Test Results Reporting and Follow-Up

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Download the PDF guide to access the checklist of recommended practices for self assessment and a supporting worksheet to identify action steps to achieve those recommended practices.

The Test Results Reporting and Follow-Up SAFER Guide identifies recommended safety practices intended to optimize the safety and safe use of processes and EHR technology for the electronic communication and management of diagnostic test results. Processes relating to test results are fragile, requiring careful planning, implementation, and maintenance to deliver correct information promptly to the intended recipients.1 In the EHR-enabled healthcare environment, providers rely on technology to support and manage the reporting and follow-up of test results. This guide offers recommended practices related to the content and communication of test results to the clinician, as well as recommended practices related to the documentation and follow-up of test results.2,3

If implemented and used correctly, EHRs have the potential to improve diagnostic test result reporting and follow-up. Initial evaluation of the impact of health IT for test results reporting and follow-up has produced mixed results.4-7 Furthermore, initial research finds that laboratory and radiology/imaging systems are frequently associated with EHR-related adverse events.46 Failure to follow-up appropriately on diagnostic test results can lead to misdiagnosis, patient harm, and liability.

The Test Results Reporting and Follow-Up SAFER Guide recommends practices that optimize the safety and safe use of the EHR with respect to diagnostic testing. It will enable assessment of whether those aspects of the EHR associated with communication of diagnostic test results (and related processes) work as they should, are used correctly, and are designed and implemented to minimize the potential for errors.5,6,8-11 Completing the self-assessment requires the engagement of people both within and outside the organization (such as EHR technology developers and diagnostic services providers). Clinician leadership in the organization should be engaged in assessing whether and how any particular recommended practice affects the organization’s ability to deliver safe, high quality care. Collaboration between clinicians and staff members while completing the self-assessment in this guide will enable an accurate snapshot of the organization’s EHR status (in terms of test results-related safety), and even more importantly, should lead to a consensus about the organization’s future path to optimize EHR-related safety and quality: setting priorities among the recommended practices not yet addressed, ensuring a plan is in place to maintain recommended practices already in place, dedicating the required resources to make necessary improvements, and working together to mitigate the test results-related safety risks introduced by the EHR.

1

Test names, values, and interpretations for laboratory results are stored in the EHR as structured data using standardized nomenclature.6,11,13-17

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Rationale:

Structured laboratory results facilitate EHR-based result reporting and tracking functions.4 Structured data enable use of clinical decision support (CDS) that can avoid errors and optimize patient safety.

Examples:

  • Test result IDs (e.g., sodium, potassium) that are sent with LOINC codes are stored as coded data.18
  • Abnormal test result values and interpretations are defined and stored in a standardized, coded format (e.g., high/low sodium; critical potassium; positive/negative fecal occult blood test, etc.).9
  • There is a process to handle paper-based test results that includes, at a minimum, the entry of a coded value into the EHR to indicate whether the result was normal or abnormal along with a scanned copy of the report in the EHR.

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

2

Predominantly text-based test reports (e.g., radiology or pathology reports) have a coded (e.g., abnormal/normal at a minimum) interpretation associated with them.

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Rationale:

Coded results in structured fields facilitate EHR-based result reporting and tracking functions.4

Examples:

  • Imaging results are coded as abnormal using a structured code if there is a new or unexpected abnormality that requires follow-up.19,20
  • Mammography results are stored according to BI-RADS® criteria.

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

3

Functionality for ordering and reporting results is tested pre- and post-go-live.

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Rationale:

Problems related to system configuration errors leading to results routing logic errors are inevitable. With testing, many such unforeseen problems can be identified and addressed before they result in patient harm. Errors related to closed loop test order entry and results delivery are difficult to detect and can lead to delays in care.

Examples:

  • Efforts are made to proactively identify failure points related to EHR-enabled test results delivery.
  • Specifically designed testing scripts are used to identify remediable points of vulnerability21 in order to build systems that are more fault-tolerant.
  • Specific testing of routing logic, provider recipients, and configuration is performed to ensure accurate results delivery.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

4

After system changes in components or applications related to CPOE and diagnostic services, the data and data presentation are reviewed to ensure accuracy and completeness.

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Rationale:

System changes can unexpectedly affect the integrity of the data as it moves through organizations in ways that may not be recognized without proactive review.

