Using a linked EHR-PHR for lab test result reporting

Reporting of laboratory test results to patients is a challenge to most practicing physicians. Ineffective management of this process can result in suboptimal care, as well as malpractice liability. Many practices rely on a “no news is good news” approach, only reaching out to patients for abnormal results – however, this practice is clearly risky (though common).

A survey of patient preferences in 2009 showed that patients as well as physicians both prefer the US mail for notification of normal test results, and phone call by the physician for notification of abnormal results. Even so, new research shows that physicians failed to report clinically significant abnormal test results to patients (or to document that they had informed them) in one out of every 14 cases of abnormal results.

The study published in the Archives of Internal Medicine showed that physician groups using simple processes to manage test results had lower failure rates. But groups that did not consistently use these processes had both higher failure rates and physicians who were dissatisfied with their group’s processes for managing test results.

Notably, the study also found that having an Electronic Health Record(EHR) system did not reduce failure-to-inform rates – and even increased them – if the practice did not have good processes in place for managing test results.

A review of lab test result reporting processes published in the Journal of Family Practice describes a set of 4 steps involved in laboratory test result management: (1) tracking test results until they are received; (2) notifying patients of the results; (3) documenting that the notification occurred; and (4) assuring that recommended follow-up occurs for abnormal test results.

Can modern EHR technology be constructed with this issue in mind, so as to facilitate carrying out of these 4 steps? That vision is part of how we are building Practice Fusion, and other EHRs may want to learn from our experience to find a “best practices” way of helping physicians with this challenge.

Tracking test results until the are received : When the test-ordering process is disconnected – a lab form is given to a patient and told to get the lab test – then tracking of orders is laborious. Some practices create the work habit of giving patients lab test order forms on exit from a current visit, to be drawn just before the next visit, and therefore fresh results can be reviewed during the next visit – such a method helps, but still is disconnected.

However, integrating lab ordering into the EHR, so that a linkage with the lab system is wrapped into the EHR, can result in a much more systematic way of tracking “ordered but not yet reported” labs. Many lab integrated EHRs will accept lab test results reporting, but wrapping lab ordering into the system allows a much tighter tracking of tests – this, of course, requires good interoperability between the EHR and the lab IT system.

Notifying patients of the result : When lab test results are received, a systematic way of letting patients know the results needs to be carried out. With a linked EHR/PHR system (like Practice Fusion and Patient Fusion), reporting to patients automatically and electronically is straightforward. A number of e-Patient advocates have even recommended that result reporting should be placed directly into a linked PHR and not await “physician review,” as this may introduce delays and potentially overlooked abnormals – the principle is that “the more eyes, the better.”

Granted, 100% of the practice’s patients will likely not be on the linked PHR, but having such an option reduces the volume of burden, so that more traditional methods of notification can be done: mailed notification cards for normals, and phone calls for abnormals. An EHR can help print out lab notification cards from the list of patients needing notification who do not have secure email contact, or the linked PHR.

Documenting that the notification occurred : When the EHR is used either to send results to the PHR, or to create a secure email, or to print a notification card to be mailed, then automatic documentation of that step is straightforward, if it is part of the design of the EHR system. When notification is done using a manual and disconnected process, then a manual entry should be made into the EHR documenting the reporting (even something simple, like “test result notification mailed”).

Assuring that recommended follow-up occurs for abnormal test results : The traditional way of demonstrating that lab reports have “passed before the eyes of the physician” is for the physician to somehow mark on the report sheet (usually initials). In EHRs, lab reports also need to demonstrate that they have been reviewed, so that action can be taken. In Practice Fusion, as in other EHRs, “raw” lab reports drop into a bin, or into a patient’s “pending” section, with a prompt to the physician to review the report. Upon physician review (usually a simple click on a button), the lab report becomes a permanent part of the patient chart, and a date/time stamp of physician review is placed on
it. A messaging system that can be called upon during the process of reviewing will then be the method of documenting action upon abnormals.

If the report has already passed to a linked PHR, then doctor-patient communication (initiated by either side) can also serve as documentation that something has been done to address an abnormal result.

***

EHRs, when designed well and when they take into account these 4 steps in managing lab test reporting, can be tools that facilitate Best Practices. Of course, failure to implement these tools will achieve poorer results (and poorer results faster). In particular, the use of a linked EHR/PHR system may be the biggest reason for physicians to actively enroll patients into the PHR, so that lab result notification can be done in the most automated and least-burdensome way.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.