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.

*Persons using assistive technology may not be able to fully access information in this file. For assistance, contact ONC at onc.request@hhs.gov.

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