Case Objectives

• Recognize the general responsibilities of an outpatient provider with regard to test result management.
• Describe how workload associated with test results contributes to clinician burnout.
• Understand that teamwork within a clinical practice is essential for optimal test result management.
• Identify handoffs between providers as an important aspect of inbasket management.
• Understand the role of patient health records with regard to test results.

Case & Commentary—Part 1

A 76-year-old man had previously presented with a right-sided headache, jaw claudication, and one episode of transient visual loss. He was diagnosed with giant cell arteritis (GCA) and was seen in rheumatology clinic for follow-up. Steroids were initiated for treatment and discontinued a year later, as his symptoms had resolved. Laboratory testing was ordered for follow-up and monitoring.

A month after stopping steroids, the headaches recurred. A blood test revealed that his C-reactive protein (CRP) was now elevated, suggesting that cessation of steroids had led to increased inflammation and a flare of GCA. His rheumatologist was out of town at a conference and did not receive the test result. Her colleague was covering the electronic inbox (the portal within the electronic health record in which test results needing follow-up were sent) and noticed the elevated CRP.

Management of test results in the ambulatory setting presents unique challenges.(1,2) Because ambulatory encounters are episodic and test results often arrive days to weeks after they are ordered, decisions regarding test results are stretched out across time and space. As this case illustrates, results may arrive when the ordering provider is unavailable or distracted, creating opportunities for critical pieces of information to fall through the cracks. These opportunities are not rare, as each full-time primary care physician reviews 930 chemistry/hematology results and 60 pathology/radiology reports per week.(3) As a result of this deluge, clinicians spend significant time addressing test results—about 75 minutes per day reviewing, communicating, and following up on both normal and abnormal results.(4) Studies suggest that delays in reviewing test results are common despite the use of electronic health records (EHRs).(4-7) In a retrospective review of closed malpractice cases involving missed or delayed diagnoses, failure to receive diagnostic test results or to transmit them to patients played a significant role in 12% of cases.(8)

With the widespread adoption of modern EHRs (9), certain aspects of test result management have become easier. For example, the chaotic streams of paper test results from different testing facilities can now be collated automatically in electronic inbaskets (sometimes called inboxes), linked to clinical documentation and other details associated with the encounter during which the test was originally ordered, and the severity of abnormality can be flagged, creating a valuable visible cue for the responsible provider. Furthermore, follow-up actions associated with test result management (such as ordering additional studies, referring patients to additional specialists, changing therapies, setting reminders for future actions, or generating correspondence with patients) can be executed within the EHR and recorded for future reference by members of the clinical team.(6)

However, implementation of technology has also created additional work for providers. The patient health record (PHR) tethered to the EHR has made it easier for patients to reach out to the provider directly with questions and requests (related to test result follow-up or otherwise), increasing the workload of providers in practices that do not have the resources to triage these incoming messages.(J.M. Perkins, D.E. Attarian, written communication, November 2017) In addition, administrative notifications abound in the inbasket, creating a new stream of tasks. Some studies suggest that management of the inbasket may be seen as a Sisyphean chore, and the clerical burden associated with the volume of messages, test results, and requisite follow-up is contributing to the epidemic of provider burnout.(10,11)

In light of the challenges associated with test result management in the ambulatory setting, how can clinicians maximize the reliability and conveniences offered by the inbasket while maintaining a reasonable work–life balance? Teamwork plays a key role in ambulatory test result management. When thoughtfully organized and executed, teamwork allows each member of the team to practice "at the top of their license" so that each team member does work he or she is uniquely suited to perform. For example, thoughtful implementation of workflow protocols could allow nurses to safely and effectively manage specific types of abnormal test results, e.g., abnormal pap smears. In addition, certain aspects of test result follow-up, such as making referrals or notifying patients of normal test results, could be performed by medical assistants, freeing up physicians' time to focus on tasks that require their specialized expertise. Importantly, teamwork also allows abnormal test results to be handled safely during periods when the responsible provider may be away from the office. To the credit of the rheumatology practice in this case, its providers have developed a coverage system in which they can designate a colleague to be responsible for new inbasket items during periods of absence. Such efforts at simultaneously promoting safety for patients and work–life balance for providers should be lauded.

A safe, reliable, and efficient test result management system requires thoughtful design. Such design requires collaboration among clinicians, administrators, and technology experts who can come together to understand the current state, build a vision, develop new workflows, and anticipate unintended consequences.(12) These efforts must typically be iterative, and staff buy-in is crucial to success. Quality improvement tools and frameworks can be leveraged to define roles and responsibilities, help team members hold each other accountable, and sustain the initiative.(13)

Case & Commentary—Part 2

When the patient's rheumatologist returned from her conference the following week, the covering physician gave her the patient's last name but did not provide his medical record number or date of birth as a second form of patient identification. The rheumatologist happened to have two patients with the same last name, and both had GCA. She logged into the medical record of one of these patients—the wrong one—and saw a normal CRP value, so she took no action.

