Laboratory and Diagnostic Test Tracking in Ambulatory Practice
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.
As evidence of this, ECRI Institute’s Executive Brief on the 2019 Top 10 Patient Safety Concerns named diagnostic stewardship and test result management using electronic health records (EHRs) as number one on its list of concerns. This ranking is especially compelling because the analysis included 2.8 million patient safety events over a 10-year period.1
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. Missed or delayed diagnosis leading to serious injury or death can occur if standard workflow is not established for the testing process.
In a systematic review of the influence of information technology (IT) on managing laboratory tests in primary care, findings suggested some positive and negative impacts. Positive impacts of IT use included easier access to results, reduced turnaround times, and more frequent testing using evidence-based guidelines. Negative impacts included cognitive overload with the potential for increased medical error when electronic and paper-based processes are used simultaneously. Additionally, some systems were simply not deemed user-friendly, affecting the clinician’s performance. Lastly, when workflow wasn’t fully established, the reliance on the prescriber’s memory led to a potential for errors.2
Findings from 424 patient safety risk assessments performed by The Doctors Company revealed that issues related to test tracking were identified in 14 percent of assessed practices. The most common finding was that practices depended on passively waiting for test results or for the patient to return before checking the result. Additional issues included lack of provider review before filing test results in the chart and delays in ordering or failure to order diagnostic tests, leading to delayed or missed diagnoses.3 These findings are further evidence of the continuing challenges associated with test-tracking standardization in physician 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 follow-up plan of care.
A fully established process incorporates a standard workflow that includes the following components:
- Reconcile (proactively track) ordered tests with the results received:
- Include all clinical laboratory, pathology, and diagnostic tests (such as imaging and biopsy specimens).
- Use the EHR tracking feature to track the results of tests ordered but not yet received. This is in addition to using a test result in-basket.
- Use an alpha file with retained requisitions and/or a test tracking log (computerized or manual) if the EHR does not have optimal tracking features or if there is no EHR.
- 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/or the testing center. Do not rely on the patient’s next appointment as an acceptable method for reconciliation.
- Establish an agreement with the testing center that critical test results are reported by telephone, in addition to being immediately transmitted.
- Document timely review of results by a physician or a delegated licensed advanced practice provider, as evidenced in the chart (e.g., written initials and the date, or an e‑signature/attestation in the 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.
- Communicate 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—both normal and abnormal—will be communicated. Encourage patients to contact the practice if they do not receive results within the specified time frame.
- Consider communicating normal results through letter templates, an automated messaging system, patient portal, and/or another type of system to reduce the workload of support staff.
- Establish contingency plans 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.
- 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.
- Intervene with nonadherent patients:
- Emphasize a test’s importance to reluctant patients, including the risks of not having a particular test performed.
- Document nonadherence and efforts to improve compliance.
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.
- ECRI Institute. Top 10 patient safety concerns for 2019. ECRI Institute website. ecri.org/landing-top-10-patient-safety-concerns-2019. Accessed December 16, 2019.
- Maillet É, Paré G, Currie LM, et al. Laboratory testing in primary care: a systematic review of health IT impacts. Int J Med Inform. 2018 Aug;116:52-69.
- Shepard S. Medical office assessments uncover hidden liability risks. The Doctor’s Advocate. Third Quarter 2018. thedoctors.com/the-doctors-advocate/third-quarter-2018/medical-office-assessments-uncover-hidden-liability-risks/.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.