Critical results still go unnoticed on patient EMR

Despite use of electronic medical records, some critical imaging test result alerts are missed, even when read by one or more healthcare practitioners, according to a study published in the Archives of Internal Medicine.

One way to solve the problem is a multidisciplinary approach, according to researchers from the Department of Veterans Affairs Health Services.

Communication breakdown is consistently identified as a preventable factor in adverse event studies, and lack of follow-up is a significant factor in diagnostic errors. Electronic medical records (EMRs) can facilitate communication through either automated notification or direct access of primary reports. The researchers found, however, that verbal communication by a radiologist is the strongest predictor of a timely response and follow-up.

From November 2007 to June 2008, nearly 124,000 outpatient radiographs, CT scans, ultrasonograms, MRIs, and mammograms were performed at the Michael E. DeBakey VA Medical Center and its five satellite clinics. Of those, 1196 generated critically abnormal test results (2009;169[17]:1578-1586).

Of all the tests that generated abnormal results, the researchers found 18% were unacknowledged. Alerts had a higher risk of being unacknowledged if the ordering healthcare practitioners were trainees and when the dual-alert system was used.

Even though dual-alert communication is intended to safeguard against lack of timely follow-up, the opposite was found to be true. Healthcare providers may believe responsibility for follow-up belongs to someone else, said lead author Dr. Hardeep Singh, an assistant professor of medicine at Baylor College of Medicine in Houston.

“One of the things we need to think about is having clear policies about who follows up what,” he said. “This ambiguity led to some stuff being overlooked.”

Timely follow-up was lacking in 7.7% of all alerts, but the risk was lower when the radiologist verbally communicated results, probably because radiologists called only for emergent and life-threatening findings, the researchers said.

“Verbal communication is still a very strong, very powerful means of making sure things get taken care of,” Singh said.

Yet radiologists are often pressed for time, so there needs to be a clear protocol for which cases a radiologist should call verbally and which cases merit notification through other means, according to Singh.

“I think the big take-home message for radiologists who want to communicate findings is, there's still a small chance follow-up action will not occur because of some unrelated factors they're not thinking of right now,” he said.

For results that are not communicated directly, EMRs and subsequent alerts still keep most results from falling through the cracks. A multidisciplinary approach is needed to tighten up the process, according to Singh.

In a separate commentary in the Journal of the American Medical Association, Singh and his colleagues said hardware and software, content, user interface, personnel, workflow and communication, organizational characteristics, state and federal regulations, and monitoring all ensure EMRs are used to their fullest capacity (2009;302[10]:1111-1113).