Examples:

  • Organizations identify specific types of EHR system changes that impact CPOE and diagnostic services, such as application upgrades or changes to interfaces, and carefully review data integrity at all points where data is used.
  • Problems related to tables out of sync are identified with thorough testing.
  • Error queues are used to monitor for proper system performance; results that cannot be automatically delivered are manually delivered.
  • Order entry and result reporting interfaces are tested after every change to the laboratory or imaging ordering catalog.

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

5

Orders for diagnostic tests are placed using CPOE and electronically transmitted to the diagnostic service provider (e.g., laboratory or radiology).6,22,23

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Rationale:

A hybrid paper and electronic environment for test ordering is hazardous. CPOE can facilitate closed loop communication and results accessibility via the EHR, but only if the results are available in the system. Test results can be lost or missed if on paper, when clinicians have come to rely on the EHR.

Examples:

  • For common tests, there is a two-way system-to-system interface (i.e., for ordering, resulting, acknowledging, and cancelling orders) between the clinic/institution and the testing facility.24
  • Diagnostic tests that are not orderable through CPOE for any reason are promptly added to the system.

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

6

The EHR is able to track the status of all orders and related procedures (e.g., specimen received and collected or test completed, reported, and acknowledged).4

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Rationale:

Tracking orders facilitates closed loop communication. This enables detection of problems regarding order processing and delivery of test results.

Examples:

  • EHR can track whether or not the order was received, specimen collected, test completed, results reported, and results acknowledged.
  • Clinical practices where test result information is not fully integrated into the EHR use additional tracking strategies to enable follow-up.25

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

7

The ordering clinician is identifiable on all ordered tests and test reports, and, if another clinician is responsible for follow-up, that clinician is also identified in the EHR.8

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Rationale:

The ordering clinician is identifiable on all ordered tests and test reports, and, if another clinician is responsible for follow-up, that clinician is also identified in the EHR.8

Examples:

  • Result routing systems supports delivery of results to the ordering provider.5,9,11
  • EHR supports assignment/transfer of responsibility for test order follow-up.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

8

When test results are amended, the change is clearly visible in the EHR and printed reports.9

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Rationale:

Results that are subsequently changed carry a significant potential for delayed or wrong treatment based on outdated, incorrect results.

Examples:

  • Changed results are clearly flagged as such in the EHR (such as marked as "amended").

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

9

When test results are changed or amended, the ordering clinician and other clinicians responsible for follow-up are notified electronically. For clinically significant changes, the clinicians are also contacted directly.26

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Rationale:

Results that are subsequently changed carry a significant potential for delayed or wrong treatment based on outdated, incorrect results.

Examples:

  • The individual changing the results is responsible for notifying appropriate clinicians of those changes. Since electronic systems do not always ensure that a critical communication will be received and reviewed promptly, for clinically important changes to results, appropriate clinicians are also contacted directly.9
  • Policies and procedures ensure that changes in test results (and accompanying documentation) are effectively communicated to the appropriate clinicians responsible for patient care, including after the patient has transitioned to another setting of care.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff, Diagnostic services

10

"Send-out" (or reference lab) tests are electronically tracked, and their results are incorporated into the EHR, with a coded test name, result value, and interpretation.

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Rationale:

"Send-out" tests are vulnerable to loss of follow-up.

Examples:

  • The EHR facilitates the tracking of "send-out" tests and provides a mechanism to allow clinicians or organizations to incorporate these results into the EHR and assign them to the correct patient.
  • Procedures exist to ensure that all test results, including those received from outside the institution through fax or mail, are properly incorporated into the EHR.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff, Diagnostic services

11

Written policies specify unambiguous responsibility for test result follow-up with a shared understanding of that responsibility among all involved in providing follow-up care.4,6,9,13,14,27,28

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Rationale:

New workflows resulting from the introduction of EHRs can introduce new hazards related to miscommunication of responsibility for follow-up. Ambiguous responsibility increases the risk of follow-up failure.

