■ Physician-patient:

Communicating effectively with patients to optimize their care

Test results follow-up

Blood test tubes sit on a sheet of results.

No news is not good news

Published: March 2021
7 minutes

Introduction

Lapses in the management of follow up of laboratory, imaging or consultation results is a common cause of diagnostic delay and may be associated with patient harm. Courts have ruled that when ordering a test, physicians must be satisfied that they have a system in place to reasonably ensure the results are received and communicated to patients in a timely manner.

Many medical regulatory authorities (Colleges) have policies that set their expectations of physicians for following up on test, imaging, and consultation requests and results. In most instances, the responsibility for following up a test result rests with the ordering physician. Taking the time to analyze your test result follow-up process can help optimize workflows in your office and promote safe medical care.

The Diagnostic Test Continuum

1. Test ordered
2. Test performed
3. Result generated / tracked
4. Result returned
5. Result reviewed
6. Result documented, filed
7. Patient notified
8. Patient monitored

Adapted from the Agency of Healthcare Research and Quality, 2013.

This diagram shows the test follow-up continuum as described by the Agency for Healthcare Research and Quality (AHRQ) in the U.S.1 Efforts to address potential flaws at each step of the process may reduce the risk of failures. It is important to have a policy for the follow-up of test results in a medical practice. A reliable follow-up system includes redundancy of defenses between steps: if safeguards at any one step fail, those in another can compensate for the lapse.

Clarity and standardization of follow-up processes also mitigates the risks associated with staff turnover and high work volumes.

Good practice guidance

Identifying flaws in your follow-up system

Consider the situation of a physician who espouses a “no news is good news” philosophy, whereby the physician reassures patients they will only be contacted if there is anything abnormal. While it may appear to be efficient, such an approach is flawed. A number of Colleges have specifically cautioned physicians against using this practice.

“No news is good news” assumes that the results will make it back to the physician’s office and that the physician will be aware of them. If the test is not actually performed, if the specimen is lost, or if a software malfunction prevents the test result from reaching the office, the physician may not be aware there is a potential abnormal result and the patient would assume all is well.

Individual practice patterns will influence your decisions in developing a follow-up system that mitigates the risks of missing abnormal results. Considering the following questions may help you devise a follow up system that is tailored to your practice pattern:

  • Do you work with colleagues or are you in solo practice?
  • Do you order tests for which there are long wait times?
  • Do you work in multiple settings?
  • Do you deal with multiple laboratories?
  • Do you use an EMR or paper records?

The answers to such questions can help you tailor your approach to optimize workflow and prioritize safety.

In the following tabs, potential problems are listed for each step, along with suggestions for mitigation.

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Problems:

  • Some tests are ordered incorrectly or unnecessarily.
  • Requisitions can be mislabeled.
  • The physician does not order the appropriate test.

Suggestions:

  • Order only relevant and necessary testing.2
  • Minimize variability in ordering by using the same ordering process for a given type of test.
  • In clinics where physician names may be pre-stamped on requisitions, develop a system that forces each ordering physician to use their own requisition.

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Problems:

The investigation may not be done because the patient:

  • is too busy
  • does not appreciate the need for the investigation
  • loses the requisition
  • does not want the investigation
  • may face a long wait before being scheduled for the investigation

The test may not be done at the lab or clinic because:

  • the specimen sample is lost
  • the requisition is separated from the specimen
  • the requisition is incomplete

Suggestions:

  • Given your practice context, identify a reasonable deadline date by which you expect to receive the results.
  • Contact patients whose results are not back by that date to inquire whether they were tested. Remind them to have the test performed or schedule a return visit.
  • Foster patient engagement in managing their health and following through with testing.
  • Explain the importance of the test to patients and ask whether they understand. Document the discussion.
  • Explore whether other providers could perform the test sooner, if necessary.
  • Consider whether a conversation with a provider is warranted to expedite testing.
  • For laboratory personnel, devise procedures to track specimens within your laboratory. 

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Problems:

Some critical test results do not receive the needed attention. This may happen:

  • When the result is unexpected (for example, the test was ordered for another indication or reason).
  • The clinician only reads the “impression” portion of the result but the abnormal result is described earlier in the body of the report.
  • The clinician forgets he or she ordered the test and doesn’t receive a report.

Suggestions:

If you are a consultant:

  • Clearly flag abnormal or unexpected results with “ABNORMAL RESULT” or “WARNING – UNEXPECTED FINDING” at the top of all reports of abnormal or unexpected results.
  • Verbally notify the requesting physician of critical or unexpected results.
  • Repeat unexpected results in the impression portion of investigation reports (not just in the body of the report).

If you are a leader:

  • Devise policies whereby consultants or laboratory technologists are expected to verbally notify the requesting physician of critical or unexpected results.
  • Devise policies that require the explicit flagging of unexpected or abnormal results in reports.

If you are a clinician:

  • Read the entirety of a result, not just the impression portion.
  • Track the tests you order and cross-match that list with results received.
  • Ask yourself who the most responsible physician is, who should act on the test result, and consider whether other physicians in the circle of care should be notified, if you receive an abnormal result you did not order.

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Problems:

  • The wrong address appears on the requisition.
  • The requisition names the wrong physician.
  • There is a technological failure resulting in batches of reports not being sent.
  • There was a receiving failure (e.g. post office, fax, electronic transfer).

