Close the Loop on Test Results
By Brian Ward
In December, The Joint Commission (TJC) released Quick Safety Issue 52: Advancing Safety With Closed-Loop Communication of Test Results. Closed-loop communication means that every test result is sent, received, and addressed in a timely manner, and the patient is notified of the results and next steps.
“Diagnostic error is one of the most important safety problems in health care today. It is among the most common, catastrophic, and costly of serious medical errors and one study estimates that approximately 1 in 20 U.S. adults will have a diagnostic error annually in the outpatient setting,” according to Quick Safety Issue 52.
Serious problems can occur when results are delayed. Patients can undergo the wrong operation, be prescribed the wrong medication, or be discharged when they actually require urgent care. A delay in test results can mean the difference between a treatable problem evolving into an inoperable one. For example, sepsis is the main cause of one in three hospital deaths. Any delay in administering antibiotics to a patient with sepsis increases mortality by 10%, so every hour matters. If someone in the lab delays sending a test result until after lunch or a clinician doesn’t act on it until the end of the day, there can be an immediate and negative impact on a patient’s condition.
“The Joint Commission identified the timely reporting of results of critical tests and diagnostic procedures as a National Patient Safety Goal in 2005 (NPSG.02.03.01). However, the implementation has been inconsistent to date and this goal does not necessarily address the risks related to communicating ‘sub-critical’ test results that are not immediately life-threatening and are often communicated through nonverbal channels,” says the report.
Sue Sheridan, MIM, MBA, DHL, director of patient engagement at the Society to Improve Diagnosis in Medicine, and Hardeep Singh, MD, MPH, chief of Health Policy, Quality & Informatics Program at the Center for Innovations in Quality, Effectiveness and Safety, wrote a blog post on The Joint Commission website about closed-loop communication.
“A systematic review reported that 6.8 to 62% of laboratory results and anywhere from 1 to 36% of radiology results are not communicated, which sometimes leads to missed cancer diagnoses. This occurs despite patients’ preferences for having all results—normal and abnormal—communicated to them. Workflow factors and confusion about who is responsible for following up with patients can lead to some of these communication breakdowns,” they write.
EHR
With the advent of electronic health records (EHR), communication of results can be faster and more reliable. However, building a quality EHR system takes work, and systems still have to contend with nontechnical problems such as:
- User behaviors
- Usage practices
- Policies and procedures related to communication and follow-up
- Training issues
- Organizational practices
- Workflow-related issues
It was found that almost 8% of EHR notifications regarding abnormal outpatient test results don’t receive follow-up for four weeks.
Patients and portals
A major part of closing the communication loop is making sure that patients not only receive their results, but understand what they mean. Without engagement, it’s difficult for patients to understand what they have to do next. Do they need a follow-up appointment? Do they need to keep taking the medication last prescribed? Are they cleared to go whitewater rafting over the weekend, or do they need a few more days of rest?
“Failure to close the communication loop is also among the contributing factors for high-severity medical malpractice claims,” write Sheridan and Singh.
Another tool for delivering test results is patient portals, websites where patients can log in to see their medical records and history. However, fewer than a third of a patients use these portals, and a recent study suggests portals are “not currently designed to present test results to patients in a meaningful way.”
Providing a patient portal is pointless if it’s not updated regularly with the patient’s latest results or if it’s challenging for the patient to navigate.
Recommendations
TJC has several suggestions on how to close the loop on test results, including:
- Identify vulnerable workflows.
Find the weak points in the flow of test results and develop fixes and backups.
- Establish consistent processes.
Like all patient safety topics, quality necessitates consistency.
- Notify patients of life-threatening test results.
Results like these should be verbalized to the patient, with a system in place to ensure that the information was received.
- Forward abnormal test results to an alternate responsible provider if results are unacknowledged for a set time.
- Send all test results (abnormal or normal) to a backup provider in a timely fashion if the ordering provider is unavailable.
The appropriate timeliness should be based on the significance of the test result.
- Optimize your organization’s electronic systems for communicating test results.
You can automate some of the aforementioned processes this way.
- Make your patient portal(s) more user-friendly.
Many patients find portals confusing. Sometimes this is because of how they are designed, but sometimes it’s because people don’t have the context to understand their test results. Some issues you can address are:
- Ensure the portal works on desktop and mobile devices
- Make the patient’s EHR information accessible on the portal, preferably with real-time clinical notes and test results
- Explain test results in terms the patient understands
- Explain what the results mean for the patient, including what steps to take next
- Improve access to support services that help patients act and follow up on their results
- Set standards for updating test results on the portal
No matter how good your portal is, TJC warns to never assume patients will use it. Some might be uncomfortable or uncertain of using an online portal, prefer person-to-person contact, or lack regular access to the internet. Portals should especially never be your sole method of communicating abnormal test results—reach out directly to patients when action is needed.
A view from the lab
Dan Scungio, MT(ASCP), SLS, laboratory safety officer for multihospital system Sentara Healthcare in Virginia, and otherwise known as “Dan, the Lab Safety Man,” shares his thoughts on Quick Safety 52.
“Many labs have much of what is being discussed here in place already and call in critical values (results that need fast action) to physicians or nurses as soon as possible. This can be more difficult for outpatients, especially when offices are closed. If a physician cannot be reached, the situation may be escalated to the lab pathologist. Sometimes they may need to contact the patient directly (which lab staff would never do) and provide instructions to get immediate follow-up or even go to the hospital.
Labs have had to call in critical values for years, and many have specific ways in which they provide information and document the call.
Patient portals are generally not helpful for critical values situations, despite many now providing results to patients fairly quickly. But labs cannot rely on portals as patients may not look for results, may not understand results, and may not follow up.”