Examples:

  • In the outpatient setting, the ordering provider is responsible for follow-up unless he or she delegates this (e.g., to covering provider). Delegation should be documented and accepted by the delegate.
  • Ordering clinicians in any setting assume responsibility for follow-up care, unless that responsibility is unambiguously transferred to another clinician, who accepts responsibility.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, Diagnostic services

12

Workflows that are particularly vulnerable to mishandling of test results, especially critical ones, are identified,29 and back-up procedures ensure test results are received by someone responsible for the affected patient’s care.6,26

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Rationale:

Lost or mishandled test results, especially critical ones, are a significant risk to patients, especially in situations with workflows particularly vulnerable to such failures, such as shift changes or transitions of care.30

Examples:

  • Situations that are vulnerable to test results follow-up failures are identified. These include handoffs between clinicians (such as between residents, part-time physicians, ER physicians, and hospitalists30), and care transitions between clinical settings (such as between different units of a hospital, and between the hospital and home or a postacute facility). In these situations, processes should be in place to ensure that test results are communicated to a clinician responsible for follow-up care.
  • Life threatening results are notified through verbal means to ensure positive confirmation of receipt.9
  • Notifications that remain unacknowledged after a prespecified time period are forwarded (or escalated) to an alternate responsible provider.31
  • Diagnostic services should ensure that test results are communicated to a back-up provider in a timely fashion in the event that the ordering provider is not available. The necessary timeliness is dependent on the significance of the test result.32
  • Institution maintains an updated contact list of all practicing providers and this list includes their coverage schedules.8
  • Institution maintains a patient-provider link (e.g., patient's PCP is identified).

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff, Diagnostic services

13

Results outside normal reference ranges (or otherwise determined to be abnormal) are flagged (presented in a visually distinct way).6,9

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Rationale:

Although absence of flags does not necessarily mean the result is normal, flagging can reduce likelihood of missing abnormal or critical results.

Examples:

  • Abnormal results are flagged (e.g., bolded font, asterisk
    beside values, use of "H" or "L," different colors, etc.) or
    marked for better visualization in the EHR.
  • Color is not used as the only visual indicator of clinical
    significance.
  • Critical values are flagged in a distinct way from simply
    abnormal values.

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

14

Display of results (e.g., numeric, text, graphical, or image) should be easily accessible, clearly visible (and not easily overlooked), and understandable.

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Rationale:

Missed or misunderstood test results as the consequence of a poorly designed human-computer interface are as dangerous to patients as lost or wrong results. Results visualization and display should maximize safety in order to ensure critical information isn’t missed.

Examples:

  • Displays of test results undergo usability testing for the intended clinical users.
  • Information is displayed in columns that are sufficiently wide to allow review of all pertinent information (i.e., providers do not need to drag columns on the user interface to detect abnormalities).11
  • Multicomponent results are reported together (e.g., lupus anticoagulant has 2-3 subcomponents that may be individually positive or negative but should be reported together).
  • Result details are reported on one screen, eliminating the need for horizontal scrolling. For example, providers should not have to use additional scrolling (e.g., on the “next page”) to access critical information.6,11
  • If the screen is not displaying the full message, there are clear indicators directing the user to the non-displayed remainder of the message (e.g., obvious scroll bars, ellipses, etc.).
  • Most recent test results should by default be displayed first (e.g., either at the top of a row-based display or at the left side on a columnar display) to ensure that clinicians are always aware of current data.33

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

15

Automated non-interruptive results notifications (also called “in-basket alerts” or flags) are limited to those that are clinically relevant in order to minimize “alert fatigue.” 4,11,14,27,28,34,35

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Rationale:

Information overload from too many alerts is associated with more missed test results.36

Results that are poorly displayed increase risk of misinterpretation or being overlooked completely.

Examples:

  • A multidisciplinary committee that includes frontline clinicians decides which abnormal result alerts the clinicians are required to receive and which ones clinicians can choose to suppress.
  • Outpatient clinicians have the option to receive results for their patients in the inpatient setting in their electronic inboxes.
  • Notifications of a patient's results are batched (aggregated) by type and/or date to minimize the number of notifications.
  • Institution/clinic monitors providers' inbox, i.e., the total number of alert notifications sent to providers.
  • The institution/clinic provides workflow support to help a provider when the number of unread notifications in his or her inbox grows large.

Suggested Sources of Input:

EHR developer, Health IT support staff, Diagnostic services

16

Results notifications remain in the clinician inbox until a clinician action occurs to address them.4,11,37

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Rationale:

If notifications drop off, clinicians can miss results.

