title: Developing software to "track and catch" missed follow-up of abnormal test results in a complex sociotechnical environment.
abstract: BACKGROUND
  Abnormal test results do not always receive timely follow-up, even when providers are notified through electronic health record (EHR)-based alerts. High workload, alert fatigue, and other demands on attention disrupt a provider's prospective memory for tasks required to initiate follow-up. Thus, EHR-based tracking and reminding functionalities are needed to improve follow-up.
  
  
  OBJECTIVE
  The purpose of this study was to develop a decision-support software prototype enabling individual and system-wide tracking of abnormal test result alerts lacking follow-up, and to conduct formative evaluations, including usability testing.
  
  
  METHODS
  We developed a working prototype software system, the Alert Watch And Response Engine (AWARE), to detect abnormal test result alerts lacking documented follow-up, and to present context-specific reminders to providers. Development and testing took place within the VA's EHR and focused on four cancer-related abnormal test results. Design concepts emphasized mitigating the effects of high workload and alert fatigue while being minimally intrusive. We conducted a multifaceted formative evaluation of the software, addressing fit within the larger socio-technical system. Evaluations included usability testing with the prototype and interview questions about organizational and workflow factors. Participants included 23 physicians, 9 clinical information technology specialists, and 8 quality/safety managers.
  
  
  RESULTS
  Evaluation results indicated that our software prototype fit within the technical environment and clinical workflow, and physicians were able to use it successfully. Quality/safety managers reported that the tool would be useful in future quality assurance activities to detect patients who lack documented follow-up. Additionally, we successfully installed the software on the local facility's "test" EHR system, thus demonstrating technical compatibility.
  
  
  CONCLUSIONS
  To address the factors involved in missed test results, we developed a software prototype to account for technical, usability, organizational, and workflow needs. Our evaluation has shown the feasibility of the prototype as a means of facilitating better follow-up for cancer-related abnormal test results.
authors.affiliation: Houston VA HSR&D Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine , Houston, Texas.
authors.forename: M
authors.initials: M
authors.lastname: Smith
authors.forename: D
authors.initials: D
authors.lastname: Murphy
authors.forename: A
authors.initials: A
authors.lastname: Laxmisan
authors.forename: D
authors.initials: D
authors.lastname: Sittig
authors.forename: B
authors.initials: B
authors.lastname: Reis
authors.forename: A
authors.initials: A
authors.lastname: Esquivel
authors.forename: H
authors.initials: H
authors.lastname: Singh
mesh_terms: D020000:Decision Support Systems, Clinical / Q000458:organization & administration / Q000706:statistics & numerical data; D057286:Electronic Health Records; D005500:Follow-Up Studies; D006801:Humans; D009369:Neoplasms / Q000175:diagnosis; D012984:Software; D057188:Workflow
keywords: Diagnostic errors; care delays; health information technology; patient safety; test results