Test results follow-up

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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