Patient Safety Tip of the Week
November 17, 2015
Patient Perspectives on Communication of Test Results
Test results missing from patient charts are not uncommon in
primary care offices. One study showed lab results were missing in 6.1% of all
office visits and radiology reports were missing in 3.8% of all office visits (Smith 2005).
In our July 2009 What’s New in the
Patient Safety World column “Failure
to Inform Patients of Clinically Significant Outpatient Test Results” we
noted another study which found apparent failure to inform patients of
such abnormal test results 7.1% of the time (Casalino
2009).
There are probably
over 30 steps involved between the decision to order a test and communicating
the results to the patient and taking actions based upon the results (see our
March 6, 2012 Patient Safety Tip of the Week ““Lab”
Error”). Even if the chance of error at each step was only about 1%, the
cumulative risk of an error is substantial (perhaps as high as 25%). And while
many such errors may have little or no adverse impact on patients, the failure
to follow up on abnormal lab or radiology tests can have devastating results to
patients.
Two studies by Litchfield and colleagues recently
highlighted significant gaps in both identifying missing test results and in
communicating test results to patients in the UK. In the first (Litchfield
2015a) a phone survey of primary care practices was used. The authors found
that the default method for communicating normal test results to patients was
having the patient call the practice in 80% of practices and 40% of practices
required the patient to call for abnormal test results. 36% of the practices
had a physician call the patient if the test result was sensitive or serious.
In 18% of practices administrative staff would contact the patient and ask them
to book an appointment. When asked if the practice had a system for knowing if
a blood test result had been returned, 84%
had no such system. 10% assigned a staff member to check paper records of
tests ordered against electronic records and 6% thought that their EMR system
would highlight missing test results. Significantly, none of the practices had
assigned a specific team member the task of recording whether abnormal test
results had been returned to the patients. These results in the UK apparently
occurred despite the capability of the existing EMR systems in the majority of
practices to track test results.
The Litchfield paper provides a nice diagram of all the
steps involved in the blood testing process from ordering to return to and
acknowledgement by the responsible physician, including all the steps at the
laboratory. It identifies steps at which delays or failures are likely to occur.
These included spoiled, damaged, or otherwise non-viable samples, misidentified
samples, samples with unreadable labels, lost samples, etc. (See also the list
of our previous columns on “lab” errors at the end of today’s column.) The
Litchfield paper also describes when and how the lab would convey that
information back to practices.
In the companion study, Litchfield and colleagues (Litchfield
2015b) did focus groups with both patients and staff to better understand
where errors or delays in the process might occur. This is where they
constructed a process map and service blueprint in a LEAN-like process that
identified potential points of delay and potential failure points. It’s of
interest that most of these points impacted patients much more so than
practices. They ultimately identified 6 areas where improvements could be made:
- reducing delay prior to
blood sampling
- having a fail-safe to
detect missing and delayed results
- improved management of
calls from patients seeking results
- addressing the role of
nonclinical staff in result communication
- routine communication of
non-critical results by the practice
- defining and disseminating
among patients and staff a protocol for the TTP
The delay in getting an appointment with the phlebotomist
was not only frustrating for patients but also led to many simply not getting
their blood drawn at all. Physicians and staff noted that often they would only
recognize that no results were available once the patient called to get
results. Putting the onus on patients to call the office for test results led
to telephone gridlock that angered both patients and staff. Requiring patients
to call for normal test results led to a huge volume of phone calls. Physicians
and staffs were not in favor of calls for normal test results but patients were
most interested in receiving them. Patients also were generally unhappy getting
their results from untrained office staff who could no answer clinical
questions. Patients actually seemed to be interested in the idea that text
messaging could be used as a means to communicate results. Staff, however, were
concerned about that, noting that patients’ cell phone numbers might change.
Lastly, despite the fact that the clinical management (IT)
systems at the practices had the capability of tracking tests results, few
practices used this capability or were interested in training their staffs on
such use.
In a commentary regarding 2 papers from the UK which showed
continued problems in ensuring patients were appropriately notified of abnormal
test results Kwan and Cram (Kwan
2015) note the increasing trend of putting test results directly in the
hands of patients. They note that HIT regulations and meaningful use criteria
require patients have more access to their electronic health records and that patient portals are now a feature of
most electronic medical records. They also note that patient interest in
portals is greater than physician interest in them. They do outline some of the
issues of directly reporting test results to patients, including whether to
report only normal or abnormal results or both, how to assist patients in
interpreting results, and levels of patient anxiety that may be produced by
results.
