Our institution implemented several standard operating procedures to enhance communication through the View Alert computerized test result notification system, a process currently in use in all VA facilities to report specified abnormal test results. To test its effectiveness we studied communication outcomes as a result of using this system and evaluated physician awareness of abnormal imaging test results, a problem of significant magnitude in previous studies. 4,11
Using a taxonomy of communication breakdowns, we categorized problems with alert acknowledgment and reception and identified lost to follow-up imaging results. Providers failed to electronically acknowledge over one-third of alerts according to established protocols and were unaware of abnormal results in 4% of cases 4 weeks after reporting. We found that 45 (0.2%) of 20,680 imaging reports were lost to follow-up in the study period; when translated to 190,799 outpatient visits, the rate was 0.02% per outpatient visit. Although we lack data about these rates prior to using this system, our findings suggest that lack of physician awareness of abnormal imaging results and subsequent loss of appropriate follow-up occur despite the use of a computerized test result notification system that followed standardized policies and procedures.
Surprisingly, there is a dearth of studies that report such overall rates. Two studies have reported similar data in systems that do not use similar IT and suggest that physician unawareness of abnormal imaging results is a substantial problem. 4,11
One of them reported 36% of abnormal mammograms to be lost to follow-up, 4
whereas another reported that 23% of abnormal dual-energy x-ray absorptiometry scans without evidence of review by the provider. 11
These numbers are strikingly high compared to the 4% reported in our study. The dual-energy x-ray absorptiometry scans study also reported about a 2% overall lost to follow-up imaging rate compared to the 0.2% seen in our study. Although our data are from a single site, they appear to suggest an improvement over noncomputerized notification systems.
Limited data exist from computerized notification systems related to imaging. In a recent study at another VA facility, 8 of 395 (2%) of abnormal radiology reports were lost to follow-up, a number that is not statistically different from ours. 18
However, their system was semiautomated, i.e., the radiologists notified the provider in every abnormal case, a fairly time-intensive process. The vast majority of radiologists have found this method to be frustrating, with lengthy wait times on the telephone for referring clinicians, and for this reason this method is generally not popular among radiologists. 19
Other techniques of automation-based test result notification are emerging 19,20
; however, their performance and outcome data are lacking. In general, electronic alerting has been shown to improve critical laboratory results communication in the inpatient setting, and we believe that it has a promising future in improving test result follow-up in the outpatient setting. 21–23
Our findings affirm the need for high reliability of tracking abnormal test results to achieve high-quality health care. 1
System redesign should include formal policies and procedures regarding communication and appropriate use of technology 19–21,24,25
to achieve high standards of patient safety. Several studies report communication errors in test result reporting and have addressed issues related to test result follow-up. 1–4,17,26–32
However, few studies have comprehensively evaluated outcomes by using a taxonomy of communication failures to identify points of breakdowns in the test result notification process. 11,29,32
We believe our study may be one of the first to adapt such a taxonomy to evaluate a computerized test result notification system in ambulatory care.
Our study included alerts related to a broad range of imaging studies ordered by providers of several types, including trainees. The majority of outpatient care at our institution is delivered by primary care providers, who often act as gatekeepers and can serve as a safety net to maintain quality care in a complex multispecialty health care system. The transmission of every alert to the patient’s primary care provider could have contributed to enhanced communication as evidenced by the number of cases (18%) in which the alternate (primary care) physician was the first to document responsiveness to the alert. Although this suggests that our back-up system seems to be working to an extent, it is still concerning that providers at times did not document any response to the alert in the medical record.
Despite enthusiasm about computerized test result notification systems and their potential for improving patient safety, there were several examples of near misses for which results were not followed up with additional testing, work-up, or consultation. Because we do not have appropriate comparison data for our system prior to this intervention, we cannot speculate whether this is an improvement over our previous nonelectronic notification, such as pages or telephone calls to ordering providers. Although lost to follow-up imaging accounted for only 4% of all abnormal results, in a system in which millions of imaging tests are performed the potential impact of lost test results is high. For example, in the brief 11-week time period at our institution, most of these near misses (including 33 reports that were coded as suspicious for a new malignancy) could have resulted in adverse outcomes. At the time of provider contact in these cases, providers reported recalling the case, but when asked specifically about their abnormal imaging tests, providers did not recall reading the results and admitted to being unaware and not taking action.
Practicing physicians in the ambulatory care setting are subject to many breakdowns in care processes that lead to lost test results. Primary care physicians may receive up to 40 radiology reports per week 3
in addition to several other laboratory reports, and at our institution providers may receive anywhere from 20 to 60 alerts per day. There are several other constraints, such as time and workload, that could affect the communication process, but much needs to be learned about why alerts remain unacknowledged and why test results get lost to follow-up. Future work should aim to lower the rate of lost-to-follow-up results without putting additional constraints on providers’ tasks or time.
Our study has several limitations. This was a single-institution VA study performed over a relatively brief time period with a predominantly male study population, raising questions about generalizability outside the VA. We also have no similar communication error data prior to initiation of the electronic alert system, limiting our conclusions about its effectiveness compared to previous methods. In addition, we did not examine possible alert transmission failures, such as circumstances in which the radiologist did not appropriately code the abnormal report. We did not study harm and adverse events, but only near misses at 4 weeks, which was a convenient and feasible outcome measure given our study methodology. It is possible that follow-up would have occurred for some alerts after this 4-week time period had we not intervened. We also did not assess the characteristics of the 615 abnormal imaging results that were acknowledged by the providers. Our results also may not be generalizable to the inpatient setting where the prevalence of abnormal results is likely to be higher and care is provided by teams that rotate more frequently and have a more complex structure. Because of the unique IT environment at the VA (the VA information management system integrates the EMR with ancillary systems such as the radiology information system), our results are not generalizable to other settings, such as free-standing diagnostic imaging centers, which may not communicate alerts directly to physicians’ EMR screens. Nevertheless, we believe that the VA system can be viewed as a model for communicating alerts to physicians and an important system within which innovations in patient safety methods can be developed and tested. 33
In conclusion, imaging results continue to be lost to follow-up in a computerized test result notification system that alerted physicians on their EMR screens. Although previous data comparisons are limited, communication failures in this system appear to occur at a lower rate than those reported in systems that do not use comparable IT. Future research should assess the effectiveness of various methods of notifying providers of abnormal test results and determine why some alerts are lost in computerized notification systems.