Examples:

  • Notifications remain in the inbox until a clinician signs them.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

17

There is an EHR-based process for clinicians to either assign surrogates6,8,38 for reviewing notifications or enable surrogates to look at the principal clinicians' inboxes.

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Rationale:

Not using surrogate features and functions appropriately increases risk of loss of test result follow-up.

Examples:

  • If clinicians plan to be away, they assign a covering clinician to whom the system can automatically forward test results.
  • Organizations have policies and procedures that establish expectations for timely review of test results and specifically address planned and unplanned absences.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

18

There are mechanisms to forward results and results notifications from one clinician to another.11,27

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Rationale:

Notifications sometimes are sent to incorrect clinicians, and this functionality allows clinicians to forward them to the correct person.

Examples:

  • In addition to automatic forwarding, such as when a clinician is on vacation, forwarding can be done under clinician control (e.g., when the notification is transmitted to the incorrect clinician).
  • Mechanisms are in place for tracking acknowledgment and acceptance of forwarded notifications.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

19

Summarization tools to trend and graph laboratory data are available in the EHR.

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Rationale:

Displaying certain laboratory test results over time helps identify clinically relevant anomalies or trends. Summarization tools in the EHR improve visualization, interpretation, and accessibility of results.

Examples:

  • The EHR incorporates automated tools and reports that enable selected lab results to be easily graphed and displayed over time to view trends.

Suggested Sources of Input:

EHR developer, Health IT support staff

20

Test results can be sorted in the clinician’s EHR inbox according to clinically relevant criteria (e.g., date/time, severity, hospital location, or patient).6,11,26,28

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Rationale:

Clinicians need ways to prioritize results review so they can address the most pressing issues first and cope with information overload.39 Sorting also improves visualization and accessibility of results.

Examples:

  • Results can be sorted according to important parameters such as date, type, urgency, patient, and location.

Suggested Sources of Input:

EHR developer, Health IT support staff

21

The EHR has the capability for the clinician to set reminders for future tasks to facilitate test result follow-up.28,40

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Rationale:

The EHR can help clinicians follow-up with patients regarding test results. Unless they set reminders for themselves, clinicians may forget about follow-up tasks they need to do.

Examples:

  • Functionality to record a follow-up action due at a future date exists in the EHR.

Suggested Sources of Input:

EHR developer, Health IT support staff

22

As part of quality assurance activities, organizations monitor selected practices related to test result reporting and follow-up. Monitored practices include clinician use of the EHR for test results review and clinician follow-up on abnormal test results.4-6,13,26,41-44

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Rationale:

Effective quality assurance patient safety programs include monitoring of core clinical metrics. Errors related to missed or delayed follow-up of test results are a significant cause of adverse events that harm patients.

Examples:

  • The organization has in place processes to monitor and report alert responses (e.g., acknowledged or not; time to acknowledgment)8 and test result follow-up with patients.5
  • Clinicians document communication of test results to patients in the EHR.45
  • Organizational QA activities select and measure test results-related benchmarks for ongoing monitoring, starting in areas of identified concern and high risk. A measurement system for test results reporting exists with the following potential measures:
    • Percentage of all active clinicians who have reviewed at least one laboratory test result in the EHR within the last month. If greater than 95 percent, this measure could indicate if the EHR is perceived as the "source of truth" for laboratory test results (vs. dependence on paper-based communication).
    • Test results with the lowest follow-up rate are investigated to understand root causes of the problem.6,43
    • Percentage of all test results reviewed by the ordering provider within 4 days should be greater than 90 percent.
    • Results not reviewed for more than 1 week should be minimal.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

23

As part of quality assurance, the organization monitors and addresses test results sent to the wrong clinician or never transmitted to any clinician (e.g., due to an interface problem or patient/provider misidentification).21

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Rationale:

When test results are "lost in the system," there is a danger that there will be no follow-up, posing a significant risk of patient harm.

Examples:

  • Error logs are used to detect results such as those that were never delivered, results without any ordering provider, results with unidentifiable providers, etc.
  • National Provider ID (NPI) is used for provider attribution of orders.
  • Monitor provider master files to ensure that they are synchronized to avoid scenarios in which the ordering provider’s contact information is outdated or unknown.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff, Diagnostic services

{@Wednesday, February 26, 2014@}
{@Tuesday, February 25, 2014@}