Improving Laboratory Monitoring in Community Practices: A Randomized Trial

Medication errors and preventable adverse drug events (ADEs) occur commonly among patients in the ambulatory setting, and constitute an important target for patient safety and quality improvement. Laboratory monitoring to ensure the safety and effectiveness of drug therapy and the timely management of abnormal results of laboratory testing has been increasingly recognized as an important way to improve patient safety in ambulatory care. Promising interventions have been developed for practices affiliated with hospitals and integrated delivery systems, but efforts to date have not adequately reached solo physicians practicing solo or in small community practices.

This project was designed to assess clinical decision support (CDS) point-of-care alerts and evaluate a results management system to address barriers to and facilitators of laboratory monitoring. The study used a widely used and commercially available electronic health record (EHR) that allowed findings to be generalized to other settings that use the same EHR. The project included a qualitative analysis of the barriers and facilitators of laboratory monitoring and timely followup of abnormal results among clinicians in ambulatory primary care practices. This information was used to develop, implement, and evaluate computerized alerts to facilitate indicated laboratory monitoring of medications at initiation or continuation of therapy.

The specific aims of the project were to:

• Identify the barriers to and facilitators of laboratory monitoring and timely followup of abnormal results.
• Design, implement, and evaluate clinical decision support (point-of-care alerts) for laboratory monitoring in a widely used, commercially available EHR that address the barriers to and facilitators of laboratory monitoring.
• Design, implement, and evaluate a results management system for the timely handling of abnormal laboratory test results in ambulatory care.
• Develop a detailed dissemination guide that will be made widely available to other practices and communities interested in implementing the same or similar interventions.         

An evaluation of the impact of the CDS alerts found a decrease from 70.7 to 62.4 percent in appropriate monitoring of drug therapy of medications in control practices; and from 79.4 to 77.7 percent of medications in intervention practices. Although adherence to laboratory monitoring recommendations decreased over time in both groups, this was less pronounced for the intervention group than the control group, suggesting that the intervention may have had a positive effect. Based on these findings it appears that future interventions may need to target both patients and clinicians to improve the complex behavior of laboratory medications monitoring.

For the evaluation of the results management system, the number of laboratory results posted to the portal decreased over time from 30 to 17 percent of all notifications, and the proportion of patients who logged into the system decreased over time. Despite these observations, preliminary analysis from a single pediatric practice showed that after portal adoption there was a 9 percent increase from 54 to 63 percent in laboratory results notifications made within 30 days through all forms of communication. These preliminary data suggest that a large fraction of patients may prefer to have their results communicated by telephone rather than a patient portal. However, while patient portal use decreased over time, those patients who did use the portal were notified more quickly. Therefore, when implementing a portal, understanding patient preferences for test notification will improve timely results management.