results in patients being treated for hypothyroidism.

DESIGN

We developed an algorithm using structured EHR data to identify patients with hypothyroidism who had delayed follow-up (>60 days) after an abnormal TSH. We then retrospectively applied the algorithm to a large EHR data warehouse within the Department of Veterans Affairs (VA), on patient records from two large VA networks for the period from January 1, 2011, to December 31, 2011. Identified records were reviewed to confirm the presence of delays in follow-up.

KEY RESULTS

During the study period, 645,555 patients were seen in the outpatient setting within the two networks. Of 293,554 patients with at least one TSH test result, the trigger identified 1250 patients on treatment for hypothyroidism with elevated TSH. Of these patients, 271 were flagged as potentially having delayed follow-up of their test result. Chart reviews confirmed delays in 163 of the 271 flagged patients (PPV = 60.1%).

CONCLUSIONS

An automated trigger algorithm applied to records in a large EHR data warehouse identified patients with hypothyroidism with potential delays in thyroid function test results follow-up. Future prospective application of the TSH trigger algorithm can be used by clinical teams as a surveillance and quality improvement technique to monitor and improve follow-up.

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.

Lessons learned from the introduction of an electronic safety net to enhance test result management in an Australian mothers' hospital

This study describes the implementation and impact of an electronic test result acknowledgement (RA) system in the Mater Mothers' Hospital in Brisbane, Australia. The Verdi application electronically records clinicians' acknowledgement of the review of results. Hospital data (August 2011-August 2012) were extracted to measure clinicians' acknowledgement practices. There were 27,354 inpatient test results for 6855 patients. All test results were acknowledged. 60% (95% CI 59% to 61%) of laboratory and 44% (95% CI 40% to 48%) of imaging results were acknowledged within 24 h. The median time between report availability and acknowledgement was 18.1 h for laboratory and 1 day 18 h for imaging results. The median time from when a result was first viewed to its acknowledgement was 7 min for laboratory and 1 min for imaging results. The longest recorded time to acknowledgement was 38 days. Electronic RA provides a safety net to enhance test result management.

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.

Communication factors in the follow-up of abnormal mammograms

OBJECTIVE

To identify the communication factors that are significantly associated with appropriate short-term follow-up of abnormal mammograms.

DESIGN

Prospective longitudinal study involving medical record review and patient survey.

SETTING

Ten academically affiliated ambulatory medical practices in the Boston metropolitan area.

PARTICIPANTS

One hundred twenty-six women with abnormal mammograms requiring short-term (6 months) follow-up imaging.

MEASUREMENTS

Proportion of women in the study who received appropriate follow-up care.

RESULTS

Eighty-one (64%) of the women with abnormal mammograms requiring short-term follow-up imaging received the appropriate follow-up care. After adjusting for patients' age and insurance status, 2 communication factors were found to be independently associated with the delivery of appropriate follow-up care: 1). physicians' documentation of a follow-up plan in the medical record (adjusted odds ratio, 2.79; 95% confidence interval, 1.11 to 6.98; P =.029); and 2). patients' understanding of the need for follow-up (adjusted odds ratio, 3.86; 95% confidence interval, 1.50 to 9.96; P =.006). None of the patients' clinical or psychological characteristics were associated with the delivery of appropriate follow-up care.

CONCLUSIONS

Follow-up care for women with abnormal mammograms requiring short-term follow-up imaging is suboptimal. Documentation of the follow-up plan by the physician and understanding of the follow-up plan by the patient are important factors that are correlated with the receipt of appropriate follow-up care for these women. Interventions designed to improve the quality of result follow-up in the outpatient setting should address these issues in patient-doctor communication.