Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain?

doi:10.1016/j.amjmed.2009.07.027

The American Journal of Medicine

Volume 123, Issue 3, March 2010, Pages 238-244

https://doi.org/10.1016/j.amjmed.2009.07.027 Get rights and content

Abstract

Background

Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions.

Methods

We studied 4 alerts: hemoglobin A1c ≥15%, positive hepatitis C antibody, prostate-specific antigen ≥15 ng/mL, and thyroid-stimulating hormone ≥15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up.

Results

Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84).

Conclusions

Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

Section snippets

Methods

The study was conducted in a large multispecialty ambulatory clinic of the Michael E. DeBakey Veterans Affairs Medical Center and its 5 satellite clinics located in Southeast Texas from May to December 2008. To reliably assess follow-up actions on outpatient laboratory test alerts, we focused only on abnormal tests that generated a “high-priority” mandatory automated notification to a specified ordering provider without a concomitant verbal notification. Hence we excluded abnormal tests that:

Results

Between May and December 2008, 27,092 HbA1c, 22,837 PSA, 6271 HCV, and 21,958 TSH tests were performed. A total of 1163 (1.49%) results were electronically transmitted as mandatory high-priority alerts (including 29 HbA1c ≥15%, 448 PSA ≥15 ng/mL, 433 positive HCV, and 253 TSH ≥15 mIU/L.). Acknowledged alerts constituted 89.8% of the total high-priority alerts (n = 1163). The Figure illustrates the outcomes of these 1163 alerts. No evidence of documented follow-up action was found in 307 (26.4%)

Discussion

We tested whether certain abnormal outpatient laboratory tests were followed-up in a timely manner in a multi-specialty clinic that used an integrated electronic medical record for automated notification. We found that 6.8% of alerts lacked follow-up at 30 days, suggesting that follow-up of abnormal outpatient laboratory test results is not fail-safe even when providers are alerted about abnormal results through the electronic medical record. Of concern was the finding that there was lack of

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: Funding: The study was supported by an NIH K23 career development award (K23CA125585) to Dr. Singh, the VA National Center of Patient Safety, Agency for Health Care Research and Quality Health Services Research Demonstration and Dissemination Grant (R18 HS17244-02) to Dr. Thomas, and in part by the Houston VA Health Services Research & Development Center of Excellence (HFP90-020). These sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

: Conflict of Interest: The authors have no conflicts of interest to report.

: Authorship: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

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Clinical research studyNotification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Jt Comm J Qual Patient Saf

Jt Comm J Qual Patient Saf

Jt Comm J Qual Patient Saf

Jt Comm J Qual Patient Saf

J Am Med Inform Assoc

J Biomed Inform

J Biomed Inform

Int J Med Inform

Am J Med

Am J Med

Outpatient diagnostic errors: unrecognized hyperglycemia

Eff Clin Pract

Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network

Qual Saf Health Care

“I wish I had seen this test result earlier!”: dissatisfaction with test result management systems in primary care

Arch Intern Med

Clinical research study
Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain?