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HEALTH CARE REFORM
Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient SettingAre Electronic Medical Records Achieving Their Potential?
Hardeep Singh, MD, MPH;
Eric J. Thomas, MD, MPH;
Shrinidi Mani, BA;
Dean Sittig, PhD;
Harvinder Arora, MD, MPH;
Donna Espadas, BS;
Myrna M. Khan, PhD, MBA;
Laura A. Petersen, MD, MPH
Arch Intern Med. 2009;169(17):1578-1586.
Background Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem.
Methods We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up.
Results Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment.
Conclusions Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.
Author Affiliations: Department of Veterans Affairs Health Services Research & Development Service, Center of Excellence, and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, Michael E. DeBakey Veterans Affairs Medical Center, and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas (Drs Singh, Khan, and Petersen, and Mss Mani and Espadas); University of Texas at Houston–Memorial Hermann Center for Healthcare Quality and Safety, Division of General Medicine, Department of Medicine, University of Texas Medical School at Houston (Dr Thomas); University of Texas School of Health Information Sciences and the University of Texas–Memorial Hermann Center for Healthcare Quality & Safety, Houston (Dr Sittig); and Department of Medicine, Baylor College of Medicine, Houston (Dr Arora).
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