professor andrew georgiou - macquarie university
TRANSCRIPT
Ensuring the quality and safety
of laboratory test result
communication, management
and follow-upProfessor Andrew Georgiou9 December 2016, National Pathology Forum, Sydney
Centre for Health Systems and Safety Research
Australian Institute of Health Innovation
Centre for Health Systems and
Safety Research
• Medication Safety and e-Health
• Communication and Work Innovation
• Human Factors & eHealth
• Pathology and Imaging Informatics
• Safety & Integration of Aged and Community Care
Services
• Primary Care Safety and eHealth
Rese
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Outline
1. Backgroundo Patient harm – the scope of the
problem
o What is diagnostic error?
2. Health information technology (IT) and its role in the quality use of pathology
3. Human-computer interaction
4. Safe management and communication of test results
5. Evidence promoting quality use of pathology
6. Patient access to test results
7. NHMRC partnership project
A multitude of health care harms
• 421 million hospitalisations
globally each year of which
there are 42.7 million adverse
events (Jha et al. 2013)
• >12 million US patients each
year experience a diagnostic
error in outpatient care (Singh
et al. 2014)
• Australians receive
“appropriate” care in only
57% of consultations
(Runciman et al. 2012)
What is a diagnostic error?
“… the failure to (a)
establish an accurate and
timely explanation of the
patient’s health problem(s)
or (b) communicate that
explanation to the patient.”
(Committee on Diagnostic Error in Health Care, Institute of
Medicine, 2015)
The diagnostic process
(Committee on Diagnostic Error in Health Care, Institute of Medicine, 2015)
Health information
technology (IT) initiatives*
• Tools to assist in information gathering
• Support for intelligent selection of tests
• Tools to aid result reporting
o Track pending results
o Result alerts
o Test result acknowledgement
o Auditable trail of follow-up
• Enhanced diagnostic reference material
and guidelines
• Facilitation of feedback and insight into
diagnostic performance
*El-Kareh et al. BMJ Qual & Saf 2013
Department of Health - Quality Use of
Pathology Program grant
Vecellio E, Ling L, Georgiou A, Eigenstetter A,
Gibson-Roy C, Cobain T, Golding M, Wilson R,
Lindeman R, Westbrook JI (2015)
http://aihi.mq.edu.au/project/variation-hospital-
pathology-investigations
Georgiou A, Vecellio E, Toouli G, Eigenstetter A,
Ling L, Wilson RWestbrook JI (2012)
http://www.aims.org.au/documents/item/295
Types of pre-analytical errors
• Mislabelled specimen
• Mismatched specimen
• Specimen suitability
• Leaking specimen
• Accident to specimen
• Insufficient specimen
Incident Information Management
System (IIMS) reported errors
EMR Paper
Mislabelled specimen0.1
(n=39)
0.31
(n=56)p<.001
Mismatched specimen0.49
(n=200)
1.42
(n=255)p<.001
Unlabelled specimen1.37
(n=559)
1.65
(n=296)p<.01
Georgiou et al. Impact of the implementation of electronic ordering on hospital pathology services, 2012
Impact of the EMR on repeat
laboratory test ordering
13
Age ICU Time interval Paper
% (95% CI)
E lectronic ordering
% (95% CI)
p-value
<1 year Yes ≤ one-hour 3.0 (2.7-3.3) 0.4 (0.2-0.6) <0.0001
≤ 24-hours 54.2 (53.3-55.0) 35.3 (33.9-36.6) <0.0001
14
Age ICU Time interval Paper
% (95% CI)
Electronic ordering
% (95% CI)
p-value
≥1 year Yes ≤ one-hour 2.2 (1.8-2.5) 0.9 (0.6-1.2) <0.0001
≤ 24-hours 55.2 (53.9-56.5) 47.2 (45.4-48.9) <0.0001
ECRI TOP TEN patient safety
concerns for 2016
• Health IT
configurations and
organisation workflow
that do not support
each other
• Inadequate test result
reporting and follow-
up
What are health professionals
concerned about?
Aller R, Georgiou A, Pantanowitz L, Electronic Health Records
Missed test results
• Critical safety issue – increases
the risk of missed or delayed
diagnoses World Alliance for Patient Safety, WHO, 2008; Schiff, 2006
• Clinicians are concerned that their
test management practices are
not systematic Poon et al. Arch Int Med 2004
• Medico-legal concerns Berlin, AJR, 2009
• Impact on patient outcomes Roy et al. Ann Intern Med, 2005
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
How many results are
missed for hospital patients?