In another commentary on the 2 Litchfield studies Nancy
Elder, who has written extensively on the problem of following up on test
results in primary care, talks about team dynamics in achieving quality and
safety outcomes (Elder
2015). She notes that in primary care the testing process is often carried
out in steps by individuals who are often unaware of the steps before and after
their contribution. Elder notes that all too often primary care physicians rely
on untrained staff to communicate results to patients. They also often rely on
patients to let them know when results are missing. She notes that PCP’s often
underappreciate the problem because actual cases of patient harm are relatively
rare and they are often “overloaded” responding to minimally abnormal test
results of no clinical significance.
So patients are very interested in seeing their test
results, whether they are normal or abnormal. But the mode preferred by
patients for receiving such results has received little attention.
Now a new study surveyed patients in the US on their
preferences for receiving reports of test results (LaRocque 2015).
Importantly, in the survey they asked questions about results of specific types
of test. The survey assessed comfort with 7 delivery methods: fax, personal voicemail,
home voicemail, personal E-mail, letter, mobile phone text message, and password-protected
website. The also assessed preferences for receiving information on cholesterol
levels, colonoscopy results, tests for non-HIV sexually transmitted infections,
and 3 genetic tests.
Not surprisingly, receiving results by fax was the least
comfortable for results of all test types. (Note that we caution against
hospitals or offices even using fax for sending test result reports to
physicians. We’ve seen cases where a physician office fax number changed and a
patient report was faxed to a local supermarket! Fax is simply not a secure
method for transmission of personal health information and could land you in a
heap of trouble for HIPAA violations.)
Home voicemail was also not a preferred method for most
people responding to the survey (and, again, we caution you about the potential
HIPAA implications of leaving PHI on a voicemail or messaging machine that
might be easily accessed by parties other than the intended one). Mobile phone
text messaging was also not a popular method for receiving test results. On the
other hand, over 60% of respondents were comfortable with receiving results of
cholesterol tests and colonoscopy results via personal voicemail, though less
than 50% found this method acceptable for STI or genetic test results. Similar
results were found for use of personal e-mail and password-protected websites. Password-protected
websites were the only method in which >50% of respondents were comfortable
receiving STI results and no method was acceptable by >50% for receiving
genetic test results.
Interestingly, age was not a factor regarding technology as
personal e-mail and password-protected websites were not affected by age. Age
was a factor regarding a very old technology: the letter. 71% of respondents
age 55 and older would be comfortable receiving a letter with results of the
common tests (cholesterol level or colonoscopy results) compared to only 35%
for those aged 18 to 24.
Overall, the method with which the largest portion of
respondents was comfortable was the password-protected website. The authors
note other research has shown patients who have access to patient portals
prefer this method over phone calls.
The LaRocque study
also shows how comfort levels with technology have probably increased over
time. In our October 13, 2009 Patient Safety Tip of the Week “Slipping
Through the Cracks” we noted a study (Leekha
2009) that looked at patient preferences for notification of test results
and noted disparities between those preferences and how they were actually
notified. A majority wanted notification via phone call from the physician or
nurse practitioner but in reality the majority received notification either via
a phone call from a nurse or by a return visit to the office. Use of more
hi-tech methods (e-mail, automated answering mechanisms, etc.) were not highly
regarded methods, though the average age of the population studied being 70
years may somewhat limit the generalizability of these conclusions. The authors
discuss how misalignment of incentives can be a root cause for dissatisfaction
(eg. patients dislike having to spend time and money for a followup office
visit, whereas providers only get reimbursed for such visits and do not get
reimbursed for phone calls).
Undoubtedly a big factor is the patient’s comfort level with
technology. Though almost all young people have grown up with technology and
use it daily, many of our older patients are not comfortable using computers,
smartphones, and other technology tools. (But don’t paint all older patients
with one brush! We know lots of our older patients who spend lots of time on
computers and are very comfortable with modern technology.)
Any acceptable system for tracking followup on patient tests
needs to do the following:
- Show that the test was
done and results reached the office
- Show that the physician
read the reports and acknowledged the results, whether normal or abnormal
- Show that results were
communicated to the patient in an acceptable manner
- Show that the patient
acknowledged receipt of the results and had the opportunity to ask
questions about them
- Hopefully show that any
recommended action on these results was actually undertaken
You’d think that today’s sophisticated EMR’s would have
built in even better systems for tracking test results. But one big problem is
still lack of interoperability among various systems. Many reports still arrive
back at the office in paper format rather than an electronic format. Of course,
we can scan those paper reports into most EMR’s. Don’t forget: paper-based
reports always were vulnerable to the issue of two pages sticking together,
often resulting in a report being filed in the chart of the wrong patient.
Also, all the above fail to mention the other huge
vulnerability – those tests that the primary care physician did not order but
were ordered by others. That is especially a problem with test results done
during a hospitalization where a hospitalist or specialist, rather than the
PCP, attended to the patient. We discussed those in our Patient Safety Tips of
the Week for March 1, 2011 “Tests
Pending at Discharge” and August 21, 2012 “More
on Missed Followup of Tests in Hospital. That transition of care
necessitates that responsibility for follow up needs to transferred and the new
responsible physician (the PCP in most cases) needs to know what test results
are pending at the time of discharge.
