Decision Making and Clinical Work of Test Result Followup in Health Information Technology Settings

A significant number of patients with abnormal test results “fall through the cracks” of the healthcare system and experience delays in diagnosis and treatment. Although electronic health records (EHRs) expedite the communication of abnormal test results, they do not guarantee the prompt followup that is required for timely care. The researchers’ previous work indicated that followup for abnormal tests is influenced by a multitude of technological and non-technological factors such as user behaviors, workflow, information load, policies and procedures, and training. Improving test result followup requires a better understanding of how followup processes fit within the complex “socio-technical” context of EHR-enabled healthcare.

Guided by a human factors-based conceptual model, this project conducted cognitive task-analysis among providers who ordered tests at four clinical sites. Structured observations, brief surveys, and key informant interviews were used to understand result followup in EHR-based systems. Finally, the team conducted a socio-technical risk assessment of factors that impact EHR-based test result followup.

The specific aims of the project were as follows:

• Understand the cognitive factors that affect the task of test result followup by individuals and teams in EHR-based health systems. 
• Understand the nature of clinical work related to EHR-based test result followup in the sociotechnical context of health information technology (IT)-enabled outpatient settings. 
• Conduct prospective risk assessments to characterize socio-technical contextual factors that present risks to appropriateness and timeliness of abnormal test result followup in EHR-enabled healthcare systems. 

The project team found that a broad range of socio-technical factors may lead to delays in abnormal test result followup. Barriers to test followup were identified throughout the testing process and most frequently occur at steps involving health IT, including usability of the EHR by clinicians, and communication interfaces between the EHR and diagnostic services. Personnel training, workflow optimization and standardization, and improved electronic communication between clinics and diagnostic services were identified as facilitators for test followup. The researchers concluded that in clinical workflow there is a need for dedicated personnel for lab results followup. In EHRs, there is a need for decreasing alert load, implementing EHR designs to facilitate followup, and improving patient engagement.