Study: Having an EMR doesn't necessarily solve high failure-to-inform rate

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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, according to new research published June 22 in the Archives of Internal Medicine. The researchers found that having an EMR does not reduce failure-to-inform rates--and even increases them--if the practice does not have good processes in place for managing test results.

Lawrence P. Casalino, MD, chief of the division of outcomes and effectiveness research in the department of public health of Weill Cornell Medical College in New York City, and colleagues analyzed 5,434 patient records for patients aged 50 to 69 years from 23 physician practices in 19 community-based and four academic medical center primary care practices.

They analyzed records that contained abnormal results for blood tests, x-rays and other imaging studies, and searched for documentation that the patient had been properly informed of the problem in a timely way. Primary-care practice physicians were surveyed about their processes for managing test results. Individual physicians were notified of apparent failures to inform and asked whether they had informed the patient.

Casalino and his colleagues revealed that groups using simple processes to manage test results had lower failures rates. Groups that did not consistently use these processes had both higher failure rates and a higher rate of physicians who were dissatisfied with their group's processes for managing test results.

According to the results, the rate of apparent failures to inform or to document informing the patient was 7.1 percent, with a range of zero to 26.2 percent. In mixed-effects logistic regression, higher process scores were associated with lower failure rates. The use of a "partial electronic medical record" (paper-based progress notes and electronic test results or vice versa) was associated with higher failure rates compared with not having an EMR or with having an EMR that included both progress notes and test results, according to the researchers.

"Failure to report abnormal test results can lead to serious, even lethal consequences for the patient," said Casalino. "The good news is that physicians who use a simple set of systematic processes to deal with test results can greatly lessen their error rates."

The study suggested that five simple, common-sense processes are useful for dealing with test results:
1. all test results are routed to the responsible physician;
2. the physician signs off on all results;
3. the practice informs patients of all results, normal and abnormal, at least in general terms;
4. the practice documents that the patient has been informed; and
5. patients are told to call after a certain time interval if they have not been notified.

"We found that very few physician practices had explicit rules for managing test results," said Casalino. "In many practices, each physician devised his or her own method. And in many cases, physicians and their staff told patients that 'no news is good news' -- meaning they should assume that their tests are normal unless they are contacted. This is a dangerous assumption."

"With the recent enactment of federal stimulus legislation to support greater adoption of health information technology, this study demonstrates why health IT hardware alone will not improve care," commented Mark Smith, MD, president and CEO of the California HealthCare Foundation, which funded the research. "Ensuring that processes are in place to efficiently notify patients of their lab results should be part of the meaningful use of electronic health records."