Goldman RE, Soran CS, Hayward GL, et al. "Doctors' perceptions of laboratory monitoring in office practice."

Goldman RE, Soran CS, Hayward GL, et al. Doctors' perceptions of laboratory monitoring in office practice. J Eval Clin Pract 2010 Dec;16(6):1136-41.
Background: Laboratory monitoring has been increasingly recognized as an important area for improving patient safety in ambulatory care. Little is known about doctors' attitudes towards laboratory monitoring and potential ways to improve it. Methods: Six focus groups and one individual interview with 20 primary care doctors and nine specialists from three Massachusetts communities. Results: Participants viewed laboratory monitoring as a critical, time‐consuming task integral to their practice of medicine. Most believed they commit few laboratory monitoring errors and were surprised at the error rates reported in the literature. They listed various barriers to monitoring, including not knowing which doctor was responsible for ensuring the completion of laboratory monitoring, uncertainty regarding the necessity of monitoring, lack of alerts/reminders and patient non‐adherence with recommended monitoring. The primary facilitator of monitoring was ordering laboratory tests while the patient is in the office. Primary care doctors felt more strongly than specialists that computerized alerts could improve laboratory monitoring. Participants wanted to individualize alerts for their practices and warned that alerts must not interrupt workflow or require too many clicks. Conclusions: Doctors in community practice recognized the potential of computerized alerts to enhance their monitoring protocols for some medications. They viewed patient non‐adherence as a barrier to optimal monitoring. Interventions to improve laboratory monitoring should address doctor workflow issues, in addition to patients' awareness of the importance of fulfilling recommended therapeutic monitoring to prevent adverse drug events.

To characterize doctors' perceptions of the barriers to and facilitators of laboratory monitoring in the office practice setting.

Tools Used
Type Clinic
Primary care and specialty care
not applicable
Other Information
Practices are in three different communities in Massachusetts.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
Computerized alerts built into the EHR system to facilitate laboratory monitoring.
Context or other IT in place
All sites using an EHR from the same vendor.
Workflow-Related Findings
Doctors have developed office and workflow systems to increase the likelihood that patients in their practices undergo recommended monitoring. Some require patients to come into the office to obtain refill prescriptions every few months.
All participants had experienced EHR alert systems that they found to be annoying and cumbersome. Some alerts arose too frequently and, in effect, desensitized the doctors into ignoring them. This often occurred when the doctor made a decision to treat a patient in a way that varied from the standard protocol. Most participants were concerned about the number of clicks that
would be necessary to address the alert. As one doctor commented: "For some things we have in [our EHR] now, it takes me seven clicks, and that’s terribly redundant. You really lose time." Some wanted to be able to order the relevant laboratory test whenever the alert appears, as long as it could be done with a minimum of clicks, although others did not want to be distracted from the task in which they were already engaged.
Doctors noted that some existing alerts provide too much information and take too long to read and address. Participants wanted alerts to be parsimonious, with the option of clicking to open a window with more detailed information regarding the need for laboratory monitoring for the particular medication. Participants were almost unanimous in their rejection of alerts that block their system until the alert is acted upon. However, they felt equally strongly that doctors should not be given the option to turn off the alert. An ideal system, according to participants, would provide a balance between these competing tensions: it would not promote alert fatigue; it would provide critical information in a timely and efficient way to allow the doctor to address the issues quickly and easily; it would not require having to open too many additional windows; and it would not divert the doctor far from the original task at hand.
Study Design
Only postintervention (no control group)
Study Participants
Total of 29 physicians participated: 20 internal medicine or family medicine and 9 specialists.