Suggestions:

  • Set up an electronic reminder (in your EMR or calendar) to check that you received a pending test result by a specified date.
  • Tell your patients they should call your office if they have not been contacted about their test result. Explain that this is a safeguard against occasional loss of test results.
  • Perform regular audits of your system to ensure results are being received as they should.
  • Alert local laboratories or imaging facilities of a known name duplication with another physician (to reduce the risk of results being sent to someone else).

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Problems:

The investigation is not read by the physician because:

  • the report was filed in error
  • the physician is away
  • a different physician  receives the result
  • results are filed without the physician seeing them
  • the physician does not review their results
  • EMR alerts have been turned off

Suggestions:

  • Review test results regularly to keep your inbox manageable.
  • Work with your office staff to determine a process for identifying and flagging abnormal results.
  • Identify someone to be available to receive and act upon critical results after hours.
  • Do not click “reviewed” or “OK” on EMR reminders or alerts if you have not reviewed the individual results.
  • Instruct locum physicians to keep a list of pending results. Upon your return, review the list and assume responsibility for following up on these results.
  • If you work at many sites, consider how often you visit each location and whether you are able to perform a timely review of test results.
  • Do not turn off EMR alert functions.
  • Consider booking a follow-up appointment when you order the test.

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Problems:

The test result is filed before the physician has reviewed it.

Suggestions:

  • Sign off the results and make a brief note of the action taken.
  • Train staff not to file reports that you have not reviewed.

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Problems:

The physician has delegated this task to staff who have:

  • no clear office procedures for following up with patients
  • the wrong contact information for the patient
  • not alerted the physician to their inability to reach the patient
  • not reached the patient due to competing priorities or miscommunication

The result is read but no action is taken by the physician because:

  • the significance of the abnormality is not recognized
  • the physician assumes the action is someone else's responsibility (i.e. another physician ordered the test)
  • the result is a secondary finding, not related to the main clinical reason for ordering the investigation, and/or the physician assumes someone else is in a better position to follow up
  • the physician forgets to action the item due to competing priorities
  • the result is unclear or not easily identified

Suggestions:

  • Create an alert for the result, which you and your staff will see at the next contact with the patient.
  • Train staff to confirm the patient’s contact information, including a potential secondary contact when patients register at your office, in order to optimize the ability to reach the patient.
  • Use medication refill requests as a trigger to determine whether a result is pending.
  • Set a policy on the number of documented follow-up phone calls your office will make to a patient concerning a specific test result. Include when and how to use alternative methods for follow-up (e.g. mail result or with prior consent contacting the patient’s alternative contact).
  • Create policies for imaging or laboratory staff to guide the communication of critical or unexpected results with the ordering physician.
  • Discuss issues that impact test follow up with hospital administration and/or clinic management so that procedures can be established to facilitate timely test result follow-up.

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Problems:

  • The patient fails to come for follow-up (no-show).
  • There is a language barrier or lack of reliable contact information to reach patient
  • The physician fails to formulate a plan for follow-up.

Suggestions:

  • Have a system for following up patients who do not attend follow up visits.
  • Identify and adapt your follow up system for patients at risk (language barrier, under housed, repeated no-show)
  • If a follow-up investigation is warranted, order it right away where possible.
  • Include test results with consultation requests to facilitate prioritization by the consultant.
  • If you are uncertain about the follow-up plan, contact other physicians in the circle of care to verify who is taking action.

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Checklist: Follow-up of test results

Creating a robust follow-up system so that results are received, reviewed, and acted on in a reasonable period of time

Have you:

  • considered whether this investigation is necessary?2
  • conveyed to the patient the significance of the test and the importance of getting it done?
  • made yourself (or a colleague) available to be notified of any critical results?
  • devised a way to:
    • record the tests you order?
    • record the results you receive?
    • reconcile the two?
  • reviewed your medical regulatory authority (College) policies for test result management?

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Do you have:

  • a system to track the reception of requisitions, specimens, or blood work?
  • a policy for notifying the ordering health provider of a critical result?
  • a policy for dealing with critical results if the ordering health provider cannot be reached?

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Have you:

  • recorded when the results were received and reviewed?
  • read the report carefully and considered whether further investigation or referral is indicated?
  • clarified any areas of uncertainty about the findings?
  • ascertained who is responsible for follow-up if more than one physician is on the copy list?
  • determined whether a two-step follow-up is required (i.e. review culture and sensitivity reports that may follow later)?
  • determined whether to proceed with a radiologist's or pathologist’s recommendations for further diagnostic tests, and if not, documented your rationale?
  • documented your action plan and reasoning?

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Have you:

  • verified the patient’s contact information?
  • devised a policy for determining which notifications can be delegated to a staff member?
  • documented your attempts to contact the patient?
  • considered alternative methods for notifying the patient, if appropriate?
  • offered an opportunity to answer any follow-up questions the patient may have?
  • documented “no-shows” and arranged appropriate follow-up of the patient, if necessary?

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Have you:

  • notified the laboratory or diagnostic facility of the error?
  • considered notifying the intended receiving physician of the result, if appropriate?
  • considered notifying the patient of the result, if appropriate?

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References

  1. Improving Your Laboratory Testing Process. Rockville (MD): Agency for Healthcare Research and Quality. Reviewed 2018 Jan. Available from: https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-care/labtesting-toolkit.html
  2. For more information about appropriate use of clinical tests and treatments, visit Choosing Wisely Canada at www.choosingwiselycanada.org 
CanMEDS: Communicator, Collaborator

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.