CPOE could signal last orders for unread test results

Almost half of all test results ordered on the day of discharge from hospital are not reviewed, even when using a computerised test-reporting system, new Australian research shows.

In a study of a 370-bed metropolitan teaching hospital that used such a system, researchers from the Centre for Health Informatics at the Australian Institute of Health Innovation at the University of NSW found that of the tests ordered on the day of discharge, 46.8 per cent were not reviewed at discharge and 41.1 per cent had still not been read two months later.

The study, published in the Archives of Internal Medicine this week, found that while tests ordered on the day of discharge represented less than seven per cent of all tests performed, they contributed disproportionately to the total number of tests that were not followed up.

The prevalence of missed laboratory tests was determined by inspecting electronic time stamps that were generated when the tests were viewed and was calculated as the proportion of tests that were not reviewed at patient discharge or two months after discharge.

Study co-author Enrico Coiera, director of the Centre for Health Informatics, said earlier planning for discharge and better communication between members of the clinical team in charge of the patient would help solve the problem.

“That is the core message – better discharge planning and co-ordination seems the key to fixing this,” Professor Coiera said.

While some computerised test-reporting systems have the ability to send electronic alerts to doctors when results are available, Professor Coiera said there was a risk in this practice when many test results come in every day.

“Alert fatigue could make this a non-optimal solution unless well designed,” he said.

The system used at the study hospital did have the capability to alert the pathologist that test results hadn't been read, but Professor Coiera said this may not be a useful way to fix the problem.

“It is many thousands of tests we are talking about … and the lab already calls doctors when extreme results are found,” he said.

In addition to better and earlier discharge planning, Professor Coiera said a potential measure to solve the problem could be a computerised physician order entry (CPOE) system that flags a patient's discharge date when a test is ordered.

“The CPOE could generate a weekly list to clinical teams of discharged patients with new results, and one day the GP will be able to log on to the hospital system and check for themselves when the patient returns to the community,” he said.

“The remedies will vary with different hospitals and their local communities – the story in health is that one size never fits all.”

He said hospitals should perhaps list all test orders and results on their discharge summaries, including those with results still pending at the time of report.

Giving a copy of the discharge summary to the patient as well as the GP might also assist, and electronic discharge summaries would improve this even more. "The GP is in a great place to be the safety net and follow up on incomplete tests results post-discharge, and electronically is the way to do that,” he said.

"When we do eventually have a truly interoperable national eHealth record system, then a GP will be able to log onto a hospital record system and look at the test results of their patients, making this problem potentially disappear. In the mean time, these other fixes should make a big dent in the problem."

Posted in Australian eHealth

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