■ Safety of care:

Improving patient safety and reducing risks

Results and expectations: Test follow-up and the office-based family physician

Abstract composite of a clock and a calendar.

Published: December 2020
The information in this article was correct at the time of publishing
20-17-E

Communicating test results is a critical part of patient care. Test results that are not appropriately attended to in a timely and effective manner can lead to serious patient harm or even death.

Despite the significance of this stage of the diagnostic process, physicians often face challenges in managing, tracking, and communicating test results. While little Canadian data is available, a 2015 survey of 50 U.K. primary care practices showed that 42 of the sites had no safeguards in place to confirm that patients had received their results.1

To better understand gaps in test result follow-up in the Canadian context, the CMPA conducted a review of College complaints and legal cases related to the management and communication of both non-urgent and urgent test results. Specifically, we reviewed 351 legal and medical regulatory authority (College) cases closed between 2015 and 2019 involving test result follow-up by office-based family physicians. Our review indicated three key factors contributed to medical errors in these cases: documentation issues, a failure to follow or maintain clearly outlined test follow-up procedures, and problems with patient communication. Of the 351 cases reviewed, patient harm occurred in 308 cases, with one in five cases resulting in severe harm or death.

Case example: Diagnostic delay of an adenocarcinoma

Having not seen his physician for two years, a patient arrives at a small office practice for the resumption of routine visits. The physician orders blood tests and a urinalysis, and asks the patient to return for a digital rectal exam in a week’s time. The patient does not attend the follow-up appointment. When the patient’s blood test arrives several days later, it indicates an elevated PSA level. The physician attempts to inform the patient, but is unable to reach him. The contact information on file is out of date.

Eighteen weeks later the patient returns. A digital rectal exam is performed, and a nodule is discovered. The patient undergoes surgical resection for an adenocarcinoma of the prostate and recovers well. In his complaint, the patient asserts that the physician delayed his cancer diagnosis by failing to contact him about the test result showing an elevated PSA level. The College supports the care provided, but criticizes the physician for not maintaining up-to-date contact information, not documenting his attempts to contact the patient, and not maintaining a systematic approach to test follow-up.

Spotlight on family physicians

The CMPA’s review shows that family physicians, while making up 35% of the CMPA membership,2 are frequently the subject of complaints and civil actions related to test result follow-up, accounting for 56% of the complaints and civil actions reviewed between 2015 and 2019 (351/630). Peer experts3 reviewing these matters were able to provide support only 6% of the time (23/351).

 

CMPA advice on test results follow-up

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  • Optimize efficiency by designing a test follow-up system that integrates easily with existing practices.
  • Work with staff to encourage knowledge and use of follow-up procedures, and to develop clear triggers for physician and staff notification about delayed or urgent test follow-up tasks.
  • Designate who on the team is responsible for notifying, and who will be notified. Include a process for escalating responsibility when follow-up tasks are delayed.
  • Design reminders in a way that minimizes alert fatigue, and try to schedule a dedicated, daily time when you will not be interrupted or distracted to review tests and follow-up reminders.

The CMPA offers a face-to-face Test Results Follow-Up Workshop. However, due to the COVID-19 pandemic the workshop is on hiatus. We are currently investigating an online version to help physicians who are looking to build a reliable follow‑up system for test results in their practice.

Documentation and test result follow-up procedures

In 145 of 351 (41%) of the College and legal matters reviewed, peer experts noted documentation as a contributing factor. Tests ordered, reviewed, and any plans for follow-up should be clearly documented to facilitate their management and to demonstrate that reasonable efforts were made to contact the patient, should care be questioned. Most EMRs have the capacity to track tests and generate reminders and can be a useful resource for organizing this information.

Evidence also suggests that having well-defined systems, policies, and procedures for following up on test results improves the effectiveness of test follow-up.5 Almost 26% of the matters reviewed (91/351) involved the administration of a test follow-up system. In 24% of the matters (83/351), the College recommended the implementation of a test follow-up tracking system or improvements to an existing system.

