Communication outcomes of critical imaging results in a computerized notification system
Open accessAbstract
OBJECTIVE: Communication of abnormal test results in the outpatient setting is prone to error. Using information technology can improve communication and improve patient safety. We standardized processes and procedures in a computerized test result notification system and examined their effectiveness to reduce errors in communication of abnormal imaging results. DESIGN: We prospectively analyzed outcomes of computerized notification of abnormal test results (alerts) that providers did not explicitly acknowledge receiving in the electronic medical record of an ambulatory multispecialty clinic. MEASUREMENTS: In the study period, 190,799 outpatient visits occurred and 20,680 outpatient imaging tests were performed. We tracked 1,017 transmitted alerts electronically. Using a taxonomy of communication errors, we focused on alerts in which errors in acknowledgment and reception occurred. Unacknowledged alerts were identified through electronic tracking. Among these, we performed chart reviews to determine any evidence of documented response, such as ordering a follow-up test or consultation. If no response was documented, we contacted providers by telephone to determine their awareness of the test results and any follow-up action they had taken. These processes confirmed the presence or absence of alert reception. RESULTS: Providers failed to acknowledge receipt of over one-third (368 of 1,017) of transmitted alerts. In 45 of these cases (4% of abnormal results), the imaging study was completely lost to follow-up 4 weeks after the date of study. Overall, 0.2% of outpatient imaging was lost to follow-up. The rate of lost to follow-up imaging was 0.02% per outpatient visit. CONCLUSION: Imaging results continue to be lost to follow-up in a computerized test result notification system that alerted physicians through the electronic medical record. Although comparison data from previous studies are limited, the rate of results lost to follow-up appears to be lower than that reported in systems that do not use information technology comparable to what we evaluated.
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The result from the baseline EHR group is in line with findings from real clinical settings that indicated physicians did not acknowledge abnormal test results in approximately 4% of cases.
“The result from the baseline EHR group is in line with findings from real clinical settings that indicated physicians did not acknowledge abnormal test results in approximately 4% of cases.19,20”
From Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians (2019) · cites this paper as [19]
The Discussion reports that providers failed to electronically acknowledge over one-third of abnormal-result alerts, not approximately 4%. The 4% figure refers instead to cases in which providers were unaware of abnormal imaging results four weeks after reporting. (LLM, conf=0.85)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredEven in the EHR environment, with alerts and reminders in place, physicians continue to often inappropriately manage abnormal test results.
“Even in the EHR environment, with alerts and reminders in place, physicians continue to often inappropriately manage abnormal test results.12,13,14,15,16,17,18,19,20,21”
From Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians (2019) · cites this paper as [19]
The Discussion (page not available) reports that abnormal imaging results were sometimes lost to follow-up despite electronic alerts. But the study found this in 4% of alerted abnormal imaging results at one VA institution; it does not establish that physicians often inappropriately manage abnormal test results generally. Failure to acknowledge an alert also did not necessarily mean failure to respond. (LLM, conf=0.86)
Experimental — accuracy not yet measuredA sample size of 30 participants, each reviewing 35 test results, was required to achieve 80% power to detect a statistically significant difference in cognitive workload and performance.
“On the basis of the anticipated rate of appropriately identified abnormal test results in the literature12,13,14,15,16,17,18,19,20,21 and the anticipated magnitude of the association of the enhanced EHR, we required a sample size of 30 participants, each reviewing 35 test results, to achieve 80% power to detect a statistically significant difference in cognitive workload and performance.”
From Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians (2019) · cites this paper as [19]
Missed laboratory results or delayed recognition of results creates a significant potential for outpatient diagnostic errors, adverse events, and liability claims.
“missed laboratory results or delayed recognition of results leads to a significant potential for outpatient diagnostic errors, adverse events and liability claims.”
From Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain? (2010) · cites this paper as [15]
IT-based interventions alone cannot assure improvements in communication.
“IT-based interventions alone, however, cannot assure improvements in communication.”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [25]
Communication breakdowns are an increasingly recognized preventable factor in medical mishaps.
“Communication breakdowns are an increasingly recognized preventable factor in medical mishaps, and emerging data suggest a high prevalence of communication breakdowns among physicians, patients, and important members of the health care team who assist with the diagnostic process.21,25–32”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [25]
Computerized information systems themselves can lead to unintended errors including those that involve communication processes.
“For instance, computerized information systems themselves can lead to unintended errors including those that involve communication processes.25,34,42”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [25]
Emerging data suggest a high prevalence of communication breakdowns among physicians, patients, and important members of the health care team who assist with the diagnostic process.
“Communication breakdowns are an increasingly recognized preventable factor in medical mishaps, and emerging data suggest a high prevalence of communication breakdowns among physicians, patients, and important members of the health care team who assist with the diagnostic process.21,25–32”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [25]
The VA's View Alert system tracks acknowledgement of abnormal test results, and results that go unacknowledged receive a higher degree of oversight to reduce the chance that the report would be lost in the system.
“For instance, the VA’s View Alert system tracks acknowledgement of abnormal test results, and results that go unacknowledged receive a higher degree of oversight to reduce the chance that the report would be lost in the system (e.g., Example 12).25”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [25]
Studies including our own have reported communication breakdowns among providers even in systems that use advanced IT.
“Studies including our own have reported communication breakdowns among providers even in systems that use advanced IT.25”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [25]
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- Authors
- Singh, H., Arora, H. S., Vij, M. S., Rao, R., Khan, M. M., & Petersen, L. A.
- Affiliations
- Michael E. DeBakey VA Medical Center (US)
- Corresponding author
- Singh, H.
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2007-07-01
- Volume
- 14
- Issue
- 4
- Pages
- 459-466
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC2244901
- OpenAlex
- W124570340
- Cited by
- 140
- References
- 32
- Citations by year
- 2025: 5 · 2024: 1 · 2023: 1 · 2022: 1 · 2021: 11 · 2020: 6 · 2019: 12 · 2018: 10 · 2017: 9 · 2016: 3 · 2015: 10 · 2014: 12 · 2013: 10 · 2012: 8
- FWCI
- 22.51
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Medical Informatics Association (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Veterans Affairs
- American Heart Association (0540043N)
- National Institutes of Health
- National Center for Research Resources (K12 RR 17665, K12RR017665)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Radiology practices and education
- Keywords
- communication errors, loss to follow-up, electronic health record alerts, outpatient imaging, patient safety, outpatient care, follow-up activities
- MeSH terms
- Communication, Diagnostic Imaging, Hospitals, Veterans, Humans, Outpatient Clinics, Hospital, Prospective Studies, Radiology, Texas, Medical Records Systems, Computerized, Reminder Systems, Decision Support Systems, Clinical
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