We tested whether certain abnormal outpatient laboratory tests were followed-up in a timely manner in a multi-specialty clinic that used an integrated electronic medical record for automated notification. We found 6.8% of alerts lacked follow-up at 30 days, suggesting that follow-up of abnormal outpatient test results is not fail-safe even when providers are alerted about abnormal results through the electronic medical record. Of concern was the finding that there was lack of timely follow-up even when providers acknowledged notifications through the electronic medical record, which was comparable to when they did not acknowledge them. These findings are similar to our previous findings of follow-up on abnormal imaging alerts in the same electronic medical record suggesting that this phenomenon may exist for all alerts of abnormal diagnostic test results. Unexpectedly, we found 17% of abnormal test alerts were related to tests that we deemed redundant based on pre-determined criteria. Alerts related to these tests were less likely to lack timely follow-up.
Our findings have several significant implications for electronic medical record use in the future. One, it cannot be assumed that automated notification of abnormal lab results within an electronic medical record and the resultant acknowledgement will translate into timely actions to address these alerts. Two, notifications of abnormal redundant tests appear to be a distracting influence on providers who are missing essential alerts for newly diagnosed conditions. Three, high-reliability tracking systems to monitor potential patient harm and outcomes are needed, which also should account for follow-up actions by providers. Currently, the only way to track follow-up actions on abnormal alerts is through medical record review, a time-consuming and expensive procedure. However, individual-level tracking of follow-up actions taken in response to abnormal test result notifications could be designed within the electronic medical record. Thus, when providers process an alert, they could be provided order sets of appropriate follow-up actions in a separate “pop-up” window (such as having a nurse call the patient, setting up a return appointment, ordering a consultation or follow-up test, or an option indicating no further action is required such as when a patient is already in hospice care). These actions could be tracked through the electronic medical record and a reporting process could be created for clinic administrators to review and identify patients who may have truly “slipped through the cracks” without performing extensive record reviews. For instance, in cases of inaction on an abnormal lab at 2 weeks, the ordering provider or their surrogates could be informed.
We previously determined rate of lack of timely follow-up for abnormal imaging alerts in the same system and setting and found comparable results. Future work needs to confirm the extent to which these findings exist in other electronic medical record systems. Because there could be many potential reasons why busy providers in the front lines of health care delivery miss abnormal test results, a multidisciplinary approach is needed to address test result follow-up in future. For instance, an approach involving human computer interaction and informatics3;21
that accounts for issues related to usability, organizational characteristics, technology, work-flow and provider factors could be useful to explain why providers are unable to follow-up results despite reading them and hence improve safety in this area. 22;23
Computerized reminders have been shown to reduce redundant tests in the inpatient setting.24
However, our computerized reminder system would have prompted the ordering provider only 7% of the time. Notably, in 131 cases where a positive Hepatitis C test previously existed in the electronic medical record, the reminder logic was not set to prompt providers that they were ordering a repeat, redundant test. Current computerized reminder systems could be better designed to reduce test redundancy. For instance, these reminders are designed to prompt providers based only on the date of test order and not the date of the result of the last test. If the system had been configured as giving off a prompt based on both these dates, all 28 providers who unnecessarily ordered a PSA, Hba1c or a TSH would have received a prompt. Future work is essential to better document whether the use of information technology can reduce the enormous costs associated with redundant tests especially in the outpatient setting. 25;26
Our study had several limitations. Because of the study population (e.g. predominantly male veterans) and the unique VA setting, our findings may not be generalizable outside the VA. However, with increasing emphasis on electronic medical records the potential relevance of these findings is significant. We also lack comparable data from non-electronic medical record based systems and cannot comment on the effectiveness of automated notification compared to these systems. Due to the lack of similar tracking and documentation capabilities, such an evaluation study would be very difficult to carry out. Conversely, many factors including a large sample size, multiple clinics, large number of providers (over 500 from different specialties), rigorous methods to determine follow-up, explicit criteria for determination of redundant tests, various types of abnormal lab alerts and an advanced integrated electronic medical record used in VA facilities throughout the US, all add several unique strengths to our study.
In conclusion, current systems of mandatory automated notification of abnormal lab results do not guarantee timely follow-up on the abnormality in the outpatient setting. Additionally, provider acknowledgment of receipt of the test result also does not automatically result in timely follow-up. Multidisciplinary interventions involving human-computer interaction 3;21
and high-reliability tracking systems to monitor test result notification outcomes, such as follow-up actions by providers on these tests, are needed to alleviate these safety concerns.