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Service Delivery Innovation Profile

Primary Care Practices Improve Patient Satisfaction With Communication of Outpatient Laboratory Test Results


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Snapshot

Summary

Primary care clinicians were able to expedite communication of outpatient laboratory and imaging test results to patients with the help of an automated test results management system. A 2.5-year study at 26 adult primary care practices found that patients of physicians who participated in the project reported greater satisfaction with both test results communication and information provided about their treatment and/or condition than did a control group of similar patients.

Evidence Rating (What is this?)

Strong: The evidence consists of results from a prospective RCT using a validated survey instrument and multivariate logistic regression models to analyze data from 570 patient encounters in 26 outpatient clinics.
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Developing Organizations

Brigham and Women's Hospital; Harvard Medical School; Partners Healthcare System
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Use By Other Organizations

  • The Results Manager is specific to Partners HealthCare System, although several commercially available electronic health records provide similar results reporting functionality.

Date First Implemented

2002
December 1

Problem Addressed

Accurate and timely physician–patient communication of the results of outpatient tests is critical to patient safety, health outcomes, and patient satisfaction with care, yet, many patients do not receive results on a timely basis (or sometimes at all).
  • Poor communication of outpatient test results: Unlike in a controlled inpatient environment, communication of the results of outpatient tests occurs between patient visits, thus making such communications more difficult.1 As a result, the quality of communications tends to be highly variable and often poor; a survey of 262 physicians found that approximately 17 to 32 percent had no reliable method of ensuring that test results were received by patients; that one-third did not always notify patients of abnormal results; and that physicians often depend on followup visits to inform patients of results.2 Physicians themselves are not satisfied with these processes; a survey of 262 physicians found that only 41 percent were satisfied with how they managed test results.3
  • Negative impact on quality, potential for malpractice liability: Poor test result communications are associated with delays in treatment and missed opportunities for followup care. For example, a study of 126 women with abnormal mammograms found that patients' understanding of the need for followup was independently associated with the delivery of appropriate followup care.4 Ineffective communication about test results can also increase the risk of malpractice liability; failures or delays in diagnosis constitute the fastest growing area of malpractice cases, with about one-fourth attributable to avoidable failures related to followup communication.1
  • Unclear patient expectations a part of the problem: A survey found that patients typically do not discuss their preferences for test result notification with providers, thus making it more difficult for providers to meet patient expectations.5

What They Did

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Description of the Innovative Activity

Physicians at Partners HealthCare System, Inc., enhanced the quality of physician communication with patients by making it as easy as possible for physicians to report laboratory and radiology results. The effort took advantage of an automated test result notification system (known as the Results Manager) embedded in its main ambulatory electronic health record (known as the Longitudinal Health Record) that provides physicians with a concise summary of results, a template-based letter that can be modified to send to patients, and patient contact information. Key elements of the project include:
  • Centralized collection of results: All testing sources within the health system send test results electronically through the Longitudinal Health Record to the Results Manager.
  • Physician access to results: A clinician can log into the system to see a summary page listing all laboratory and radiology test results associated with their patients. The clinician can also review the details of each test result in this online system. Clinicians who see patients 8 hours a day typically require approximately 30 to 60 minutes a day to review test results (including results letter generation but excluding telephone contact time).
  • Flagging of abnormal results: The system flags abnormal laboratory test values and stratifies them by level of severity. (Radiology and biopsy results, because they are written in free text rather than quantified, cannot be flagged.) Because the Results Manager is linked to the electronic health record, the clinician can easily call up the patient's chart, review pertinent information, and then return to the laboratory results.
  • Facilitating communication with patients: The clinician can use the system to act on each test result, either by automatically generating a patient notification letter, making a telephone call to the patient, or simply acknowledging receipt of the result and documenting that communication will be made at a later time. The results and the response are documented in the electronic health record, and each acted-on test result is cleared from the system's inbox. Patient letters are prepopulated with the patient's address, the quantitative test results, and a generic assessment of the results that can be modified and customized by the physician. The system prints the letter, which can then be mailed by a staff member.
  • Opportunities for physician time savings: Physicians may choose to delegate the initial monitoring and review of test results to another clinical staff member, such as a nurse practitioner, who can automatically generate letters for all patients with normal test results, leaving the physician to review and act on only the abnormal results.

Context of the Innovation

The Partners HealthCare System, an integrated system comprising Brigham and Women's Hospital, Massachusetts General Hospital, several community hospitals, and Partners Community HealthCare (a physician network including more than 4,000 clinicians), had no enterprise-wide guidelines or support systems for handling communication of test results with patients. Like most doctors, Partners physicians found it difficult to keep track of the tests ordered for patients. To do so, they had to embark on a time-consuming process that included entering the electronic health record, determining which patient tests were performed and when, finding the results, and then communicating those results to the patient. No systems were available to help with these steps, and, as physicians became busier, the potential for missed test results grew. Recognizing this, Partner physicians wanted to reduce the likelihood that they would miss results and improve the chances of patients receiving communication about those results, thus enhancing patient safety and satisfaction. They believed that information technology (IT) was the key to these improvements, as it could be used to automate many aspects of the results communication process.

Did It Work?

