In our May 1, 2007 Patient Safety Tip of the Week “The Missed Cancer” we talked about the need for all physicians to have a system for tracking patient test results to help avoid such disasters as the missed cancer. Offices that have incorporated audits of tracking tests results into their QI activities have shown gaps that could lead to significant adverse patient outcomes. Eastwood (1) in a 6-month audit of a practice in the UK noted a 0.48% rate of missing test results. That may sound like a small number but given the thousands of tests ordered each year in a typical practice, that translates into a substantial quality and patient safety issue.
Tracking test results is obviously important for the well-being of your patients. But it is also important for the well-being of your practice. Failure to diagnose and delay in diagnosis are two of the most common reasons for medical malpractice awards and test results “falling through the cracks” are a big reason for both. In addition, CMS is now working on development of physician office quality measures and one in the making is “Tracking of Lab Test Results and Referrals” (2).
Last week, while putting together our Tip of the Week on reducing errors in obstetrical care, we happened to come across an excellent ACOG Committee Opinion on Tracking and Reminder Systems (3). Such systems can be simple (such as a log book or index card files or paper-based tickler system) or complex (such as a computerized system) but need to be reliable, standardized, understood by appropriate office staff, and regularly reviewed. They stress the number of people with responsibility should be limited but responsibility should never reside solely with one person. Educating the patient on the reason for and importance of the test or referral is the first step. Also, let the patient know that your office will get back to them with the results of the test whether it is normal or otherwise and tell them to contact your office if the have not heard from your office within a specified period of time. When a patient fails to keep a followup appointment, that should be recorded in the medical record and attempts should be made to reschedule that appointment.
The tracking system should have an office policy and procedure and input from the staff during planning of that system is important. This should include how the patient should be contacted and documentation of followup in the chart. Specific time frames for followup of the various types of tests should be established. A central location for the system is critical so that it is accessible by appropriate office staff and it is not appropriate to keep the reminders in individual patient charts. Staff members should be cross-trained on the use of the system so that the system does not fail in the absence of key individuals. And, of course, that system for conveying results to patients must be in compliance with HIPAA regulations.
The article provides samples of some of the elements to keep in the tracking system. When results come back, the appropriate clinician should review, date, initial or sign, and document in the chart and in the system what is to be done next. When the patient is contacted, there should be a note to that effect in the chart along with the date and documentation of the discussion that took place. If more testing or referrals or other follow-ups result, those should be put back into the tracking system as well.
The practice needs to prioritize what it wants to put in the tracking system. But that usually includes all laboratory and radiological tests, other diagnostic tests, and referrals to specialists. We recommend also including special attention to items related to recent ER visits or hospitaliziations.
It is also not enough just to have a policy, procedure and system in place. Your quality improvement activities must also periodically and regularly audit, measure and review the outcomes of such system.
In our November 2007 What’s New in the Patient Safety World column we mentioned The Kentucky Medical Association published a nice tool for Tracking Test Results Within a Physican Practice (4). It notes that as many as a third of physicians surveyed had no reliable way to track test results. It provides solid advice on setting up a system in your office, whether electronic or paper-based. This paper, and the ACOG paper above, both stress that keeping the system simple, with as few steps as possible, is very important. The KMA paper addresses creating a log of the tests ordered and creating a “pending” file, regardless of whether your system is electronic or paper-based. They suggest keeping a “pending” tray for patient charts awaiting test results. They discuss some of the electronic/computer solutions available but also note, as we did in our May 1, 2007 Patient Safety Tip of the Week “The Missed Cancer”, that simple off-the-shelf computer programs such as Microsoft Excel, Access, Word or Outlook may be utilized for many of the necessary functions. They go on to discuss the physician review of results and designation of who and how the patient will be contacted. They stress that results of all tests, whether abnormal or normal, should be communicated to the patient. They note HIPAA issues, such as the fact you should never send results on a postcard or leave results on a personal answering maching. They do discuss potential use of automated test result voice mail systems that have built in confidentiality security. They do point out, however, that abnormal results should be addressed differently than normal results. The physician, after reviewing the abnormal results, should contact the patient by phone. If they cannot be contacted by phone, a certified letter should be sent asking them to contact the physician. And the system should have a provision for handling emergent or life-threatening results. And they discuss documentation in the chart both of the results and the patient notification. Lastly, they discuss the importance of explaining the results tracking system to the patient, perhaps even providing them with a flow chart and instructions or FAQ’s on the system.
Overall, the ACOG and KMA documents are very worthwhile reads for every office practice (or hospital-based practice).
Other good sources of information about results tracking systems include medical malpractice carriers. CRICO/RMF, the patient safety and medical malpractice company owned by and serving the Harvard medical community, provides online samples of effective and exemplary practices for tracking test results (6). They also provide a larger downloadable document “What Works: Effective Practices for Office-based Care”. The Amercian Physicians Assurance Corporation also has an online document for “REDUCING PHYSICIAN LIABILITY WITH TRACKING AND FOLLOW-UP
SYSTEMS” (7) by: R. Stephen Trosty, JD, MHA, CPHRM, that has good suggestions.
However, even computerized alert and reminder systems aren’t 100% successful. Singh et al (8) reported followup on 1017 imaging report alerts transmitted electronically. They found that over a third of the alerts went unacknowledged, including 4% of abnormal results. Overall, 0.2% of outpatient imaging was lost to followup. Clearly, we still have a long way to go in fixing the barriers and system issues in ensuring test results get appropriately acknowledged and acted upon. Another study (9) looked for followup after abnormal imaging reports were telephoned to referring physicians and found that 9.3% had no evidence of imaging followup even after multiple communications (though there might be legitimate reasons for lack of imaging followup in some cases).
Update: See also our July 2009 What’s New in the Patient Safety World column “Failure to Inform Patients of Clinically Significant Outpatient Test Results” and our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks”.
(1) Eastwood B. Tracking the fate of laboratory test results. British Journal of General Practice 2003; 53: 493
(2) CMS Special Project: Development of Physician Office Quality Measures
(3) ACOG Committee on Quality Improvement and Patient Safety. Committee Opinion. Tracking and Reminder Systems. Obstetrics & Gynecology 2006; 107: 745-747
(4) Kentucky Medical Association. Tracking Test Results Within a Physician Practice. http://www.kyma.org/Patient_Safety/Member_Resources/documents/Tracking Test Results.pdf
(5) CRICO RMG. Tracking Test Results. 2006
(6) CRICO RMF. What Works: Effective Practices for Office-based Care. 2006 http://www.rmf.harvard.edu/patient-safety-strategies/office-practices/main/menu.aspx
(7) Trosty RS. Amercian Physicians Assurance Corporation. REDUCING PHYSICIAN LIABILITY WITH TRACKING AND FOLLOW-UP SYSTEMS. 2005 http://www.apassurance.com/RiskMgt/Articles_RM/Tracking_FollowUp_Systems_42005.pdf
(8) Singh H, Arora HS, Vij MS, MDc, Rao R, Khan MM, Petersen LA. Communication Outcomes of Critical Imaging Results in a Computerized Notification System .J Am Med Inform Assoc. 2007; 14:459-466
(9) Ridley EL. Using informatics to meet communication challenges.
Accessed February 7, 2008.