Improving Management of Test Results that Return After Hospital Discharge (Indiana)

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Summary:

Many patients discharged from a hospital with pending test results experience medical errors. These errors occur because pending tests are often not communicated to the followup provider, and systems to manage results are generally suboptimal. Discharge summaries – the primary mode of inpatient-to-outpatient communication – infrequently mention pending tests, and those that do contain inaccuracies and inadequacies. Outpatient providers report being unaware of up to 60 percent of results that require a change in patient management, and are dissatisfied with existing systems to follow results. While the problems related to poor management of test results returning after hospital discharge are widely acknowledged, little has been done to implement and evaluate interventions to improve existing systems.

This project developed, implemented, and evaluated the impact of a computerized tool to automatically identify tests with pending results at hospital discharge, and assist in communicating those to followup providers through the hospital discharge summary. A copy of the pending tests can be printed and given to patients for outpatient appointments. In addition, this project created a modification to an existing clinical messaging tool so that results of pending tests were automatically delivered to followup providers.

The specific aims of this project were to:

  • Develop and implement a computerized tool to automatically identify tests with pending results at hospital discharge and assist in the incorporation of these tests into the discharge summary. 
  • Evaluate the impact of this tool on accuracy of documenting pending tests in discharge summaries. 
  • Modify an existing clinical-messaging program to enable automatic delivery of returning results for pending tests to the designated outpatient followup providers. 
  • Evaluate how the automatic delivery of test results impacts followup providers' actions and attitudes. 

The tool was evaluated with a before-and-after time series study. Providers were surveyed on how to identify the responsible provider to manage pending tests. Chart reviewers rated each test result on whether it required a change in patient management and determined if and when appropriate actions were taken in response to each result. Inpatient and outpatient providers were surveyed to assess their attitudes toward their systems for managing test results returning after hospital discharge, and their specific attitudes toward automatic delivery of results.

The project team found that providers did not agree on the responsible provider for pending inpatient tests, and indicated a need for a consensus policy to be developed on this issue. There was a statistically significant increase in documentation of pending tests following implementation of the tool. Surveys indicated that inpatient providers believe that the “tests with pending results” field on the discharge summary impacts the quality of patient care, improves the quality of documenting tests with pending results into discharge summaries, and believe this field should be a permanent part of the discharge summary. Providers who received the results following hospital discharge generally felt that the delivery of the results improved quality of care, decreased errors in care, reduced time searching for results, and that the automatic delivery of results returning after hospital discharge should continue.

Improving Management of Test Results That Return After Hospital Discharge - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS09-085: Mentored Clinical Scientist Research Career Development Award (K08)
  • Grant Number: 
    K08 HS 018539
  • Project Period: 
    October 2009 – September 2013
  • AHRQ Funding Amount: 
    $577,880
  • PDF Version: 
    (PDF, 300.06 KB)

Summary: Hospital patients discharged with pending test results are at risk for medical errors related to missed results for those tests. These errors may arise from poor methods of managing test results and poor communication with followup providers. Discharge summaries, the main mode of in-to-outpatient communication, remain highly inadequate at documenting tests with pending results at discharge. While the problems related to poor management of test results returning after hospital discharge is widely acknowledged, little has been done to implement and evaluate interventions to improve existing systems.

The goal of this project is to improve management of tests with pending results at hospital discharge with two health information technology (IT) interventions. The project team developed the first tool, the Pending Test Processor (PTP), which automatically identifies tests with pending results at hospital discharge and incorporates them into the discharge summary. The second is a modification of the DOCS4DOCS® clinical-messaging tool to deliver results for pending tests automatically to followup providers.

This work is being conducted at Wishard Memorial Hospital (WMH), a 353-bed urban public hospital on the campus of the Indiana University School of Medicine. The first tool was evaluated by a before-and-after time-series study to identify if it increased the percentage of tests with pending results that are mentioned in the discharge summary and increased the number of mentioned pending tests whose results eventually come back as actionable. The study team is evaluating the clinical messaging tool by randomizing returning test results to be delivered automatically to the followup providers using DOCS4DOCS® as soon as the result is available (intervention group), or to be delivered using existing systems of communicating test results (control group). The main outcome of the randomized controlled study will be whether an actionable test has led to an appropriate action by any followup provider after hospital discharge.

