Decision Making and Clinical Work of Test Result Follow-up in Health Information Technology Settings (Texas)

A significant number of patients with abnormal test results “fall through the cracks” of the health care 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 at the Veterans Health Administration (VHA) revealed that almost 8 percent of abnormal outpatient test results transmitted as EHR-based alerts lacked followup at 4 weeks, and that followup of abnormal tests is influenced by a multitude of technological (software/hardware) and non-technological (user behaviors, workflow, information load, policies and procedures, training, etc.) factors. Improving test result followup will require a better understanding of how followup processes fit within the complex “socio-technical” context of EHR-enabled health care.

It is especially important to clarify how these contextual features influence the cognitive processes that are necessary to perceive, comprehend, and act on abnormal findings in a timely manner. Because laboratory test result reporting is a Stage 2 Meaningful Use criterion of the Centers for Medicare & Medicaid Services EHR Incentive Program, further exploration of vulnerabilities in EHR-based test result followup is imperative. This project will apply human factors-based frameworks to understand system and cognitive vulnerabilities that affect EHR-based outpatient test result followup.         

The specific aims of the project are to:

• 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-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 health care systems.

The researchers will conduct a mixed-methods study in three non-VHA settings where established EHRs are used for test result communication and followup. For the first aim, they will conduct retrospective record reviews to identify abnormal test results with and without timely followup and assess potential risk factors using automated process measures and cognitive task analysis. For the second aim, they will characterize the nature of work related to EHR- based test result followup through usability analysis and multiple qualitative assessment methods. For the third aim, they will conduct prospective risk assessments to identify key risk determinants that influence EHR-based test result followup.