Test Result Management Practices of Canadian Internal Medicine Physicians and Trainees

Abstract

BACKGROUND: Missed test results are a cause of medical error. Few studies have explored test result management in the inpatient setting. OBJECTIVE: To examine test result management practices of general internal medicine providers in the inpatient setting, examine satisfaction with practices, and quantify self-reported delays in result follow-up. DESIGN: Cross-sectional survey. PARTICIPANTS: General internal medicine attending physicians and trainees (residents and medical students) at three Canadian teaching hospitals. MAIN MEASURES: Methods used to track test results; satisfaction with these methods; personal encounters with results respondents Bwish they had known about sooner.K EY RESULTS: We received surveys from 33/51 attendings and 99/108 trainees (response rate 83%). Only 40.9% of respondents kept a record of all tests they order, and 50.0% had a system to ensure ordered tests were completed. Methods for tracking test results included typed team sign-out lists (40.7%), electronic health record (EHR) functionality (e.g., the electronic Binbox^) (38.9%), and personal written or typed lists (14.8%). Almost all trainees (97.9%) and attendings (81.2%) reported encountering at least one test result they Bwish they had known about sooner^in the past 2 months (p = 0.001). A higher percentage of attendings kept a record of tests pending at hospital discharge compared to trainees (75.0% vs. 35.7%, p < 0.001), used EHR functionality to track tests (71.4% vs. 27.5%, p = 0.004), and reported higher satisfaction with result management (42.4% vs. 12.1% satisfied or very satisfied, p < 0.001). CONCLUSIONS: Canadian physicians report an array of problems managing test results in the inpatient setting. In the context of prior studies from the outpatient setting, our study suggests a need to develop interventions to prevent missed results and avoid potential patient harms.

Variation in electronic test results management and its implications for patient safety: A multisite investigation

“…For example, WAD has highlighted the uncertainty and variation in use of the of the results forwarding functionality for managing results that return after a patient has been admitted and the potential impact on electronic results notifications or communication with inpatient teams. Uncertainty also compelled clinicians to avoid using the functionality, or find alternatives, which concurs with the findings of Bodley et al, 17 who concluded, “If physicians are not taught how EHR functions can improve efficiency and patient safety, it seems logical that physicians would not use these functions....” Our findings therefore have implications for EMR training to ensure the scope of training not only covers how to use an application, but also addresses why functionality should be used, the benefits of use (including safety) and how the system processes information. Our findings add to existing literature in describing the challenges clinicians reported in using an electronic test results management application in an ED setting and take a step toward answering the call to “identify the problems” relating to HIT usability.…”

“…Despite the availability of an electronic test results management application, clinicians in the current study reported using a combination of both manual and electronic tracking strategies to ensure test results requiring follow-up were actioned (themes 1 and 5). This need to support “memory of pending tasks” 36 for managing test results and using paper-based strategies in HIT-enabled settings such as sticky notes, 17 , 35 lists, and logs, has been previously reported in the literature 17 , 18 , 35 , 36 and characterized as “workarounds.” 35 The paper and electronic tracking strategies we identified meet the definition of workarounds stated in Debono et al as “observed or described behaviors that may differ from organizationally prescribed or intended procedures.” 45 The context surrounding our participants’ adoption of workarounds are indicative of clinicians actively employing strategies to support the cognitive demands of tracking test results through to follow-up and completion. Thus, they also fall under the definition of resilience stated in Smith et al as “positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions.” 46 Although resilience strategies can maximize positive outcomes, they also risk obscuring underlying barriers or threats to safety.…”

“… 15 , 16 Evaluations of HIT interventions have reported improvements in awareness, communication, and access to clinical test results, 4 , 11 , 14 as well as in efficiency, response time, and the proportions of tests being followed up. 5 , 16 Notwithstanding the benefits of HIT, delayed 17 or missed test results 10 , 18 and failure to follow-up test results 19–21 persist and pose a serious safety issue in healthcare. Furthermore, there is growing recognition that HIT may have occasioned a new category of safety-related issues, with inadvertent consequences potentially arising from usability challenges.…”

“…Although clinician management of test results in EHR enabled settings has been studied in the literature, the body of evidence is predominantly associated with inpatient or admitted 17 , 33 , 34 or outpatient or primary care settings, 15 , 35–38 with relatively few studies in the emergency department (ED) context. 11 , 12 The ED setting affords the opportunity to explore how diagnostic test results are managed in a fast-paced clinical environment providing urgent medical care to patients presenting with a broad range of conditions.…”

Improving After-Clinic Work Workflow in a Family Medicine Residency

“…Although providing education and adequate supervision to resident physicians regarding the management of in-basket tasks was a primary goal of this study, the ultimate goal was to provide competent and efficient care to patients. A test is only useful if the results are reviewed and translated into action, not just lost in the electronic medical record [8]. It has already been noted that the lack of closed-loop communication with patients can lead to increased litigation, so, engaging the patient in their own care was of the utmost importance [3].…”