A few months later, the correct patient underwent repeat lab testing, and his CRP was elevated once again. The rheumatologist quickly called the patient for a follow-up appointment and realized that the elevated CRP from 2 months earlier had been missed. In the setting of the ongoing headache and joint pain with a persistently elevated CRP, the rheumatologist diagnosed the patient with a flare of his GCA and restarted him on steroids. It was not clear if the 2-month delay would have long-term consequences beyond the untreated symptoms.

One could reasonably argue that this mishap following the return of the rheumatologist to clinic was merely a case of mistaken patient identity. If the covering rheumatologist had used a second patient identifier during the handoff (as required by The Joint Commission) (14), the returning rheumatologist would have looked up the medical record for the correct patient and made the decision to restart steroids (or not) based on the initially elevated CRP that returned while she was away. However, this mishap gives us a window into three potential opportunities for improving the test result management system used by this practice.

First, why was it necessary for the returning rheumatologist to look up the patient electronically in the first place? If the covering rheumatologist had decided that resuming steroids was a nonurgent decision best left to the treating rheumatologist most familiar with the patient's symptom trajectory (15), the CRP result should have been left in the returning rheumatologist's inbasket (6,16) (perhaps with an annotation as to why steroids had not immediately been restarted). Did the covering rheumatologist mistakenly mark the elevated CRP result as "reviewed," thus hiding the result in the inbasket of the returning rheumatologist? If so, that mistake could have been avoided if the practice had laid out the procedure for what to do with test results reviewed by a covering colleague. Ambiguities in the logistics of test result management and handoffs are areas of vulnerability. Although a variety of approaches might be effective depending on local practice culture and EHR capabilities, the chosen approach should be formalized and rehearsed by the relevant care team members. Publicly available toolkits (17,18) may be helpful in developing and hardwiring these local approaches.

Second, if we assume that the covering rheumatologist did leave the elevated CRP result in the inbasket for the returning rheumatologist to follow up upon her return, that raises another concern. It is possible that the returning rheumatologist had fallen so far behind on reviewing test results in her inbasket that the elevated CRP was buried among many other test results. The case presentation does not state whether this factor was at play, but in general, test result folders in the inbasket need to be aggressively managed by all providers, lest they create unmanageable backlogs of unfinished tasks.(19,20) In addition, clinical leaders (e.g., medical directors) need to hold all providers accountable for reviewing test results within a reasonable timeframe and for clearing the inbaskets before they are handed over to a covering provider. Electronic health records have made it possible to measure providers' adherence to these best inbasket practices (21-23), although it is unclear if organizations have fully taken advantage of this capability.

Third, this case highlights the potential role the patient could have played as part of the care team. Many PHRs automatically release test results (both normal and abnormal) to patients after a reasonable time lag. For years, patient safety organizations have educated the public that "no news [on test results] is not good news," and organizations that have chosen to release test results automatically to patients are reinforcing that message. However, patients desire more than just access to test results—they also want to know their clinicians' interpretation, particularly when test results and the follow-up actions might be unclear, as in this case. Most EHRs give clinicians the ability to summarize their interpretation of test results through electronic annotations in the PHR or through result letters delivered electronically or through traditional mail. If the practice in this case had set the expectation for the patient that he should receive timely interpretation of test results, then he might have inquired about the absence of an interpretation on an elevated CRP earlier, potentially shortening the 2-month delay in clinical decision-making by the responsible physician.

Take-Home Points

• Never assume electronic health record deployments have addressed all the problems associated with outpatient test result management and test workflows.
• Inbasket management is time-consuming. If this burden is not proactively mitigated, it could contribute to provider burnout and adverse patient outcomes.
• Clinical practices should leverage available technology to facilitate a team approach to test result management. If protocols are properly outlined and followed, nurses and medical assistants have the potential to assist physicians with test result management.
• Clinical practices should create formal processes for inbasket handoffs between providers.
• In organizations that have adopted patient health records, patients' test results should be released automatically to them electronically within reasonable timeframes.
• Providers should communicate their interpretation of test results to patients in a timely and consistent fashion.

Eric Poon, MD, MPH Chief Health Information Officer Duke Health Professor of Medicine Duke University School of Medicine

Faculty Disclosures: Dr. Poon has declared that neither he, nor any immediate member of his family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

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