Laboratory and Diagnostic Test Tracking in Ambulatory Practice

Dana Faber, MS PSL, RN, Senior Patient Safety Risk Manager, The Doctors Company

Although test results don’t trigger the same types of dramatic alarms and sirens found in some healthcare situations, tracking results should be regarded as a critical patient safety function.

ECRI Institute has named diagnostic stewardship and test result management using EHRs as a recurring patient safety challenge. Its ranking as the top concern of 2019 is especially compelling because the analysis included 2.8 million patient safety events over 10 years.¹

Managing test results in ambulatory practices can pose a significant challenge for practitioners and practice managers. Establishing a standardized workflow to track patient test results is a successful strategy for avoiding missed or delayed diagnosis that can lead to serious injury or death.

Using Technology Systems

Findings from a review of the influence of information technology (IT) on managing laboratory tests in primary care suggested largely positive but some negative impacts of using technology systems. The positive effects included easier access to results, reduced turnaround times, and more frequent testing using evidence-based guidelines. The negative effects included cognitive overload with the potential for increased error when electronic and paper-based processes were used simultaneously. Additionally, some systems were not deemed user friendly (affecting the clinician’s performance) or had the potential for error if they relied on the practitioner’s memory to track results.²

The Office of the National Coordinator for Health Information Technology’s (ONC’s) Self-Assessment: Test Results Reporting and Follow-Up can help you optimize the safe use of an EHR in managing the test tracking process. Use ONC’s Self-Assessment: System Interfaces to evaluate interoperability and identify gaps in the systems designed to enhance reliability.

In the era of the 21st Century Cures Act “Open Notes” provision, patients have access to most test results within their patient portal simultaneously to the provider receiving results. (To learn about exceptions to the open notes provision, read our article “What Open Notes Exceptions Does the Cures Act Allow?”) Relying on the portal alone as a primary method of communication for abnormal results, however, poses safety risks. Having a protocol in place for actively communicating abnormal results to patients is the best practice for abnormal results.

Standardize Workflow

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 appropriate test ordering, result reconciliation, practitioner review, patient notification, and a follow-up care plan.

A fully established process incorporates a standard workflow that includes the following actions:

• Reconcile (proactively track) ordered tests with the results received. Do not rely on the patient’s next appointment as the only method for reconciliation.
• Include all clinical laboratory, pathology, and diagnostic tests (such as biopsy specimens and imaging) in the reconciliation process.
• Use the EHR tracking feature to track the results of tests ordered but not received within a specified time frame. If the EHR does not have optimal tracking features or if an EHR is not used, develop an alternative tracking process (computerized or manual). Enlist support staff to manage outstanding test tracking.
• Act on all outstanding tests not received within the specified time frame by contacting the patient and the testing center.
• Establish an agreement with the testing center that critical test results are immediately reported by telephone followed by electronic transmission.
• Document timely review of results by a physician or advanced practice clinician, as evidenced in the patient record.
• Communicate all test results to the patient as evidenced in the chart:
  • Avoid using the no-news-is-good-news approach. Patients should expect that all normal and abnormal results will be communicated in a timely manner. Encourage patients to contact the practice if they do not receive results within the specified time frame.
  • Establish communication of normal results through the patient portal and other means (including letter templates or automated messaging systems) to reduce support staff workload.
  • Communicate abnormal results through active patient communication. Relying only on the patient portal poses safety risks.
• Establish contingency plans for notifying patients of critical results that require immediate follow-up when the patient cannot be reached.
  • Notify an emergency contact or next of kin.
  • Specialty practices: Notify the primary practitioner’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.
• Educate patients by explaining the purpose of the test, and the risks of not having the test performed. Follow the informed refusal process as necessary and document any nonadherence and efforts to improve compliance. (For more information, see our articles “Informed Refusal” and “Nonadherent and Noncompliant Patients: Overcoming Barriers.”)
• Incorporate quality oversight:
  • Conduct periodic reviews of test ordering utilization.
  • Run an EHR query periodically of all phases of test-tracking management.
  • Conduct an annual self-assessment of the laboratory and diagnostic test -tracking process.

Implementing a standardized test-tracking system can create support staff and practitioner satisfaction. Practitioners are reassured that test results are handled appropriately and that patients are more involved in their care. Most importantly, the potential for patient harm will be reduced and liability avoided.

For additional assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

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