How context affects electronic health record-based test result follow-up: a mixed-methods evaluation.
OBJECTIVE
Electronic health record (EHR)-based alerts can facilitate transmission of test results to healthcare providers, helping ensure timely and appropriate follow-up. However, failure to follow-up on abnormal test results (missed test results) persists in EHR-enabled healthcare settings. We aimed to identify contextual factors associated with facility-level variation in missed test results within the Veterans Affairs (VA) health system.


METHODS
Based on a previous survey, we categorised VA facilities according to primary care providers' (PCPs') perceptions of low (n=20) versus high (n=20) risk of missed test results. We interviewed facility representatives to collect data on several contextual factors derived from a sociotechnical conceptual model of safe and effective EHR use. We compared these factors between facilities categorised as low and high perceived risk, adjusting for structural characteristics.


RESULTS
Facilities with low perceived risk were significantly more likely to use specific strategies to prevent alerts from being lost to follow-up (p=0.0114). Qualitative analysis identified three high-risk scenarios for missed test results: alerts on tests ordered by trainees, alerts 'handed off' to another covering clinician (surrogate clinician), and alerts on patients not assigned in the EHR to a PCP. Test result management policies and procedures to address these high-risk situations varied considerably across facilities.


CONCLUSIONS
Our study identified several scenarios that pose a higher risk for missed test results in EHR-based healthcare systems. In addition to implementing provider-level strategies to prevent missed test results, healthcare organisations should consider implementing monitoring systems to track missed test results.
Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA.
Shailaja
S
Menon
Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA.
Michael W
MW
Smith
Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA.
Dean F
http://orcid.org/0000-0001-5811-8915
DF
Sittig
University of Texas School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas, USA.
Nancy J
NJ
Petersen
Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA.
Sylvia J
SJ
Hysong
Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA.
Donna
D
Espadas
Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA.
Varsha
V
Modi
Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA.
Hardeep
H
Singh
D003955:Diagnostic Tests, Routine; D057286:Electronic Health Records; D005500:Follow-Up Studies; D006801:Humans; D059012:Lost to Follow-Up; D011795:Surveys and Questionnaires
Diagnostic Errors; Elecronic Health Records; Missed Test Results; Patient Follow-up; Patient Safety; Social-Technical Model