AIM: EMRs need to better communicate critical imaging results
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“Communication breakdown is consistently identified as a preventable factor in studies of adverse events and a significant contributor to outpatient diagnostic errors from a lack of follow-up of abnormal test results,” the authors wrote.
The high volume and number of transitions between clinicians in outpatient care makes timely communication particularly challenging. For instance, the authors wrote, a primary care physician may refer a patient with respiratory symptoms to undergo several lab and imaging tests as well as a pulmonary consultation.
“Any abnormal findings, such as a lung mass, would need to be communicated quickly and effectively to all clinicians involved in treating the patient,” said Hardeep Singh, MD, of Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston.
Some healthcare systems, including the Department of Veterans Affairs, use electronic communication with alerts to notify clinicians who order imaging tests about critical abnormal results.
“However, effective communication involves more than just information transfer—it requires a response from the recipient, such as taking follow-up action and acknowledging receipt of the information to the sender,” wrote Singh and colleagues.
The researchers studied critical imaging alert notifications in the outpatient setting of one Department of Veterans Affairs facility between November 2007 and June 2008. They used tracking software to determine whether alerts about abnormal test results were read within two weeks, then reviewed medical records and contacted healthcare practitioners to determine whether timely follow-up actions, such as ordering a follow-up test or consultation, were taken within four weeks of the alert transmission.
Of 123,638 imaging tests (including x-rays, CT scans, MRI exams and mammograms) performed during the study period, results from 0.97 percent generated alerts to the ordering clinician.
Of the alerts, the researchers found that 18.1 percent were not acknowledged. Alerts were more likely to be unacknowledged if the ordering clinician was a trainee or if an alert was sent to more than one clinician, according to the authors. For example, the authors cited an instance when the ordering clinician was not the patient’s primary care physician, and alerts were sent to both the specialist and the patient’s regular physician.
According to Singh and colleagues, timely follow-up of abnormal results did not occur following 7.7 percent of all alerts, including 7.3 percent of alerts that were acknowledged and 9.7 percent of alerts that were unacknowledged. This follow up was also less likely to occur when more than one clinician received the alert, but was more likely to occur when a radiologist also communicated concerns about the results verbally, either by phone or in person.
“Nearly all abnormal test results lacking timely follow-up at four weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment,” the authors wrote.
“Our findings suggest that an EMR that facilitates transmission and availability of critical imaging results to the healthcare provider through either automated notification or direct access of the primary report does not eliminate the problem of missed test results even when one or more healthcare providers read the results,” they stated.
“Therefore, even in the best of information systems that contain advanced notification features, patients with abnormal imaging results are vulnerable to ‘falling through the cracks.’ This underscores the need for a multidisciplinary approach involving human-computer interaction and informatics to complement the benefits achieved by automated notification and the need for continuous monitoring procedures to ensure follow-up even when healthcare providers ‘acknowledge,’ i.e., read abnormal results,” Singh and colleagues said.
The study was supported by an National Institutes of Health (NIH) career development award to Singh, the VA National Center of Patient Safety, the Agency for Health Care Research and Quality (AHRQ) and in part by the Houston VA Health Services Research and Development Center of Excellence.