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The largest and fastest growing group of malpractice claims in the United States involves missed and delayed diagnoses, specifically of lung, prostate, and colorectal cancer, as well as myocardial infarction, says Saul Weingart, MD, MPP, PhD, chief medical officer at Tufts Medical Center in Boston.
Failure to follow up on abnormal test results contribute significantly to these missed diagnoses, especially relevant laboratory tests, imaging, and EKGs, he says.
"The abnormal test follow up process is more complicated than one might imagine," says Weingart. He says that each of these steps is subject to a "low but real" risk of failure: test selection, test completion, result receipt, result interpretation, and result notification.
Weingart says EMRs can help to prevent missed diagnoses if they incorporate "results management" systems. These track outstanding clinician orders for diagnostic tests. They notify the provider if the test is incomplete within a specified time period, if the test has been resulted, and if abnormal findings have been posted. "Strong systems allow for forwarding of results to covering clinicians, and for auditing or oversight of results that have not been acknowledged within a specified timeframe," says Weingart.
Some systems generate templated results letters to streamline patient notification. "These systems help to backstop the ordering clinician by creating a fail-safe mechanism to ensure and record that test results have been acknowledged and acted upon," says Weingart.
When Mark Aronson, MD, acting chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center in Boston, sends patients for a colonoscopy, "often, I see them the next year, and they tell me they couldn’t find the time to do it."
A referring tracking system was developed for the organization’s EMR, funded by the hospital’s malpractice insurer. The patient is sent a letter and two phone calls, if patients don’t make an appointment in a certain timeframe. "As a result, we have screened hundreds of patients," says Aronson."We have picked up several important findings, such as colon cancer, in a number of patients." (See related story, p. 3, on patients’ failure to obtain recommended testing.) The system sends test results to the ordering provider and allows providers to compare these to previous results. "It gives them the option of calling the patient and discussing the results at that very moment," says Aronson.
The system is especially helpful when followup is recommended for a future point in time, such as a radiologist’s recommendation that a lung nodule noted on a patient’s X-ray be followed in six months. "That turns out to be very hard for doctors to do by themselves," says Aronson. The EMR flags the provider to contact the patient in six months to remind them of the need for the followup test.
The system notifies the patient’s primary care physician of any unrelated, unusual finding. A stroke patient admitted from the emergency department might have an X-ray showing a lung module, for example. "We are working with radiology to develop a tracking system for incidental findings," reports Aronson.