Specific Aims:

  • Develop and implement a computerized tool to automatically identify tests with pending results at hospital discharge and assist in the incorporation of these tests into the discharge summary.
    (Achieved)
  • Evaluate the impact of this tool on accuracy of documenting pending tests in discharge summaries. (Achieved)
  • Modify an existing clinical-messaging program to enable automatic delivery of returning results for pending tests to the designated outpatient followup providers. (Achieved)
  • Evaluate how the automatic delivery of test results impacts followup providers' actions and attitudes. (Ongoing)

In addition to these specific research aims, Dr. Were, a recipient of the Mentored Clinical Scientist Research Career Development Award, will continue his long-term career goal of implementing and evaluating informatics-based interventions that improve quality of care and patient safety. Project funds allow him to acquire advanced skills through structured coursework, regular seminars, and mentoring with leaders in medical informatics, health services research, biostatistics, and implementation research.

2012 Activities: Data collection and analysis to evaluate the PTP was completed for 500 discharge summary reviews, each of which was reviewed by two people to ensure reliability of abstraction. The team developed a manuscript summarizing the study results, which was published in Applied Clinical Informatics. Three more manuscripts are in development.

Dr. Were and his team successfully modified the PTP system and the DOCS4DOCS® tool to enable automatic delivery of returning results for pending tests to the designated outpatient followup providers. The team also began the randomized controlled trial to evaluate the tool’s ability to improve management of test results returning after hospital discharge.

Preliminary Impact and Findings: The analysis showed that documentation of all tests with pending results significantly improved from 12 percent before to 22 percent after implementation, and documentation of tests with eventual actionable results increased from 0 to 50 percent.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Improving Management of Test Results that Return After Hospital Discharge - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS09-085: Mentored Clinical Scientist Research Career Development Award (K08)
  • Grant Number: 
    K08 HS 018539
  • Project Period: 
    October 2009 - September 2013
  • AHRQ Funding Amount: 
    $577,880
  • PDF Version: 
    (PDF, 172.53 KB)

Summary: Hospital patients discharged with pending test results are at risk for medical errors related to missed results for those tests. These errors may arise from poor methods of managing test results and poor communication with followup providers. Discharge summaries, the main mode of inpatient-to-outpatient communication, remain highly inadequate at documenting tests with pending results at discharge. While the problems related to poor management of test results returning after hospital discharge is widely acknowledged, little has been done to implement and evaluate interventions to improve existing systems.

This project is implementing and evaluating two health information technology (IT) interventions aimed at improving management of tests with pending results at hospital discharge. The first is a tool, the Pending Test Processor (PTP), which automatically identifies tests with pending results at hospital discharge and incorporates these tests into the discharge summary. The second is a modification of the DOCS4DOCS(R) clinical-messaging tool to deliver results for pending tests to follow-up providers automatically.

This work is being conducted at Wishard Memorial Hospital (WMH), a 353-bed urban public hospital on the campus of Indiana University School of Medicine. WMH uses the Regenstrief Medical Record System (RMRS) integrated with the Regenstrief-developed Gopher computerized provider order entry system. All inpatient orders and discharge summaries must be entered electronically via Gopher. The newly-developed tool will deliver pending results to providers through the Gopher system. Dr. Were and his team are using a combination of methods to discern the specific effects of each technology on processes of care.

Specific Aims:

  • Develop and implement a computerized tool to automatically identify tests with pending results at hospital discharge and assist in the incorporation of these tests into the discharge summary. (Achieved)
  • Evaluate the impact of this tool on accuracy of documenting pending tests in discharge summaries. (Ongoing)
  • Modify an existing clinical-messaging program to enable automatic delivery of returning results for pending tests to the designated outpatient followup providers. (Ongoing)
  • Evaluate how the automatic delivery of test results impacts followup providers' actions and attitudes. (Upcoming)

In addition to these specific research aims, Dr. Were, as part of the Mentored Clinical Scientist Research Career Development Award, will continue his long-term career goal of implementing and evaluating informatics-based interventions that improve quality of care and patient safety. Project funds allow him to acquire advanced skills through structured coursework, regular seminars, and mentoring with leaders in medical informatics, health services research, biostatistics, and implementation research.

2011 Activities: Dr. Were and the project team completed a randomized study to evaluate the impact of PTP on documentation of tests with pending results into hospital discharge summaries. This system is programmed to allow the Gopher system to send an HL7 trigger message to the PTP when a discharging provider signs the electronic discharge summary. Upon receiving this trigger message, the PTP identifies tests with pending results by querying the RMRS database. The tests identified through the queries are then delivered via Gopher back to the discharging provider. Data collection and analysis has been completed for 500 discharge summary reviews, each of which was reviewed by two people to ensure reliability of abstraction. The team began to develop the manuscript summarizing the study results.

