Statement of problem: Prompt, appropriate follow-up of cancer-related abnormal test results is essential. Yet critical diagnostic lab and imaging test results do not always receive timely follow-up even when provider notification occurs through electronic health records (EHRs). In order to prevent diagnostic delays in cancer, better functionality is needed in the EHR to support tracking and reminding for follow-up actions.
Description of the intervention or program: We developed a 3-part functional software prototype that works with the VA’s EHR to prompt and track follow-up actions taken in response to certain critical test result alerts: 1) A Follow-up Action Tracker that monitors electronic documentation to see if critical test result alerts for four cancer-related tests (abnormal chest x-rays, PSAs, FOBTs, and mammograms) have received follow-up. The tracker suggests order sets of appropriate follow-up actions in a separate pop-up window, taking care to fit with provider workflow and minimize disruptions. For example, follow-up actions suggested for an abnormal chest X-ray may include patient notification (letter or call), ordering another imaging test (chest CT), consulting a subspecialist (pulmonologist), hospitalization, or an option indicating no further action is required (e.g., patient already in hospice care). 2) A Critical Alert Monitor that automatically identifies the total number of critical test alerts generated and their status, i.e. acknowledged or acted upon. 3) A Critical Alert Reporting Engine that allows clinic administrators and individual providers to visualize detailed information collected by the other two components.
Findings to date: System development used a socio-technical approach that involved identification of organizational, workflow, and technical constraints related to test result follow-up. Iterative reviews were conducted with various stakeholders including primary care providers, trainees, safety managers, and IT personnel, informing design revisions. Usability testing with 24 providers showed that the ordering and documentation options window in the Follow-up Action Tracker was easy to use. Providers responded favorably and quickly realized how the new functionality could reduce missed follow-up in the outpatient setting. To ensure the efficacy of the Monitor and Reporting Engine, we conducted usability testing with 9 organizational stakeholders including clinical IT staff, resulting in design improvements.
Lessons learned: High-reliability test result tracking systems are needed to overcome the limitations of current EHRs in ensuring safety of test result follow-up. Such systems need to be developed using a multifaceted socio-technical approach that accounts for technology, workflow, personnel and organization. Once implemented, these systems have the potential to rapidly and efficiently identify patients at risk of harm from diagnostic delays.