In the cases reviewed, peer experts indicated clear expectations around the design of test follow-up systems. In addition to specific procedures for record-keeping, requisition tracking, and patient communication, experts recommended that systems include provisions for flagging significant test results, generating reminders (e.g. test receipt and review, informing patients, confirming referrals), and integrating safeguards (i.e. back-up strategies and procedures anticipating system failures).

Communication with the patient

Our review indicated that breakdowns in patient communication were the most common contributing factor in test follow-up matters. Of 351 College and legal matters, 147 (42%) involved communication problems with patients. A similar CMPA analysis from 2018 mapped cases according to the Agency for Healthcare Research and Quality laboratory testing process and found that failure to notify a patient of test results was a feature in 69% of the cases.

One promising strategy for addressing the gap is patient engagement. In Canada, tools and networks such as Québec Health Booklet, MyHealthRecords in Alberta, and MyChart in Ontario and British Columbia have, for several years now, established patient portals that provide patients online access to common lab tests, imaging, and vaccination records. Alberta is also developing ConnectCare, a centralized and standardized provincial system that will make test results available to both patients and physicians from a single source, and set harmonized laboratory values for test significance.

While physicians are responsible for communicating and following up on test results, encouraging a mutual sense of responsibility for follow up with the patient may contribute to the development of a safer and more reliable test follow-up system. However, it remains important for physicians to communicate directly and promptly with a patients when a test result is significant or where it may be difficult for the patient to comprehend its meaning. This is the case despite the patient’s ability to access their test results via an online portal. Patient portals also do not indicate to the patient why a particular test was ordered in the first place, making communication of a test’s importance at the outset an especially central aspect of fostering patient engagement in the testing and follow up process.

Elements of effective test follow-up

Physicians should consult with their College for specific test result follow-up standards and expectations. The list below summarizes some of the safeguards that peer experts in the CMPA cases studied have highlighted as key in successfully managing and sharing test results.3

Record keeping

  • documentation of all tests ordered and all test results received
  • date stamping and initialing of reports as they are received (if using paper records)
  • routine scanning or entry of test results into patient files (if receiving paper results in an EMR environment)
  • a record of any inquiries from patients into outstanding test results
  • documented review of test results before committing result to patient chart, and a record of what action was initiated

Tracking, flagging, and communicating

  • communication with the patient regarding the importance and meaning of the test
  • tracking any test requisitions ordered, and not committing any abnormal test results to the record without informing the patient
  • a way of confirming that referrals have been received and appropriately actioned
  • a procedure for transferring records to other healthcare providers, and confirming receipt
  • a procedure for flagging abnormal results, identifying patients, and generating a communication task
  • a policy outlining time-frames for communication with patients who require urgent or routine follow-up
  • a procedure for confirming that patients have received messages and booked appropriate follow-up

Reminders and safeguards

  • reminders for the physician about results that have not yet been communicated to the patient
  • reminders for the physician about test results that have not been received by the office
  • a means of informing the physician about missed or delayed appointments, and reminders about patients who have outstanding follow-up needs
  • additional strategies for relaying results when primary strategies fail
  • arrangements for continued care when a physician leaves for an extended period (i.e. parental leave or vacation) or leaves the practice

The bottom line

Patient harm can result when test follow-up systems fail or are non-existent. Office-based family physicians frequently receive patient complaints related to this aspect of practice, and criticisms often focus on inadequate test follow-up procedures and communication with the patient. Among other measures, designing and implementing an effective system of test follow-up procedures and encouraging patient collaboration can help minimize such risk and improve patient care.


References

  1. Litchfield I, Bentham L, Lilford L, at al. Test result communication in primary care: A survey of current practice. BMJ Qual Saf. 2015;24:691-699
  2. As of December 31, 2019, the CMPA’s total membership was 101,865, with 35,786 members being family physicians.
  3. Peer experts refer to physicians retained by the parties in a legal action or College matter to interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
  4. Workshop: Test results follow-up. Ottawa (CA): Canadian Medical Protective Association.
  5. Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results [published correction appears in Arch Intern Med. 2009 Sep 28;169(17):1626]. Arch Intern Med. 2009;169(12):1123-1129. DOI:10.1001/archinternmed.2009.130 https://pubmed.ncbi.nlm.nih.gov/19546413/

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.