Study Examines Factors Affecting Patient Test Results Follow-Up within VA's Electronic Health Record System

BACKGROUND:
Although electronic health record (EHR) systems appear to reduce the risk of missed test results, they do not eliminate the problem. Lack of timely follow-up of test results remains a major patient safety concern in most healthcare organizations. In organizations using EHRs, the effectiveness of test result management may be influenced by technical factors, such as hardware and software, as well as non-technical factors, such as organizational policies, procedures, and culture. These "sociotechnical" factors include issues related to EHR technology, as well as non-technical issues at the organizational, provider, and clinical-workflow levels. This study sought to identify facility-level contextual factors that increase or decrease the risk of missed test results in 40 VA healthcare facilities from across the U.S.. Higher- (n=20) and lower-risk (n=20) VA facilities were classified based on results of a previous survey of VA primary care providers (PCPs) conducted from 6/10 through 11/10, where respondents provided their perceptions of missed test results. Investigators then interviewed facility representatives to collect data on several contextual factors derived from a sociotechnical model of safe and effective EHR use, and compared these factors between facilities, adjusting for site characteristics (e.g., patient volume, academic affiliation). Facility representatives interviewed at each VA site included one Patient Safety Manager and one IT/EHR staff member. Interviews were conducted between 1/12 and 8/12.

FINDINGS:

• PCPs at VA facilities that used additional strategies or systems to prevent missed test results preceived less risk of missing test results. However, few VA facilities used monitoring strategies to prevent missed test results. For example, facilities monitored follow-up of certain test results only when they considered them "critical" (e.g., x-ray suggestive of malignancy), but the processes for doing so were highly variable.
• Qualitative analysis identified three high-risk scenarios for missed test results: 1) alerts on tests ordered by trainees (important because 78% of VA facilities were training sites for one or more medical residency programs); 2) alerts "handed off" to another covering clinician; and 3) alerts on patients not assigned in the EHR to a PCP.
• Interventions to reduce missed test results might need to target organizational factors and not just individual providers; for example, monitoring systems to track missed test results.

LIMITATIONS:

• Measures of risk at the facility level were based not on an actual number of missed results, but on subjective assessments provided by PCPs in a previous survey.
• PCP response rates were variable, and non-PCPs were not included in this study.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D. All authors are part of HSR&D's Center for Innovations in Quality, Effectiveness, and Safety in Houston, TX.

Menon S, Smith M, Sittig D, Petersen N, Hysong S, Espadas D, Modi V, and Singh H. How Context Affects Electronic Health Record-Based Test Result Follow-Up: A Mixed Methods Evaluation. BMJ Open. November 11, 2014;4(11):eoo5985.