Dr. Were and his team are currently modifying the PTP system and the DOCS4DOCS(R) tool to enable automatic delivery of returning results for pending tests to the designated outpatient followup providers, with the goal to complete by June 2012. Once the programming on the DOCS4DOCS(R) tool modification is complete, the team will begin the randomized controlled trial to evaluate the tool's ability to improve management of test results returning after hospital discharge.

Preliminary Impact and Findings: Manuscript preparation summarizing findings from the evaluation of the PTP tool on documentation of tests with pending results into the discharge summaries are ongoing.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Improving Management of Test Results that Return After Hospital Discharge - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS09-085: Mentored Clinical Scientist Research Career Development Award (K08)
  • Grant Number: 
    K08 HS 018539
  • Project Period: 
    October 2009 – September 2013
  • AHRQ Funding Amount: 
    $577,880
  • PDF Version: 
    (PDF, 303.3 KB)


Target Population: Adults

Summary: Nearly half of the hospital patients discharged with pending test results experience medical errors related to missed results for those tests. These errors largely arise from poor methods of managing test results and poor communication with the followup providers. Discharge summaries, the main mode of inpatient-to-outpatient communication, remain highly inadequate at documenting tests with pending results at discharge. While the problems related to poor management of test results returning after hospital discharge is widely acknowledged, little has been done to implement and evaluate interventions to improve existing systems.

This project will implement and evaluate two health information technology interventions aimed at improving management of tests with pending results at hospital discharge. The first is a tool to automatically identify tests with pending results at hospital discharge and assist in incorporating these tests into the discharge summary. The second is a modification of an existing clinical-messaging tool (DOCS4DOCS®) to automatically deliver results for pending tests to the followup providers.

This work will be conducted at Wishard Memorial Hospital (WMH), a 353-bed urban public hospital on the campus of Indiana University School of Medicine. WMH uses the Regenstrief Medical Record System (RMRS) integrated with the Regenstrief-developed Gopher computerized provider order entry (CPOE) system. All inpatient orders and discharge summaries must be entered electronically via Gopher. The newly-developed tool will deliver pending results to providers through the Gopher CPOE system. Dr. Were and his team will use a combination of randomized controlled studies and surveys to discern the specific effects of each technology on processes of care.

Specific Aims:
  • Develop and implement a computerized tool to automatically identify tests with pending results at hospital discharge and assist in the incorporation of these tests into the discharge summary. (Achieved)
  • Evaluate the impact of this tool on accuracy of documenting pending tests in discharge summaries (Ongoing)
  • Modify an existing clinical-messaging program to enable automatic delivery of returning results for pending tests to the designated outpatient followup providers. (Upcoming)
  • Evaluate how the automatic delivery of test results impacts followup providers’ actions and attitudes. (Upcoming)

In addition to these specific research aims, Dr. Were, as part of the Mentored Clinical Scientist Research Career Development Award, will continue his long-term career goal of implementing and evaluating informatics-based interventions that improve quality of care and patient safety. Project funds allow him to acquire advanced skills through structured coursework, regular seminars, and mentoring with leaders in medical informatics, health services research, biostatistics, and implementation research.

2010 Activities: The project team completed Java-language programming of the processor, called the Pending Test Processor (PTP), which incorporates pending tests into the electronically-prepared discharge summaries. This system is programmed to allow the Gopher CPOE system to send an HL7 trigger message to the PTP when a discharging provider signs the electronic discharge summary. Upon receiving this trigger message, the PTP identifies tests with pending results by querying the RMRS database. The tests identified through the queries are then delivered via Gopher back to the discharging provider, who can select tests for inclusion in the discharge summary. A study to evaluate the impact of this tool is underway.

Preliminary Impact and Findings: The project does not have any findings to date. Evaluations are ongoing.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Improving Management of Test Results that Return After Hospital Discharge - Final Report

Citation:
Were M. Improving Management of Test Results that Return After Hospital Discharge - Final Report. (Prepared by Indiana University under Grant No. K08 HS018539). Rockville, MD: Agency for Healthcare Research and Quality, 2014. (PDF, 311.76 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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