Joanne Callen

Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review

ABSTRACTBACKGROUNDSerious lapses in patient care result from failure to follow-up test results.OBJECTIVETo systematically review evidence quantifying the extent of failure to follow-up test results and the impact for ambulatory patients.DATA SOURCESMedline, CINAHL, Embase, Inspec and the Cochrane Database were searched for English-language literature from 1995 to 2010.STUDY SELECTIONStudies which provided documented quantitative evidence of the number of tests not followed up for patients attending ambulatory settings including: outpatient clinics, academic medical or community health centres, or primary care practices.DATA EXTRACTIONFour reviewers independently screened 768 articles.RESULTSNineteen studies met the inclusion criteria and reported wide variation in the extent of tests not followed-up: 6.8% (79/1163) to 62% (125/202) for laboratory tests; 1.0% (4/395) to 35.7% (45/126) for radiology. The impact on patient outcomes included missed cancer diagnoses. Test management practices varied between settings with many individuals involved in the process. There were few guidelines regarding responsibility for patient notification and follow-up. Quantitative evidence of the effectiveness of electronic test management systems was limited although there was a general trend towards improved test follow-up when electronic systems were used.LIMITATIONSMost studies used medical record reviews; hence evidence of follow-up action relied upon documentation in the medical record. All studies were conducted in the US so care should be taken in generalising findings to other countries.CONCLUSIONSFailure to follow-up test results is an important safety concern which requires urgent attention. Solutions should be multifaceted and include: policies relating to responsibility, timing and process of notification; integrated information and communication technologies facilitating communication; and consideration of the multidisciplinary nature of the process and the role of the patient. It is essential that evaluations of interventions are undertaken and solutions integrated into the work and context of ambulatory care delivery.

Accuracy of medication documentation in hospital discharge summaries: A retrospective analysis of medication transcription errors in manual and electronic discharge summaries

BACKGROUND Medication errors in hospital discharge summaries have the potential to cause serious harm to patients. These errors are generally associated with manual transcription of medications between medication charts and discharge summaries. Studies also show junior doctors are more likely to contribute to discharge medication error rates. Electronic discharge summaries have the potential to reduce discharge medication errors to ensure the safe handover of care to the primary care provider. OBJECTIVES (1) Quantify and compare the medication transcription error rate from handwritten medications on manual discharge summaries to typed medications on electronic discharge summaries, and (2) examine the quality of medication documentation according to the level of medical training of the doctors who created the discharge summaries. METHODS A retrospective examination of 966 handwritten and 842 electronically generated discharge summaries was conducted in an Australian metropolitan hospital. The electronic discharge summaries at the study site were not integrated with an electronic medication management system and hence discharge medications were typed into the electronic discharge summary by the doctor. The discharge medication documentation in both types of summaries was transcribed, either handwritten or typed, from inpatient medication charts in paper-based medical records. Documentation differences between medications in discharge summaries and inpatient medication charts constituted medication errors. RESULTS 12.1% of handwritten and 13.3% of electronic summaries contained medication errors. The highest number of errors occurred with cardiovascular drugs. Medication omission was the commonest error. The confidence intervals of all odds ratios indicate handwritten and electronic summaries were similar for all areas of medication error. Error rates regarding all 13,566 individual medications for the 1808 summaries were similar by doctor medical training level (intern, resident, and registrar). CONCLUSION Similar medication error rates in handwritten and electronic summaries may be due to the common factor of transcription, either handwritten or typed, known to be associated with medication errors. Clinical information systems evolve and often in the early stages of implementation electronic discharge summaries are integrated with existing paper-based patient record systems. Automatic transfer of medications from an electronic medication management system to the electronic discharge summary holds the potential to reduce medication errors through the elimination of the transcription process.

The safety implications of missed test results for hospitalised patients: a systematic review

Background Failure to follow-up test results is a critical safety issue. The objective was to systematically review evidence quantifying the extent of failure to follow-up test results and the impact on patient outcomes. Methods The authors searched Medline, CINAHL, Embase, Inspec and the Cochrane Database from 1990 to March 2010 for English-language articles which quantified the proportion of diagnostic tests not followed up for hospital patients. Four reviewers independently reviewed titles, abstracts and articles for inclusion. Results Twelve studies met the inclusion criteria and demonstrated a wide variation in the extent of the problem and the impact on patient outcomes. A lack of follow-up of test results for inpatients ranged from 20.04% to 61.6% and for patients treated in the emergency department ranged from 1.0% to 75% when calculated as a proportion of tests. Two areas where problems were particularly evident were: critical test results and results for patients moving across healthcare settings. Systems used to manage follow-up of test results were varied and included paper-based, electronic and hybrid paper-and-electronic systems. Evidence of the effectiveness of electronic test management systems was limited. Conclusions Failure to follow up test results for hospital patients is a substantial problem. Evidence of the negative impacts for patients when important results are not actioned, matched with advances in the functionality of clinical information systems, presents a convincing case for the need to explore solutions. These should include interventions such as on-line endorsement of results.

Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries

BACKGROUND Hospital discharge summaries have traditionally been paper-based (handwritten or dictated), and deficiencies have often been reported. On the increase is the utilisation of electronic summaries, which are considered of higher quality than paper-based summaries. However, comparisons between electronic and paper-based summaries regarding documentation deficiencies have rarely been made and there have been none in recent years. OBJECTIVES (1) To study the hospital discharge summaries, which were either handwritten or electronic, of a population of inpatients, with regard to documentation of information required for ongoing care; and (2) to compare the electronic with the handwritten summaries concerning documentation of this information. METHODS The discharge summaries of 245 inpatients were examined for documentation of the items: discharge date; additional diagnoses; summary of the patients progress in hospital; investigations; discharge medications; and follow-up (instructions to the patients general practitioner). One hundred and fifty-one (62%) discharge summaries were electronically created and 94 (38%) were handwritten. Odds ratios (ORs) with their confidence intervals (CI) were estimated to show strength of association between the electronic summary and documentation of individual study items. RESULTS Across all items studied, the electronic summaries contained a higher number of errors and/or omissions than the handwritten ones (OR 1.74, 95% CI 1.26-2.39, p<0.05). Electronic summaries more commonly documented a summary of the patients progress in hospital (OR 18.3, 95% CI 3.33-100, p<0.05) and less commonly recorded date of discharge and additional diagnoses (respective ORs 0.17 (95% CI 0.09-0.31, p<0.05) and 0.33 (95% CI 0.15-0.89, p<0.05). CONCLUSION It is not necessarily the case that electronic discharge summaries are of higher quality than handwritten ones, but free text items such as summary of the patients progress may less likely be omitted in electronic summaries. It is unknown what factors contributed to incompleteness in creating the electronic discharge summaries investigated in this study. Possible causes for deficiencies include: insufficient training; insufficient education of, and thus realisation by, doctors regarding the importance of accurate, complete discharge summaries; inadequate computer literacy; inadequate user interaction design, and insufficient integration into routine work processes. Research into these factors is recommended. This study suggests that not enough care is taken by doctors when creating discharge summaries, and that this is independent of the type of method used. The importance of the discharge summary as a chief means of transferring patient information from the hospital to the primary care provider needs to be strongly emphasised.

The development, design, testing, refinement, simulation and application of an evaluation framework for communities of practice and social-professional networks

BackgroundCommunities of practice and social-professional networks are generally considered to enhance workplace experience and enable organizational success. However, despite the remarkable growth in interest in the role of collaborating structures in a range of industries, there is a paucity of empirical research to support this view. Nor is there a convincing model for their systematic evaluation, despite the significant potential benefits in answering the core question: how well do groups of professionals work together and how could they be organised to work together more effectively? This research project will produce a rigorous evaluation methodology and deliver supporting tools for the benefit of researchers, policymakers, practitioners and consumers within the health system and other sectors. Given the prevalence and importance of communities of practice and social networks, and the extent of investments in them, this project represents a scientific innovation of national and international significance.Methods and designWorking in four conceptual phases the project will employ a combination of qualitative and quantitative methods to develop, design, field-test, refine and finalise an evaluation framework. Once available the framework will be used to evaluate simulated, and then later existing, health care communities of practice and social-professional networks to assess their effectiveness in achieving desired outcomes. Peak stakeholder groups have agreed to involve a wide range of members and participant organisations, and will facilitate access to various policy, managerial and clinical networks.DiscussionGiven its scope and size, the project represents a valuable opportunity to achieve breakthroughs at two levels; firstly, by introducing novel and innovative aims and methods into the social research process and, secondly, through the resulting evaluation framework and tools. We anticipate valuable outcomes in the improved understanding of organisational performance and delivery of care. The projects wider appeal lies in transferring this understanding to other health jurisdictions and to other industries and sectors, both nationally and internationally. This means not merely publishing the results, but contextually interpreting them, and translating them to advance the knowledge base and enable widespread institutional and organisational application.

