Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?
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.
Department of Veterans Affairs Health Services Research & Development Service, Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA. hardeeps@bcm.tmc.edu
Hardeep
H
Singh
Eric J
EJ
Thomas
Shrinidi
S
Mani
Dean
D
Sittig
Harvinder
H
Arora
Donna
D
Espadas
Myrna M
MM
Khan
Laura A
LA
Petersen
D003142:Communication; D003266:Continuity of Patient Care; D003952:Diagnostic Imaging; D006787:Hospitals, Veterans; D006801:Humans; D016347:Medical Records Systems, Computerized; D010044:Outpatient Clinics, Hospital; D010818:Practice Patterns, Physicians'; D017064:Process Assessment, Health Care; D011871:Radiology / Q000379:methods; D017010:Reminder Systems; D012189:Retrospective Studies; D013997:Time Factors