Many physicians, ourselves included, do use patients
themselves as a backup check on test results. We tell them “if you have not
heard back from us about these tests within x days, call us”. But even then
you’d be surprised how many patients never make that phone call. If not given
specific instructions regarding communication of test results, the patient
should always ask the physician “When should I expect the result to be
available?” and then contact the physician if they have not heard those
results within a reasonable period of time. The patient should never assume
that the test results were normal if they have not heard from the physician
or other provider.
Yes, patients are logical partners in the process and they
have the most to lose when the process is flawed. But we agree with Nancy Elder
that putting the burden solely on patients is problematic. The perfect system
for test results management has not yet been designed. But doing the sort of
process used by Litchfield and colleagues, which is sort of a combination of
LEAN and FMEA, to identify vulnerabilities in your current practices can be very
rewarding. Just the significant reduction in unnecessary phone calls you’d
expect after implementing a new process should offset the time and effort
expended to do such a study. And make sure you include not only every member of
your staff in that endeavor but also the most important people – your patients.
See also our other
columns on communicating significant results:
- Patient
Safety Tip of the Week May 1, 2007 “The
Missed Cancer”
- Patient
Safety Tip of the Week February 12, 2008 “More
on Tracking Test Results”
- Patient
Safety Tip of the Week October 13, 2009 “Slipping
Through the Cracks”
- What’s
New in the Patient Safety World July 2009 “Failure
to Inform Patients of Clinically Significant Outpatient Test Results”
- Patient
Safety Tip of the Week March 9, 2010 “Communication
of Urgent or Unexpected Radiology Findings”
- Patient
Safety Tip of the Week March 1,
2011 “Tests
Pending at Discharge”
- Patient
Safety Tip of the Week August 21,
2012 “More
on Missed Followup of Tests in Hospital”
- What’s
New in the Patient Safety World
October 2013 “New
AHRQ Toolkit: Improving Your Office Testing Process”
- What’s
New in the Patient Safety World
January 2014 “Email
Alerts for Pending Test Results”
- What’s
New in the Patient Safety World
July 2015 “Technology
to Avoid Delays in Follow-up of Significant Results”
Some of our other
columns on errors related to laboratory studies:
- October
9, 2007 “Errors
in the Laboratory“
- November
16, 2010 “Lost
Lab Specimens”
- October
11, 2011 “LEAN
in the Lab”
- March 6, 2012 ““Lab”
Error”
- April
2012 “Specimen
Labeling Errors”
- January 22, 2013 “You
Don’t Know What You Don’t Know”
- April 15, 2014 “Specimen
Identification Mixups”
- November 25, 2014 “Misdiagnosis
Due to Lab Error”
- March 24, 2015 “Specimen
Issues in Prostate Cancer”
- May 26, 2015 “How
Safe is the Lab You Use?”
References:
Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical
information during primary care visits. JAMA 2005; 293(5): 565-571
http://jama.jamanetwork.com/article.aspx?articleid=200289
Casalino LP,
Dunham D, Chin MH et al. Frequency of Failure to Inform Patients of Clinically
Significant Outpatient Test Results. Arch Intern Med 2009; 169(12):
1123-1129
http://archinte.ama-assn.org/cgi/content/full/169/12/1123
Litchfield I, Bentham L, Lilford R, et al. Test result
communication in primary care: a survey of current practice. BMJ Qual Saf 2015; 24(11): 691-699
Published Online First: 4 August 2015
Litchfield I, Bentham L, Hill A, et al. Routine failures in
the process for blood testing and the communication of results to patients in
primary care in the UK: a qualitative exploration of patient and provider
perspectives. BMJ Qual Saf 2015;
24(11): 681-690 Published Online First: 6 August 2015
Kwan JL, Cram P. Do not assume that no news is good news:
test result management and communication in primary care. BMJ Qual Saf 2015; 24(11): 664-666
Published Online First: 18 August 2015
Elder NC. Laboratory testing in general practice: a patient
safety blind spot. BMJ Qual Saf 2015;
24(11): 667-670 Published Online First: 18 August 2015
LaRocque JR, Davis CL, Tan TP, et al. Patient Preferences
for Receiving Reports ofTest Results. J Am Board Fam Med 2015; 28: 759-766
http://www.jabfm.org/content/28/6/759.full.pdf+html
Leekha S, Thomas KG, Chaudhry R, Thomas MR. Patient
Preferences for and Satisfaction with Methods of Communicating Test Results in
a Primary Care Practice. The Joint Commission Journal on Quality and Patient
Safety 2009; 35(10): 497-501
http://www.ingentaconnect.com/content/jcaho/jcjqs/2009/00000035/00000010/art00002
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