Patients' perceptions of general practitioners using computers during the patient-doctor consultation

In this study 85 adult patients attending a Sydney general practice were asked for their views on computer-assisted consultations; 77 (91%) agreed to participate. In general, patients agreed they could still talk easily with their doctor, and felt listened to, while the doctor used the computer (87% & 75% respectively). More than half the patients felt the computer contributed to better treatment, although a quarter believed consultations were prolonged. About half the patients agreed that the doctor did not often explain the role of the computer. Given the national plans for increasing computerisation of health records (HealthConnect), this research suggests that more attention should be given to involving patients in e-health developments.

Emergency Physicians’ Views of Direct Notification of Laboratory and Radiology Results to Patients Using the Internet: A Multisite Survey

Background Patients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital’s electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians’ opinions. Objective The aim was to explore emergency physicians’ current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results. Methods A cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification. Results The response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61). Conclusions Although patients’ direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians’ concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

Electronic discharge summaries: the current state of play.

The exchange of health information between acute care providers (e.g. hospitals) and primary care providers (e.g. general practitioners) has traditionally been via hard copy discharge summaries. In recent years the advent of sophisticated information and communication technology has fuelled developments in electronic discharge referral systems (eDRS), which are credited with enabling more timely and accurate information exchange, enhancing patient care, and ultimately improving patient outcomes. The aim of this paper is to highlight key issues regarding the development and implementation of electronic discharge referral systems. A detailed literature review of information related to electronic discharge summaries was undertaken for publications between 1992 and 2006. While eDRS appear to be beneficial, further improvements are needed before systems are dependable. Through prospective enhancements and increased availability of eDRS internationally, electronic discharge referral systems have the potential to facilitate effective communication exchange across the primary-secondary care interface.

Releasing test results directly to patients: A multisite survey of physician perspectives.

OBJECTIVE To determine physician perspectives about direct notification of normal and abnormal test results. METHODS We conducted a cross-sectional survey at five clinical sites in the US and Australia. The US-based study was conducted via web-based survey of primary care physicians and specialists between July and October 2012. An identical paper-based survey was self-administered between June and September 2012 with specialists in Australia. RESULTS Of 1417 physicians invited, 315 (22.2%) completed the survey. Two-thirds (65.3%) believed that patients should be directly notified of normal results, but only 21.3% were comfortable with direct notification of clinically significant abnormal results. Physicians were more likely to endorse direct notification of abnormal results if they believed it would reduce the number of patients lost to follow-up (OR=4.98, 95%CI=2.21-1.21) or if they had personally missed an abnormal test result (OR=2.95, 95%CI=1.44-6.02). Conversely, physicians were less likely to endorse if they believed that direct notification interfered with the practice of medicine (OR=0.39, 95%CI=0.20-0.74). CONCLUSION Physicians we surveyed generally favor direct notification of normal results but appear to have substantial concerns about direct notification of abnormal results. PRACTICE IMPLICATIONS Widespread use of direct notification should be accompanied by strategies to help patients manage test result abnormalities they receive.

The impact of nurse practitioners on care delivery in the emergency department: a multiple perspectives qualitative study

BackgroundDespite well-articulated benefits, the introduction of Nurse Practitioners (NPs) in Australia has been slow. Poorly defined nomenclature relating to advanced practice roles in nursing and variations in such roles both across Australia and worldwide have resulted in confusion and uncertainty regarding the functions and roles of NPs. Qualitative studies focussing on the perceived impact on the care settings into which NPs are introduced are scarce, but are valuable in providing a complete contextual account of NPs in care delivery settings. This study aimed to investigate the perceived impact of the NP on the delivery of care in the ED by senior doctors, nurses, and NPs. Results will facilitate adoption and best use of this human resource innovation.MethodsA cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior doctors (staff specialists and ED directors) and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the impact of the NP role on the ED. Member checking of results was conducted by revisiting the sites to clarify findings with participants and further explore emergent themes.ResultsThe impact of the NP role was perceived differently by different groups of participants. Whilst NPs were observed to deliver few quantitative improvements to ED functioning from the perspective of ED directors, NPs believed that they assisted doctors in managing the increasing subacute presentations to the contemporary ED. NPs also believed they embraced a preventative paradigm of care which addressed the long term priorities of chronic disease prevention and cost containment in the broader healthcare environment. The ambiguous position of the NP role, which crosses the gap between nursing and medicine, emerged and resulted in a duality of NP governance.ConclusionsInterpretation of the NPs’ role occurred through different frames of reference. This has implications for the development of the NP role in the ED. Collaboration and dialogue between various stakeholders, such as ED doctors and senior nursing management is required.