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Results

The automated test results management system was rapidly adopted by physicians and enhanced patient satisfaction with communication of test results and with the information given to them about their conditions and treatments.
  • Rapid adoption of the system by physicians: Although adoption of the system varied across clinics, roughly 50 percent of physicians used the system regularly within the first 6 to 9 months of implementation; usage was higher in academic practices than in community practices.
  • Increased satisfaction with communication of test results and information provided: A prospective randomized controlled trial (RCT) of 570 patient encounters in 26 outpatient primary care practices between December 1, 2002, and April 31, 2005, found that satisfaction with communication of test results increased from 82.5 percent before the intervention to 92.5 percent after (compared with 89.9 and 85.1 percent, respectively, in the control group). Satisfaction with the information provided by physicians about conditions and treatments increased from 86.8 percent before the intervention to 95.8 percent after the intervention in the intervention group (compared with 95.3 and 93.5 percent, respectively, in the control group).
  • No change in satisfaction with listening skills and general communication: Patient satisfaction with physician listening skills and their general communication remained unchanged, likely because listening skills are relevant primarily for interpersonal communications (most test results are sent via letter or over the phone) and because many other factors influence perceptions of general communication skills.

Evidence Rating (What is this?)

Strong: The evidence consists of results from a prospective RCT using a validated survey instrument and multivariate logistic regression models to analyze data from 570 patient encounters in 26 outpatient clinics.

How They Did It

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Planning and Development Process

The Results Manager was developed and implemented as a customized application within the Partners HealthCare electronic health record. Key steps in the process are outlined below:
  • User input and feedback: The developers held focus groups with physicians to determine the desired characteristics of the workflow and user interface. The developers created a series of mockups of that interface and obtained periodic feedback from users in different divisions and departments within Partners.
  • Programming and development: After the user interface was finalized, the application entered a programming development phase that lasted approximately 6 months.
  • Pilot testing and rollout: After being pilot tested by a small group of clinicians, the application was rolled out to the entire health system.
  • Training: After a standardized process that Partners Health System uses to rollout new IT enhancements, nurse technologists trained physicians and interested clinical office staff members to use the system in a series of 1-hour demonstration sessions. System analysts and clinical "champions" of the system also provided ongoing support to users.

Resources Used and Skills Needed

  • Staffing: The staff involved in developing the system consisted primarily of individuals with expertise in IT. Programmers were recruited from inside the health system because the application was developed specifically to fit Partners' electronic health record.
  • Costs: Costs will vary tremendously by organization, depending on the specifics of the electronic system and whether internal programmers, external consultant programmers, or commercially available software are used. Once the system is up and running, ongoing maintenance costs are minimal.
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Funding Sources

Agency for Healthcare Research and Quality; National Library of Medicine; Partners Healthcare System
The Partners Health System, the Division of General Medicine, and the Agency for Healthcare Research and Quality (AHRQ) provided financial support for the development and implementation of the system. The evaluation study was supported by grants from AHRQ and the National Library of Medicine.end fs

Tools and Other Resources

Sample screens from the interface have been published1 and are also available from the innovator.

Adoption Considerations

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Getting Started with This Innovation

  • Seek out leadership support for the program, which is critical to generating the significant level of funding necessary for development and implementation; highlighting the potential for enhanced patient safety and quality can help to sell the idea.
  • Make sure the system is compatible with the electronic health record (the existence of which is a prerequisite to developing and using this system), and that all laboratories and other testing facilities can communicate test results to individual practices electronically.
  • Use skilled IT staff members to handle programming and ongoing maintenance.
  • Begin by developing a user interface, and then work backwards to build the results reporting system to fit the electronic health record.
  • Seek the input of would-be users frequently during the development process to make sure that the resulting system adequately meets user needs and fits into existing workflows.

Sustaining This Innovation

  • Encourage early adopters to engage in "word-of-mouth" dialogue about the system. If early adopters use it, like it, and start talking about it, then eventually other physicians will try it as well. Formal presentations and education can help get the early adopters on board, and then provider use should escalate from there.
  • Program any new laboratory tests into the system as they are developed.
  • Invest in ongoing training/ongoing support of users to encourage and sustain use of the system.

Use By Other Organizations

  • The Results Manager is specific to Partners HealthCare System, although several commercially available electronic health records provide similar results reporting functionality.

More Information

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Contact the Innovator

Eric G. Poon, MD, MPH
Division of General Medicine
Brigham and Women’s Hospital
Harvard Medical School
1620 Tremont Street
Boston, MA 02120
E-mail: epoon@partners.org

References/Related Articles

Matheny ME, Gandhi TK, Orav EJ, et al. Impact of an automated test results management system on patients’ satisfaction about test result communication. Arch Intern Med. 2007;167(20):2233-9. [PubMed]

Poon EG, Wang SJ, Gandhi TK, et al. Design and implementation of a comprehensive outpatient Results Manager. J Biomed Inform. 2003;36(1-2):80-91. [PubMed]

Footnotes

1 Matheny ME, Gandhi TK, Orav EJ, et al. Impact of an automated test results management system on patients' satisfaction about test result communication. Arch Intern Med. 2007;167(20):2233-9. [PubMed]
2 Boohaker EA, Ward RE, Uman JE, et al. Patient notification and follow-up of abnormal test results: a physician survey. Arch Intern Med. 1996;156(3):327-31. [PubMed]
3 Poon EG, Gandhi TK, Sequist TD, et al. "I wish I had seen this test result earlier!" Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164(20):2223-8. [PubMed]
4 Poon EG, Haas JS, Louise Puopolo A, et al. Communication factors in the follow-up of abnormal mammograms. J Gen Intern Med. 2004;19(4):316-23. [PubMed]
5 Baldwin DM, Quintela J, Duclos C, et al. Patient preferences for notification of normal laboratory test results: a report from the ASIPS Collaborative. BMC Fam Pract. 2005;6(1):11. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 20, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.