Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication

Abstract

BackgroundEarly detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response.MethodsUsing both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention.ResultsData from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p < 0.01) and was sustained at month 4 following the intervention.ConclusionElectronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.

A New Socio-technical Model for Studying Health Information Technology in Complex Adaptive Healthcare Systems

“…We recently evaluated why, despite implementation of an automated notification system to enhance communication of fecal occult blood test (FOBT) results, providers did not take follow-up actions in almost 40% of cases [63]. Again, our findings highlighted multiple dimensions corresponding to our socio-technical model.…”

Impact of Automated Alerts on Follow-Up of Post-Discharge Microbiology Results: A Cluster Randomized Controlled Trial

“…2,11 Clinicians are often dissatisfied with their systems to manage test results, 12,13 and health information technology has the potential to assist clinicians in this important aspect of patient care. [14][15][16] One study found that 38/533 (7.1%) positive post-discharge non-urine microbiology results that were reviewed led to initiation, prolongation or change of antimicrobial therapy in the outpatient setting. 4 Comprehensive electronic result management systems have been successfully implemented in ambulatory settings; 16,17 however, gaps in test result management remain.…”

Next steps for electronic health records to improve the diagnostic process

“…In particular, strategic use of EHRs in the following categories appears potentially beneficial to the diagnostic process: documentation, care coordination, patient engagement, automation, physician and patient checklists, next step guidance, redundancy avoidance, monitoring, and broadened differential diagnoses [10,16,[18][19][20]22]. For example, when applied judiciously and in the appropriate workflow context, diagnostic error triggers already have a growing body of evidence behind their benefits [18,23]. The risk of implementing these system changes, however, is that unless the system effects are carefully monitored, it is possible that interventions may be associated with worsened care as was seen with critical imaging alerts [24].…”

“…Access to the chart enables patients to see diagnostic results and use secure messaging for any questions. Given ongoing physician failures to follow-up on results, portal access with direct patient engagement should provide another layer of diagnostic safety [23,24]. Further, despite some misgivings from physicians, progress note access by patients is becoming more common [26].…”

“…are not yet common [18,23,24]. To increase systembased reliability, unviewed results could be resent to providers or escalated to a practice director if still unviewed after 5 days.…”