Abnormal subcritical tests may not require immediate attention, but missed or delayed follow-up of these tests can lead to patient harm. Research on the topic suggests that new technology and workflow solutions are needed. Therefore, at ASCENT, we sought provider perspectives on the barriers and facilitators to managing subcritical test results. We conducted five focus groups with 43 multidisciplinary clinicians in an urban, academic, integrated, safety-net health system. We summarize the major barriers to safe and effective test results management and solution characteristics identified in these focus groups below.
The lack of health information technology (HIT) system integration may cause stress among healthcare providers. An example of HIT is an electronic health record (EHR) that contains patient information, like a patient’s medical history and diagnoses, along with tools for providers to better manage care. However, medical departments may have different types or versions of an EHR, preventing seamless communication between all providers engaged in a patient’s care. As a result, clinicians often have to manage multiple EHRs and other HIT systems. Participants articulated a need for fully integrated EHRs in order to easily obtain up-to-date patient information.
Unreliable Tracking of Tests and Results
Health providers reported that they lacked the ability to track test results in a reliable manner. For instance, some medical departments used paper registries that do not automatically sync with the EHR, making it difficult for clinicians to manage test results. Participants envisioned a re-designed workflow and electronic alert tool to help ensure that a patient’s appropriate healthcare provider, e.g. primary care physician, is made aware of subcritical test results, and that the patient receives appropriate follow-up.
There are differing beliefs among healthcare professionals about who is responsible for managing subcritical abnormal test results. For example, some inpatient, emergency, and radiology departments thought that primary care physicians are ultimately responsible for a patient’s test results. Other participants believed that the healthcare provider responsible for a patient’s test result may vary depending on the urgency of follow-up. For instance, an inpatient physician may be responsible for a patient who needs immediate follow-up, but a primary care provider should hold responsibility for longer-term follow-up. Participants suggested that re-developed work flows or guidelines can help ordering physicians contact the appropriate healthcare provider.
Focus group participants spoke about the challenges of communication between healthcare providers, which can be complicated by inaccurate contact information and the lack of a protocol that outlines which clinician to contact about patient follow-up procedures. Participants stressed the importance of clear communication protocols and improved workflows for keeping provider contact information up-to-date.
Many healthcare providers felt that they would be unable to manage a test registry, contact patients and providers, and schedule follow-up appointments in addition to existing responsibilities. Participants suggested that each department have an additional staff member to focus on test results management to ameliorate workload challenges.
Organizational characteristics, such as providers rotating on and off services, can contribute to additional safety gaps in the management of subcritical test results. This lack of provider continuity across inpatient, emergency department, and ambulatory settings introduces additional challenges to test results management, such as assigning responsibility in a clinic that has frequently changing personnel.
The clinicians also spoke about the additional barriers experienced by vulnerable populations cared for in safety-net health systems, such as the lack of a primary care provider or accurate contact information listed in the EHR. Any solution must consider these challenges and integrate patient-centeredness into its design.
Through these focus groups with clinicians across departments, we found that timely, accurate, and active test result management requires improved tracking systems, but that these solutions must be paired with workflows and role clarifications that are designed with the individuals involved, setting, and processes in mind. ASCENT is integrating these findings into the development of an HIT-facilitated intervention and workflow redesign to improve test results management across the San Francisco Health Network.
Clarity, C., Sarkar, U., Lee, J., Handley, M., & Goldman, L. E. (2017). Clinician Perspectives on the Management of Abnormal Subcritical Tests in an Urban Academic Safety-Net Health Care System. The Joint Commission Journal on Quality and Patient Safety.
What is an Electronic Health Record (EHR)? HealthIT.gov. Updated 16 Mar 2013. https://www.healthit.gov/providers-professionals/faqs/what-electronic-he...