We investigated reasons why follow-up actions on a large proportion of positive FOBT results that needed a diagnostic colonoscopy were not documented by clinicians despite the use of a system to electronically communicate positive results. In addition to order-entry workarounds in the electronic health record, we discovered that the communication system intended to alert PCPs of positive FOBT results was not configured correctly, leading to certain situations in which PCPs never received the test result. Upon correction of the software configuration error, the percentage of positive FOBT results lacking follow-up were dramatically reduced. Although the rate did not drop to zero, it was comparable to the rate of lack of timely follow-up we found for other types of non-life threatening, high-priority lab notifications in the same system [23
]. Our findings suggest that communication of cancer-related test results in the electronic health record must be monitored to avoid compromising the promise of cancer screening programs.
Of the over 800 patients each year who have positive FOBTs at our institution, about 10-15% of them are eventually diagnosed with some form of colon disease (including cancer). None of the patients in our study had any delay in cancer diagnosis or related harm. Although it is possible that follow-up may have occurred beyond our 30 day "timely response" window had we not intervened, previous work suggests that many of these findings would ultimately never be followed-up [10
]. Thus, our seemingly small intervention could potentially have a large impact on decreasing time to referral for colonoscopy, thereby reducing the risk of a missed or delayed diagnosis of colorectal cancer, a common reason for ambulatory malpractice claims [24
]. Previous literature has highlighted the need for system-based interventions to improve follow-up of positive cancer screens and our study is one of few that contributes to this body of knowledge [6
Our findings also highlight how electronic health record use can have dramatic effects on follow-up care of patients. Electronic health records have potential to address the fragmented and discontinuous care that usually characterizes care in the outpatient setting. Critical information flow between different practitioners, settings and systems of care is essential to high quality care. Through good decision support systems, transmission of information to the right provider at the right time is within the reach of integrated electronic health records. However, as we find, electronic health record use must take into account the effect electronic communication will have on workflow and vice versa. Not doing this correctly would lead to circumstances that reduce the situational awareness of providers and perhaps other unintended adverse effects.
A limitation of our study was a lack of comparable data from other VA or non-VA facilities. However, our work illustrates how electronic test result communication systems are susceptible to errors that may limit their intended outcomes. Furthermore, it should be noted that other VA investigators [10
] have demonstrated high rates of lack of positive FOBT follow-up, so it is possible that this problem exists at other VA sites. We are currently investigating whether this problem exists in other VA facilities or if this was an isolated event. Additionally, in this study we did not address many other systems issues that should be considered to address follow-up of abnormal test results in addition to provider, technology and work-flow. In our work, we are now using a socio-technical model that accounts for many other systems issues beyond the responsible provider, including the role of organizations and policies and procedures to address monitoring of abnormal test results [27
]. For instance, an institutional policy that all FOBTs are ordered through computerized order entry would be another intervention to address this area. In our future work, we will propose multifaceted solutions to address the many complex issues related to abnormal test result follow-up.
Although electronic health records likely offer many benefits over paper-based systems for improving communication of abnormal cancer screening results [17
], our findings highlight the need to account for inherent complexities of clinical practice. This complexity may introduce circumstances requiring special attention to EHR workflow to prevent loss of follow-up of important clinical information. In our setting, several workarounds of the FOBT ordering and reporting process resulted in disruption of the normal electronic health record workflow, creating a reliance on a secondary PCP notification system, which was not functioning as intended. The challenge of recognizing these complexities and their effects underscores the need for continuous monitoring of key electronic health record features that may impact safety. The work described here was a direct result of quality assurance work that is highly regarded in the VA health care system. Other institutions could use our methods to track the effectiveness of electronic communication. However, quality monitoring procedures such as used by the VA to ensure system safety must also be used to identify red flags that would lead to similar future investigations. Without the safeguards used by the VA, the problems related to test result communication may go undetected.
Health care systems should aim to achieve a high reliability for tracking delivery of abnormal cancer screening results. An example viewed as an ideal model for tracking systems is that of FedEx, which is considered to have 99.6% tracking reliability for its packages [28
]. To achieve such high tracking reliability would not only require implementation of comprehensive technology-based systems for communication, but also formal policies and procedures regarding their use [28
]. The test result communication system evaluated in our study addressed several criteria [28
] for effective critical results reporting systems, such as computerized tracking and back-up procedures. However, to achieve tracking comparable to other industries, cancer screening programs should continuously monitor and oversee the timely delivery of positive cancer screening results to the right clinicians. For example, we recommend that cancer screening programs using electronic health record systems should develop and monitor multiple metrics of performance of automated communication processes. Failure to implement such monitoring systems could lead to sub-optimal screening success, which may otherwise be difficult if not impossible to trace.