• Hospital inpatients20% - 62% of tests are
missed
• ED patients (discharged)
1% - 75% of tests are
missed
Callen et al. BMJ Qual Saf 2011;20;194-199
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Clinical Excellence Commission
(NSW) incidence analysis*
11% (3/27) of reported
clinical incidents resulting in
serious harm (e.g., pt. death)
and 32% (24/75) of clinical
incidents with major pt.
consequences were related
to poor test result follow-up
practices.
*Clinical Excellence Commission, Clinical Focus Report 2012 Sydney, NSW, Australia
The management and communication of high risk
laboratory results – consensus statement of the RCPA and
AACB Working Party for High Risk Results
• Laboratory should compile an alert list in
consultation with users
• There should be procedures to ensure that high risk
results are reliably identified
• There should be agreement about the modes of
transmission of high risk results
• There should be a list of users authorised to receive
the results
• There should be a definition about the data to be
communicated
• There should be a system for the acknowledgement
of receipt of results
• Every high risk result notification should be
appropriately documented
• Procedures for maintaining and monitoring the
outcomes of these practices
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
• Mater Mothers’ Hospital (Brisbane)
• 249 beds
• 9525 births; 15,246 inpatient discharges;
66,667 outpatient encounters (2011)
• IP Health Verdi software which allowed
clinicians to electronically document
review and acknowledgement of test
results (2010)
• Hospital data (Aug ’11 – Aug ‘12) involving
27,354 inpatient tests for 6855 patients
*Georgiou et al. J Am Med Inform Ass (2014)
An electronic safety net to
enhance test result management*
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Test result acknowledgement
• All test results were acknowledged
• Longest acknowledgement took nearly 38 days for imaging
• 60% of lab and 44% of imaging results acknowledged
within 24h
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
• Registrars perform the most
acknowledgments
• Median time between report
availability and
acknowledgement 18.1h (lab),1
day 18h (imaging)
• % of acknowledgement >3 days
was highest on Fridays (34.4%
lab and 63.4% for imaging)
Who acknowledges, when?
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Patient access to information
• Patient access to information –
essential element of effective health
care (Al-Shorbaji 2013)
• Electronic patient portals connected
to the hospital EMR
• Secure on-line access
• Access to appointments, test
results, clinical information and to
clinicians
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Study methods
Cross sectional survey* of senior emergency physicians (61/89) at 2 metropolitan teaching hospitals in Sydney.
Significantly abnormal results – not life threatening but need short-term
follow-up (e.g., chest x-ray with new shadow, abnormal PSA)
Automatic patient notification methods– Patient portal, Email, SMS, fax, mail or
phone
*Callen et al. Journal of Medical Internet Research 2015; e60
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
In my practice there are standardised
policies and procedures for
notification of abnormal test results
75
12
13
Standard policies and procedures (%)
Agree
Disagree
Neither
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Perceptions of missed test
results
19.2
26.9
53.9
In the past year I have missed an abnormal result that led to delayed
patient care
Yes (%)
No (%)
Don't know (%)
38.5
11.5
50
In the past year a colleague has missed an abnormal results that
led to delayed patient care
Yes (%)
No (%)
Don't know (%)
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Who is responsible for notifying
the patient of a test result?
65 65
43
35
3
15
0
32
42
0
10
20
30
40
50
60
70
Doctor who ordered thetest
Primary care doctor It is not always clear whoshould notify patients
Agree (%)
Disagree (%)
Neither agree nor disagree (%)
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Are you comfortable with
patients receiving direct
notification of test results
(%)?
39
54
7
Yes
No
Don't know
Main concerns regarding direct
notification of results to
patients
85
92 90
15
8 10
0
20
40
60
80
100
Patient anxiety about
test result
Patient confusion
about test result
Patient lacks
expertise to interpret
result
Yes (%)
No (%)
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Delivering safe and effective test result
communication, management and follow-up
• National Health & Medical Research Council
partnership grant (APP1111925)
• Partners:
• South Eastern Area Laboratory Services
• Australian Commission on Safety and
Quality in Health Care
• Royal College of Pathologists of
Australasia (Pathology Information,
Terminology and Units Standardisation)
• Health Consumers NSW
• Australian Association of Clinical
Biochemists
• Centre for Health Systems & Safety
Research, Australian Institute of Health
Innovation, Macquarie University
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES
Aims of the project
Establishment of effective test result
management systems in hospitals• Clear processes of communication, responsibility and
accountability
• Guidelines and standards for safe test result follow-up
Harnessing health information
technologies (IT)
• Informing and monitoring test result management
Enhancing the contribution of consumers
• What do consumers want?
• Establishing patient-centred health care
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION
FACULTY OF MEDICINE AND HEALTH SCIENCES