EMR alerts can signal abnormal tests, but some doctors don't use them

Advocates of electronic medical records believe they will boost health care quality and patient safety by improving communication. But a new study shows that even the most sophisticated EMR cannot, by itself, help doctors always follow up on abnormal imaging test results.

The Sept. 28 Archives of Internal Medicine study found that 7.7% of the time, office-based physicians using an EMR failed to take action on clinically meaningful abnormal results within a month. More than a quarter of the tests that initially were overlooked resulted in a new disease diagnosis, with 42% of those being a cancer diagnosis, the study said.

The study of nearly 1,200 electronic alerts sent to doctors practicing at the Michael E. DeBakey Veterans Affairs Medical Center and five satellite clinics in Houston showed that physicians failed to click open the alerts nearly 20% of the time.

The results came as a surprise to researchers, said lead author Hardeep Singh, MD, MPH.

"Test-result communication has been a problem that institutions have been struggling with for a long time," said Dr. Singh, a Houston VA internist whose research has focused on using health information technology to reduce diagnostic errors. "We thought that if you can get the result of the imaging test from the radiologist to the ordering doctor electronically, then you should eliminate the problem of missed follow-up, because the most common breakdown is things get lost in the paper shuffle or sit on a physician's desk for a while before getting noticed."

There is little directly comparable research on clinics still relying on paper, Dr. Singh said. An April 2004 Journal of General Internal Medicine study found that only 64% of women with abnormal mammogram test results got proper follow-up care at their Boston-area clinics. Failure to diagnose regularly tops the list of reasons why medical liability suits are filed, with cancer being the most common allegedly missed diagnosis.

Doctors at the Houston VA clinics were more likely to follow up on results when radiologists took the extra step of calling instead of relying on only the EMR alert. Systems should be designed to leave important alerts on the screen until physicians take action to deal with them, the study said.

Other factors, such as clarifying who is responsible for follow-up, also should be addressed. The failure to eliminate communication gaps should not deter investment in EMR systems, Dr. Singh said.

"When technology comes to medicine, we're going to discover issues that we're going to need to go around and fix," Dr. Singh said. "We are already moving to high reliability as an industry in health care. We just need to figure out how to go from 92% to 100%. But we're far better than we were without electronic health records."