Timothy R. McEwen

Management of Test Results in Family Medicine Offices

PURPOSE We wanted to explore test results management systems in family medicine offices and to delineate the components of quality in results management. METHODS Using a multimethod protocol, we intensively studied 4 purposefully chosen family medicine offices using observations, interviews, and surveys. Data analysis consisted of iterative qualitative analysis, descriptive frequencies, and individual case studies, followed by a comparative case analysis. We assessed the quality of results management at each practice by both the presence of and adherence to systemwide practices for each results management step, as well as outcomes from chart reviews, patient surveys, and interview and observation notes. RESULTS We found variability between offices in how they performed the tasks for each of the specific steps of results management. No office consistently had or adhered to office-wide results management practices, and only 2 offices had written protocols or procedures for any results management steps. Whereas most patients surveyed acknowledged receiving their test results (87% to 100%), a far smaller proportion of patient charts documented patient notification (58% to 85%), clinician response to the result (47% to 84%), and follow-up for abnormal results (28% to 55%). We found 2 themes that emerged as factors of importance in assessing test results management quality: safety awareness—a leadership focus and communication that occurs around quality and safety, teamwork in the office, and the presence of appropriate policies and procedures; and technological adoption—the presence of an electronic health record, digital connections between the office and testing facilities, use of technology to facilitate patient communication, and the presence of forcing functions (built-in safeguards and requirements). CONCLUSION Understanding the components of safety awareness and technological adoption can assist family medicine offices in evaluating their own results management processes and help them design systems that can lead to higher quality care.

Creating Safety in Primary Care Practice with Electronic Medical Records Requires the Consideration of System Dynamics

Improvement in quality and safety in health care often depends on eliminating errors. Using examples from our research on the medical testing processes in primary care medical practices, we argue that designing safer systems requires moving beyond frameworks that focus exclusively on error elimination to consider the broader system dynamics including information loops that can be critical to the overall stability of the system. We focus on describing the nature of information coupling in relation to the constructs of essential friction, autonomation, and ecological interface design and how these can lead to more resilient systems. With the recent push in the United States to move towards electronic medical records (EMR), we conclude with suggestions for improving EMR systems based on these concepts.

Lessons for Electronic Medical Records from Family Medical Practices

Motivated by the push towards the adoption of electronic medical record (EMR) systems, we conducted a series of observations, interviews, and patient record audits at four family medical practices to investigate the nature of record keeping in diagnostic testing processes. One lauded benefit of EMR is to reduce the number of steps required to process test results and reduce the number of errors. We found this to be the case. However, in offices with paper records, we found many instances where people helped create safety by correcting errors made at previous stages due to naturally occurring feedback loops that allowed for compensation. The EMR office faced unique challenges in this regard because of impoverished communication and feedback loops, both from the EMR system and support staff. It is important to appreciate the safety dynamics of paper based systems in the design of EMR systems and consider incorporating dynamics such as checks and redundancies into them.