Laboratory and Diagnostic Test Tracking in Ambulatory Practice
Reviews of closed claims and patient safety assessments reveal that inadequate clinical laboratory and diagnostic test tracking is a top factor leading to patient injury.
Test result management in ambulatory practices can pose a significant challenge for physicians and practice managers. To be fully successful, tracking test results requires a standardized workflow. It is not a process that can rely solely on due diligence. Standardizing test result management reduces the reliance on memory and helps newcomers understand and use the process safely.1
To remain effective, the process should be continuously evaluated for failure points and refined as necessary. When offices enhance associated workflow systems, it is imperative to redesign test-tracking steps to coincide with the changing technology. Avoid delays in test result management by immediately addressing unexpected internal and external events, such as unavailability of assigned staff to maintain workflow or a disrupted testing center report transmission.
Missed or delayed diagnosis leading to serious injury or death can occur if no formal tracking process is in place. In a systematic review of six test-tracking studies, four of the studies revealed a missed cancer diagnosis as a significant finding. Several study participants reported lack of established procedures of who was responsible for what, including follow-up with the patient.2
Findings from 221 patient safety assessments performed by The Doctors Company from 2014 through early 2015 revealed 70 consequential test-tracking findings. The most common finding was that practices depended on passively waiting for test results or for the patient to return before checking the result. This finding validates that continuing challenges are associated with test-tracking standardization among large multispecialty and small office practices.
The goal of every practice is to provide optimal care to patients. Although tracking methods can differ depending on many variables in the practice setting, effectively managing patient care always includes steps to ensure result reconciliation, physician review, patient notification, and a plan of care. The Agency for Healthcare Research and Quality (AHRQ) has published a toolkit that provides information and resources to help physicians’ offices, clinics, and other ambulatory care facilities assess and improve the testing process in their offices. An example of the test-tracking process is outlined below.3
A fully established process incorporates a standardized workflow that includes the following:
- Ordered tests are reconciled (proactively tracked) with the results received:
- Take action on all outstanding tests not received within the specified time frame by contacting the patient and/or the testing center. Do not rely on the patient’s next appointment as an acceptable method for reconciliation.
- Use an alpha file with retained requisitions and/or a test-tracking log (computerized or manual).
- Include clinical laboratory tests and diagnostic tests, such as MRIs, PAP tests, and mammograms.
- Track pathology specimens. It is not enough to log that the specimen was sent for interpretation. Tracking must follow a standardized workflow to avoid missed specimen results.
- An agreement with the testing center that critical test results are reported by telephone, in addition to being immediately transmitted.
- Timely review of results by a physician or a delegated licensed mid-level practitioner, as evidenced in the chart (e.g., written initials and the date or an e-signature/attestation in the electronic health record [EHR]):
- Do not file reports in the chart until they have been reviewed and initialed/dated by the physician. A missed or delayed diagnosis can occur if an automatically transmitted alert in the physician’s EHR list is processed without review.
- Communication of all test results to the patient as evidenced in the chart:
- Avoid using the no-news-is-good-news approach. Inform patients of all test results. Patients should expect that results will be communicated. Encourage them to contact the practice if they do not receive results within the specified time frame.
- Consider communicating results through letter templates, an automated message system, or another type of system to reduce the workload of support staff.
- Contingencies for notifying patients of critical results that require immediate follow-up when the patient cannot be reached through normal channels:
- Notify an emergency contact or next of kin.
- For specialty practices, notify the primary physician’s office for assistance.
- Request a wellness check through local law enforcement in extreme circumstances.
- Document all efforts to make patient contact.
- Document follow-up care.
- Intervention for nonadherent patients:
- Provide emphasis of a test’s importance to reluctant patients. Include the risks of not having a particular test performed.
- Document nonadherence and efforts to improve compliance.
AHRQ and The Doctors Company support the following requirements for successful practice improvements:4
- The desire to improve.
- Office leadership support for improving quality and safety.
- Teamwork, with everyone involved in the improvement process.
- A commitment to honest and open communication.
- Regular discussion of performance improvement at staff meetings.
- A focus on office systems rather than on individual performance.
- Persistence—a promise to stick with it.
Implementing a standardized test-tracking system can create job satisfaction for those responsible for the process. Physicians can be reassured that test results are handled appropriately and that patients are more involved in their own care. Most importantly, the potential for patient harm will be reduced and liability avoided.