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In Practice: How Well Do You Monitor Patient Test Results? BMJ Review Finds Result Follow-up is Often Lacking

DR. MICHAEL KAMINSKI: “Effective management of the data requires teamwork and includes nurses and other caregivers. Physicians can't manage this on their own and they need a network that provides safeguards and some redundancy to get this element right. EMRs can be an essential component, but the human piece is just as important.”

How seamless is your practice's follow-up on patients' test results? A recent study in the British Medical Journal (BMJ) suggests that for many patients, test results are not followed up appropriately. The systematic review of the evidence, conducted by scientists at the Centre for Health Systems and Safety Research at the University of New South Wales in Australia, found that the lack of follow-up on tests for hospitalized patients ranged from 20.04 percent to 61.6 percent (as a proportion of tests ordered). Lack of test follow-up for patients in the emergency department ranged from 1 percent to 75 percent of tests.

Problems were particularly acute for critical test results, and for patients transitioning across health care settings, the authors noted. And the lack of follow-up had significant consequences for a number of patients, including missed cancer diagnoses and cases of chlamydia that led to the subsequent development of pelvic inflammatory disease.

It also had major consequences for physicians. One study in the review examined 122 closed malpractice claims for injuries that emergency department (ED) patients sustained between 1979 and 2001. The study found that 79 of the 122 claims (64.8 percent) involved missed ED diagnoses that harmed patients, and 13 of these 79 claims (16.5 percent) identified the breakdown to have occurred at the step of “test results transmitted to and received by the provider.”

RISK OF MISDIAGNOSIS

While the BMJ review wasn't specific to neurology, nor were any of the studies it examined, there is no reason to assume that neurologists are doing any better than other specialists and general practitioners at following up on test results.

“Failure to properly follow up on testing is one of many problems that can result in misdiagnosis. While this is an issue relevant to all medical specialties, we know that failure to diagnose is the most frequent allegation in claims and lawsuits involving neurologists,” said Donna Vanderpool, JD, vice president for risk management with Professional Risk Management Services, Inc., which manages The Neurologists' Program, an AAN-endorsed malpractice insurance program.

“As risk managers, we have always addressed tracking test results as crucial to the ongoing assessment and patient monitoring necessary to provide good clinical care and increase patient safety, which minimizes professional liability risk.”

PRMS has also covered this topic in its CME courses, in risk management newsletters, and when providing telephone risk management advice to individual neurologists via its Risk Management Consultation Service helpline. [PRMS risk managers discussed the need to track test results as one of the necessary steps for neurologists to avoid recurring risks in medical professional liability claims in an article in the inaugural issue of Neurology Clinical Practice.]

DONNA VANDERPOOL: “Outpatient neurologists should take steps to obtain discharge information — either directly from the hospital or the patient's primary care physician — and document these efforts. Patients should also be asked to bring their hospital paperwork, including discharge instructions, to the outpatient appointment for the neurologist to review. Also, neurologists should work with hospitals to ensure procedures for handoff communications, such as outstanding test results, are standardized and utilized.”

“In both hospital and office-based neurology, managing test results is a big issue,” said Michael Kaminski, MD, co-chair of the AAN Patient Safety Subcommittee. “Our office has gone through various systems over the years. First we kept every test ordered in a folder, then we had check sheets for pending results, and now we use our computer to help us manage this element. But if an item doesn't make it into the computer, then what? That's part of why data gathering is so challenging.”

RISK MANAGEMENT STRATEGIES

PRMS recommends two basic risk management strategies to improve testing follow-up across all patient care settings: 1) Neurologists need to ensure that they have the information they need for ongoing monitoring and treatment purposes, and 2) they need to work on effective communication channels, which may be particularly compromised when there is a handoff from one clinician to another or a transition of care situation.

Any time more than one physician is providing care, there will be some type of handoff that potentially sets the stage for communication errors. For example, patients discharged from the hospital may have pending test results. How are outpatient-treating neurologists made aware of these outstanding test results? Outpatient neurologists should take steps to obtain discharge information either directly from the hospital or the patientAs primary care physician — and document these efforts, Vanderpool said. Patients should also be asked to bring their hospital paperwork, including discharge instructions, to the outpatient appointment for the neurologist to review. Also, neurologists should work with hospitals to ensure procedures for handoff communications, such as outstanding test results, are standardized and utilized.P

Health information technology, such as electronic health records (EHRs), has the potential to help manage the increasing volume of test results across treatment settings, Vanderpool observed. “While it may take time for this potential to be realized, this type of system solution, along with good interpersonal communication among caregivers, should increase follow-up on testing, which supports patient safety, and thereby reduces medical professional liability risk.”

But both of these elements have major challenges in real-world practice, said Dr. Kaminski. “Most of us have some form of an electronic medical record [EMR] that doesn't necessarily communicate with the hospital's EMR. Outside data come to us in paper or electronic form from other sources. You may have radiology reports, labs, pathology, and other diagnostic studies, all coming in from outside at different times and in different formats. Most of us are looking to EMRs to help with this critical step, by providing a repository of pending tests with serial reminders. Even then, you also need a system that allows documentation of the next essential steps of communication with the patient and ensuring follow-up.”

Dr. Kaminski noted that one of the key areas that the BMJ authors identified as problematic for test follow-up — handoffs of care — is the subject of the Patient Safety Colloquium at this year's AAN annual meeting.

“There needs to be a seamless transfer of data and pending results when patient care is transferred from the hospital setting to the office or vice versa,” he said. “Effective management of the data requires teamwork and includes nurses and other caregivers. Physicians can't manage this on their own and they need a network that provides safeguards and some redundancy to get this element right. EMRs can be an essential component, but the human piece is just as important.”

REFERENCE:

Callen J, Georgiou A, Westbrook JI. The safety implications of missed results for hospitalized patients: A systematic review. BMJ Qual Saf 2011;20:194–199.