Spotlight Case No News May Not Be Good News

2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case –See the full article at –CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicine –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Bradley A. Sharpe, MD –Managing Editor: Erin Hartman, MS

3 Objectives At the conclusion of this educational activity, participants should be able to: Describe the frequency with which ambulatory test results are not followed up by providers Appreciate that inadequate follow-up of ambulatory test results needs a system-based solution State how automated results management systems can help with ambulatory test results Understand the hazards of alert fatigue in automated results management systems

4 Case: No News (1) A 10-year-old girl with a history of asthma was brought by her mother (a nurse) to see a pediatrician because of a 15-pound weight loss over a period of 3 months. There were no notable changes in the child's diet or urination and no other systemic symptoms. A physical examination was unremarkable, and the pediatrician ordered basic labs on a Thursday morning. On Monday morning, the patient's mother called the pediatrician's office to obtain results of the blood tests. The pediatrician was busy all day long but near the end of the day found the result.

5 Case: No News (2) He was shocked to learn the patient's glucose level was 320 mg/dL (normal random blood sugar: 70–125 mg/dL). The pediatrician immediately contacted the mother and had her bring her daughter to the office. A repeat stat blood test showed that the patient's blood sugar was now 450 mg/dL and she had moderate ketones on urinalysis (showing early signs of diabetic ketoacidosis, which can be life threatening). She was given insulin and specific instructions on management at home.

6 Case: No News (3) The patient and mother had to return to the clinic each day for the next few days for ongoing management. The patient did not experience any long-term consequences. When reviewing the case, the pediatrician was surprised that no one had been notified about the elevated blood sugar level. He came to learn that a fax of the laboratory results had been sent to the clinic on Saturday with the urgent result but, for unclear reasons, the physician covering for the weekend never saw it. This clinic did not have an electronic medical record (EMR).

7 Background: Ambulatory Testing (1) Almost one quarter of all medical errors in ambulatory settings are due to inadequate follow-up of abnormal test results Fastest growing area of malpractice litigation involves failures or delays in diagnosis –Up to 25% of these lawsuits are from avoidable failures in the test follow-up system See Notes for references.

8 Background: Ambulatory Testing (2) Follow-up of outpatient test results has become a major priority for many organizations Safety concerns are echoed by physicians –In one survey, 83% of physicians reported at least one delay in reviewing test results over the past 2 months –In a survey of internal medicine residents, 46% stated that, at least a few times a year, they have seen a patient worsen due to delays in lab test follow-up See Notes for references.

9 Missed Test Results are Common (1) Many studies document how often tests are missed in the outpatient setting In one study, 15% of abnormal tests suggestive of diabetes were never followed up by clinicians; about 9% of these patients had unrecognized (and untreated) diabetes See Notes for reference.

10 Missed Test Results are Common (2) In a study in a primary care practice over a 4- year period, the median time for follow-up for marked hyperkalemia was 3 days In 14% of these cases, no follow-up occurred until patients returned for routine follow-up or they visited the practice for other reasons See Notes for reference.

11 Missed Test Results are Common (3) In another study, in more than 2% of patients with abnormal thyroid function tests (either hypo- or hyperthyroid), there was no follow-up An additional 5% of patients were lost to follow- up or unaware of their results See Notes for reference.

12 Reasons for Missed Test Results Not likely due to lack of provider effort Physicians report spending more than 70 minutes per day on test result management, reviewing more than 1000 results per week on average Inadequate test result follow-up should be viewed as a system problem requiring a system solution See Notes for reference.

13 Information Technology Solutions Automated test results management systems are usually integrated into electronic medical records (EMRs) and can help with results management Well-designed systems alert clinicians to the presence of abnormal results Automated systems ideally classify the degree of the abnormality (e.g., mild, moderate, severe) and present relevant clinical information to providers

14 Results Management Systems Automated results management systems can improve result follow-up One study showed that timely follow-up of marked hyperkalemia improved after implementation Patient satisfaction has also been shown to improve with automated test results systems See Notes for references.

15 Capability of determining when ordered laboratory tests have been completed Highlighting laboratory test results that require urgent attention Presenting results in the context of previous results, medication lists, and problem lists Forwarding capability and allowing the use of surrogates during planned absences See Notes for references. Features of an Ideal Results Management System (1)

16 Ability to order additional tests or treatments in the computer system while reviewing results Capability of creating reminders to perform tasks in the future Capability to select important or critical laboratory test results for more urgent review and customizing alerts to prevent alert fatigue A population-based view that allows clinicians to easily identify laboratory test results that appear to have not been reviewed See Notes for references. Features of an Ideal Results Management System (2)

17 Improving Results Management Ensure that all laboratory tests include the correct ordering provider Ensure staff have adequate time specifically to review test results Create policies and systems to ensure that results are consistently communicated to patients in a timely manner Provide clear handoff procedures to manage results during times of provider absence (i.e., weekends) See Notes for references.

Limitations to Systems Solutions In one study, after implementation of a results management system –10% of alerts for abnormal tests were unacknowledged by the clinicians –7% of abnormal labs lacked timely follow-up after 30 days The authors believed this was due to "fatigue" on the part of the clinicians (too many alerts become overwhelming) 18 See Notes for references.

Alert Fatigue Any well-designed results management system should have some method for clinicians to reduce alert fatigue Most common solution is modifying or turning off alerts for non-critical events 19

Back to the Case It appeared the pediatrician had no tracking system and relied on finding time during his hectic schedule A results management system would have facilitated timely follow-up The mother's diligence prompted follow-up We should continue to encourage patients' engagement in health care to ask about results of tests taken 20

21 Take-Home Points (1) Inadequate follow-up of laboratory test results is fairly common and can lead to patient harm Barriers to effective management of laboratory test results are time pressures and cognitive overload on clinicians Inadequate laboratory test result follow-up is a system problem requiring a system solution

22 Take-Home Points (2) Well-designed automated results management systems combined with clinical workflow changes can improve laboratory result follow-up Alert fatigue from poorly designed automated results management systems can be a significant barrier to timely follow-up of laboratory results