Progress sought in managing test results; information technology seen as key

Gordon D. Schiff, MD, said the health care system needs to do a better job of managing and communicating critical test results -- and he has a piece of paper in his pocket that proves his point.

Dr. Schiff said he was working after hours when he heard the front telephone ringing incessantly and wondered why the answering service did not pick up the call. So he picked it up himself and found that it was a medical laboratory calling to let them know that one of his colleague's diabetic patients had a low blood glucose reading of 23 mg/dL.

The internist wrote down the information on a piece of paper and, after using his "broken Spanish" to communicate with the patient's family who did not speak English, Dr. Schiff was able to reach the patient at work on the telephone. The patient knew how to monitor his own blood sugar and, after some discussion, he adjusted his insulin and everything worked out fine, said Dr. Schiff, a senior attending physician at John H. Stroger Jr. Hospital of Cook County in Chicago.

This story emphasized Dr. Schiff's point, which he made in the February issue of the Joint Commission Journal on Quality and Safety, that medicine's test management system is a series of "poorly designed nonstandardized steps with frequent fumbles." And it needs to be transformed so that it resembles a trapeze artist's performance "where each hand-off is flawlessly designed, timed and executed."

"I think the image of a trapeze artist fits what we're currently doing: It's like we're flying through the air making all kinds of decisions with dangerous consequences if someone fails," Dr. Schiff said. "There are doctors all over the country with the pockets of their white coats filled with scraps of paper and Post-it notes."

He suggests that the answer to this seemingly random system is to rely less on memory and more on information technology systems that flag abnormal results and help coordinate communication between primary care physicians, specialists, testing labs and patients.

In addition to improving patient safety, Dr. Schiff said managing critical lab results is also a legal issue. He cited studies showing that 25% of malpractice suits deal with diagnostic errors, while medication errors -- which have been a major focus of the patient safety movement -- are responsible for about only 12%.

The Joint Commission on Accreditation of Healthcare Organizations made improving the effectiveness and timeliness of communication between doctors and laboratories part of its 2005 patient safety goals. To that end, it devoted the entire February issue of its Journal on Quality and Patient Safety to that subject.

Additionally, the Massachusetts Coalition for the Prevention of Medical Errors recently released a set of safe practice recommendations designed to prevent delays in reporting critical test results that could mean adverse outcomes for patients.

The subject also was explored in a March 1 Annals of Internal Medicine report, "Fumbled Handoffs: One Dropped Ball after Another."

The Annals report, by Tejal K. Gandhi, MD, MPH, medical director of the patient safety team at Boston's Brigham and Women's Hospital, summarized the issue while focusing on a specific case where communication problems delayed a tuberculosis diagnosis.

Dr. Gandhi agreed with Dr. Schiff's assessment that patient involvement is a necessary ingredient in improving management and communication of test results and said the "no-news-is-good-news" philosophy has to be made a relic of the past. "I think patient education is a critical piece of this," she said. "Patients must be educated to expect the results of all tests, and physicians must be given tools to facilitate this communication."

Dr. Gandhi said she had received a positive response to her report, which she thinks is the result of addressing a problem physicians face every day.

Nancy C. Elder, MD, University of Cincinnati associate professor of family medicine, agreed. She said the universal nature of the topic catches the attention of physicians.

"It's a nice little 'a-ha moment,' where someone realizes that they're not the only one who has these problems," said Dr. Elder, who also worked on a report published in the February Joint Commission Journal on Quality and Patient Safety.

Better decision systems

In her report, it's noted that diagnostic tests account for less than 5% of national medical expenses, but the results of those tests could be the basis for a majority of medical decisions.

These errors, the report stated, include missed or delayed diagnosis, duplication of services, unnecessary or delayed interventions, patient dissatisfaction and litigation.

"Medicine will always be about people making quick decisions," Dr. Elder said. She added that it's a positive sign that President Bush is a strong advocate for health information technology and praised the work being done in this area by the U.S. Agency for Healthcare Research and Quality, but said technology alone wouldn't be the answer.

What is needed, Dr. Elder said, are better support systems for clinical decision-making.

The researchers did not endorse any particular electronic system or offer any specifics about how to pay for them, but they said the savings these systems could generate from reducing errors and the duplication of services made them a worthwhile investment.

The report by Dr. Elder and her colleagues noted how the proposed National Health Information Infrastructure would address many of the concerns raised in their report.

"More government funding is needed, but it's also going to need to come from insurance companies," Dr. Elder said.

The AMA has a policy stating that it supports the use of electronic medical records, but it does not support mandating their purchase by physicians.