Ten Strategies to Improve Management of Abnormal Test Result Alerts in the Electronic Health Record

Abstract

Missed abnormal test results are a significant patient safety problem, especially in the outpatient setting. Failure to communicate and follow up on abnormal diagnostic test results can lead to diagnostic errors, adverse events, and liability claims.1–4 Automated alert notification systems integrated within electronic health records (EHRs) offer a potential solution.5, 6 For instance, communication of abnormal clinical information through “alerts” (computerized notifications of significantly abnormal or critical test results) can potentially facilitate rapid review of patient information.7 The Computerized Patient Record System (CPRS), an integrated EHR used at all Veterans Affairs (VA) facilities, uses an automated notification system (the View Alert system) to communicate abnormal diagnostic test results (Figure 1). Despite this automated notification system, we recently found that 7% of abnormal outpatient laboratory results and 8% of abnormal imaging results lacked follow-up within 30 days.8, 9 Therefore, electronic alerts do not eliminate the problem of missed results. We also found that clinicians did not acknowledge 18% of diagnostic imaging alerts and 10% of diagnostic lab alerts. Some clinicians received an overwhelming number of alerts (e.g., > 50 per day), some of which they never reviewed. Many clinicians had inconsistent knowledge of specific features in the EHR to help manage alerts. Figure 1 The View Alert Notification window of the VA’s electronic health record Improving critical test result reporting is a national patient safety goal of the Joint Commission.10 Additionally, the VA recently released a directive emphasizing timeliness of test result communication to practitioners and patients and further recommended that each VA facility address ordering and reporting test results.11 Based on our ongoing quantitative and qualitative evaluation work, we have identified ten strategies that clinicians can use immediately to improve their management of automated notifications related to abnormal test results. We identified these strategies on the basis of two chart review studies,9, 12 a focus group study,13 and in-depth task analysis sessions14 that we conducted over the course of a 2-year project funded by the VA National Center for Patient Safety. Subsequently, we obtained informal feedback from numerous primary care physicians who agreed that adoption of these strategies could help them manage alerts more reliably and effectively. Consistent with our recently proposed model for safe EHR use,15 the strategies are divided into three groups: clinician (user) centered, human-computer interface centered and communication and workflow centered.