Flood of test results prompts new attention on how to manage flow

With more medical tests being ordered, the odds are greater that findings requiring follow-up action will fall through the cracks.

New recommendations in The Joint Commission Journal on Quality and Patient Safety in May highlight what physician practices and hospitals can do to reduce the risk of missing test results.

The paper by physicians at the Michael E. DeBakey Veterans Affairs Medical Center in Houston draws upon a growing body of research about how frequently test results are missed. It also outlines best practices on how to ensure that critical and abnormal findings get to the right doctor and, that the right action is taken.

Among other things, the report and patient safety experts suggest that hospitals, physicians and testing facilities:

• Route test results to ordering physicians, and make them responsible for following up or assuring that the patient's primary care doctor takes action on the findings.
• Decide which test results are so urgent that they merit immediate notification. Use the "read-back" method to make sure that the physician or other health care professional receiving the results understands them.
• Have a plan for what to do when the ordering physician cannot be reached.
• Set a policy on how and when patients will be notified of test results.

Health information technology solutions are critical to reducing missed tests, but adopting the right procedures for handling test results is a necessary first step to improvement, said Hardeep Singh, MD, MPH, who co-authored the paper's new recommendations.

"A lot of places don't even have policies in place to govern test result follow-up," Dr. Singh said. "We consider this low-hanging fruit."

The paper's recommendations are similar to actions sought by an expert panel at the Partners HealthCare System in Boston, part of a five-year project aimed at improving test-result management. Between 2004 and 2008, 22 claims specifically related to the receipt and transmission of test results accounted for nearly $16 million in medical liability costs at the health care system.

"Communication is only one step in the chain here," said Christopher Lee Roy, MD, who co-chaired the Partners panel. "There is a whole life cycle of a test result that goes from when it's finalized, to when it's communicated, to when it's acknowledged and then action is taken."

Improving how test results are handled is long overdue, said Craig T. Tenner, MD, who helped implement test-result management changes at the Manhattan Campus of the Veterans Affairs New York Harbor Healthcare System.

"Everybody has to start adopting this stuff," Dr. Tenner said of the report. If anything, he said, the recommendations should go further, calling on physicians to document when they have examined abnormal test results and the actions they took in response.

The focus on test-result mishaps comes as hospitals struggle to meet a 2005 Joint Commission National Patient Safety Goal requiring that hospitals "report critical results of tests and diagnostic procedures on a timely basis." More than a quarter of hospitals surveyed in 2009 failed to comply with the goal, the commission said.

Experts said the sheer magnitude of tests contributes to the problem.

A Nov. 8, 2004, Archives of Internal Medicine study of 15 primary care practices in the Boston area found that physicians reviewed nearly 900 test results a week, spending about 75 minutes a day on the task. More than 80% of the doctors reported at least one delay in reviewing a test during the previous two months.

Between 1996 and 2006, the percentage of physician office visits in which magnetic resonance imaging, computed tomography or positron emission tomography scans were ordered for patients age 55 to 64 doubled, according to a March 2010 brief from the National Center for Health Statistics. Blood test orders also rose slightly in physician offices.

In emergency departments, the percentage of visits during which blood tests were ordered nearly doubled during the 10-year period, while the proportion of visits involving ultrasounds, MRIs or CTs tripled.

"There is such a huge volume of test results," said Gordon Schiff, MD, associate director of the Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston. "It's a Sisyphean task, because you're never caught up. As soon as you roll the ball back to the top of the mountain, it rolls back down again. ... Even with 99.9% reliability, if just a few balls are dropped, it's a problem."

A study by Dr. Singh and his colleagues in the Sept. 28, 2009, Archives of Internal Medicine found that 7.7% of the time, office-based physicians at the DeBakey VA failed to take action, within a month, on clinically meaningful abnormal results. More than a quarter of the tests that initially were overlooked resulted in the diagnosis of a new disease, with 42% of those being a cancer diagnosis, the study said.

Responsibility for follow-up

Some patients never hear about abnormal findings. A study of 5,434 medical records at 23 physician practices in the Midwest and on the West Coast found that doctors failed to inform patients of abnormal test results 7% of the time.

A few of these practices did much worse, failing to let patients know about abnormal results 20% of the time, said the study, published in the June 22, 2009, Archives of Internal Medicine. These physician groups did not follow recommended policies, such as routing results to the ordering physician, requiring doctors to sign off on results and asking patients to check in if they had not heard about their results by a certain time.

Experts said a key to properly following up on test results is establishing which physician is responsible for doing so. Determining who should act on abnormal findings is not always clear for patients being cared for by a primary care doctor and multiple subspecialists.

Physicians also are often at the mercy of testing firms that vary in how, and how quickly, they report results. Meanwhile, studies show that hospitals frequently fail to follow up on test results that arrive after patients are discharged and often neglect to include pending tests in discharge summaries.

"Our whole concept is if you order it, you own it," Dr. Tenner said. "This is something that should just be standard of care."

When physicians do get results, there are steps they can take to involve patients in the follow-up process, said internist and pediatrician Rob Lamberts, MD, a member of a four-physician primary care practice in Evans, Ga.

His group uses an electronic medical record system that securely e-mails test results to patients and notifies doctors if the patients have not opened the message after a few days.

"The biggest mistake patients make is to think, 'No news is good news,' " Dr. Lamberts said. "We say, 'If you don't hear about such-and-such within a certain time period, give us a call. You should hear about this from us.' "