professor andrew georgiou - macquarie university

Ensuring the quality and safety

of laboratory test result

communication, management

and follow-upProfessor Andrew Georgiou9 December 2016, National Pathology Forum, Sydney

Centre for Health Systems and Safety Research

Australian Institute of Health Innovation

Centre for Health Systems and

Safety Research

• Medication Safety and e-Health

• Communication and Work Innovation

• Human Factors & eHealth

• Pathology and Imaging Informatics

• Safety & Integration of Aged and Community Care

Services

• Primary Care Safety and eHealth

Rese

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Outline

1. Backgroundo Patient harm – the scope of the

problem

o What is diagnostic error?

2. Health information technology (IT) and its role in the quality use of pathology

3. Human-computer interaction

4. Safe management and communication of test results

5. Evidence promoting quality use of pathology

6. Patient access to test results

7. NHMRC partnership project

A multitude of health care harms

• 421 million hospitalisations

globally each year of which

there are 42.7 million adverse

events (Jha et al. 2013)

• >12 million US patients each

year experience a diagnostic

error in outpatient care (Singh

et al. 2014)

• Australians receive

“appropriate” care in only

57% of consultations

(Runciman et al. 2012)

What is a diagnostic error?

“… the failure to (a)

establish an accurate and

timely explanation of the

patient’s health problem(s)

or (b) communicate that

explanation to the patient.”

(Committee on Diagnostic Error in Health Care, Institute of

Medicine, 2015)

The diagnostic process

(Committee on Diagnostic Error in Health Care, Institute of Medicine, 2015)

Health information

technology (IT) initiatives*

• Tools to assist in information gathering

• Support for intelligent selection of tests

• Tools to aid result reporting

o Track pending results

o Result alerts

o Test result acknowledgement

o Auditable trail of follow-up

• Enhanced diagnostic reference material

and guidelines

• Facilitation of feedback and insight into

diagnostic performance

*El-Kareh et al. BMJ Qual & Saf 2013

Department of Health - Quality Use of

Pathology Program grant

Vecellio E, Ling L, Georgiou A, Eigenstetter A,

Gibson-Roy C, Cobain T, Golding M, Wilson R,

Lindeman R, Westbrook JI (2015)

http://aihi.mq.edu.au/project/variation-hospital-

pathology-investigations

Georgiou A, Vecellio E, Toouli G, Eigenstetter A,

Ling L, Wilson RWestbrook JI (2012)

http://www.aims.org.au/documents/item/295

http://aihi.mq.edu.au/project/variation-hospital-pathology-investigations

http://www.aims.org.au/documents/item/295

Types of pre-analytical errors

• Mislabelled specimen

• Mismatched specimen

• Specimen suitability

• Leaking specimen

• Accident to specimen

• Insufficient specimen

Incident Information Management

System (IIMS) reported errors

EMR Paper

Mislabelled specimen0.1

(n=39)

0.31

(n=56)p<.001

Mismatched specimen0.49

(n=200)

1.42

(n=255)p<.001

Unlabelled specimen1.37

(n=559)

1.65

(n=296)p<.01

Georgiou et al. Impact of the implementation of electronic ordering on hospital pathology services, 2012

Impact of the EMR on repeat

laboratory test ordering

13

Age ICU Time interval Paper

% (95% CI)

E lectronic ordering

% (95% CI)

p-value

<1 year Yes ≤ one-hour 3.0 (2.7-3.3) 0.4 (0.2-0.6) <0.0001

≤ 24-hours 54.2 (53.3-55.0) 35.3 (33.9-36.6) <0.0001

14

Age ICU Time interval Paper

% (95% CI)

Electronic ordering

% (95% CI)

p-value

≥1 year Yes ≤ one-hour 2.2 (1.8-2.5) 0.9 (0.6-1.2) <0.0001

≤ 24-hours 55.2 (53.9-56.5) 47.2 (45.4-48.9) <0.0001

ECRI TOP TEN patient safety

concerns for 2016

• Health IT

configurations and

organisation workflow

that do not support

each other

• Inadequate test result

reporting and follow-

up

What are health professionals

concerned about?

Aller R, Georgiou A, Pantanowitz L, Electronic Health Records

Missed test results

• Critical safety issue – increases

the risk of missed or delayed

diagnoses World Alliance for Patient Safety, WHO, 2008; Schiff, 2006

• Clinicians are concerned that their

test management practices are

not systematic Poon et al. Arch Int Med 2004

• Medico-legal concerns Berlin, AJR, 2009

• Impact on patient outcomes Roy et al. Ann Intern Med, 2005

AUSTRALIAN INSTITUTE OF HEALTH INNOVATION

FACULTY OF MEDICINE AND HEALTH SCIENCES

How many results are

missed for hospital patients?

• Hospital inpatients20% - 62% of tests are

missed

• ED patients (discharged)

1% - 75% of tests are

missed

Callen et al. BMJ Qual Saf 2011;20;194-199



Clinical Excellence Commission

(NSW) incidence analysis*

11% (3/27) of reported

clinical incidents resulting in

serious harm (e.g., pt. death)

and 32% (24/75) of clinical

incidents with major pt.

consequences were related

to poor test result follow-up

practices.

*Clinical Excellence Commission, Clinical Focus Report 2012 Sydney, NSW, Australia

The management and communication of high risk

laboratory results – consensus statement of the RCPA and

AACB Working Party for High Risk Results

• Laboratory should compile an alert list in

consultation with users

• There should be procedures to ensure that high risk

results are reliably identified

• There should be agreement about the modes of

transmission of high risk results

• There should be a list of users authorised to receive

the results

• There should be a definition about the data to be

communicated

• There should be a system for the acknowledgement

of receipt of results

• Every high risk result notification should be

appropriately documented

• Procedures for maintaining and monitoring the

outcomes of these practices



• Mater Mothers’ Hospital (Brisbane)

• 249 beds

• 9525 births; 15,246 inpatient discharges;

66,667 outpatient encounters (2011)

• IP Health Verdi software which allowed

clinicians to electronically document

review and acknowledgement of test

results (2010)

• Hospital data (Aug ’11 – Aug ‘12) involving

27,354 inpatient tests for 6855 patients

*Georgiou et al. J Am Med Inform Ass (2014)

An electronic safety net to

enhance test result management*



Test result acknowledgement

• All test results were acknowledged

• Longest acknowledgement took nearly 38 days for imaging

• 60% of lab and 44% of imaging results acknowledged

within 24h



• Registrars perform the most

acknowledgments

• Median time between report

availability and

acknowledgement 18.1h (lab),1

day 18h (imaging)

• % of acknowledgement >3 days

was highest on Fridays (34.4%

lab and 63.4% for imaging)

Who acknowledges, when?



Patient access to information

• Patient access to information –

essential element of effective health

care (Al-Shorbaji 2013)

• Electronic patient portals connected

to the hospital EMR

• Secure on-line access

• Access to appointments, test

results, clinical information and to

clinicians



Study methods

Cross sectional survey* of senior emergency physicians (61/89) at 2 metropolitan teaching hospitals in Sydney.

Significantly abnormal results – not life threatening but need short-term

follow-up (e.g., chest x-ray with new shadow, abnormal PSA)

Automatic patient notification methods– Patient portal, Email, SMS, fax, mail or

phone

*Callen et al. Journal of Medical Internet Research 2015; e60



In my practice there are standardised

policies and procedures for

notification of abnormal test results

75

12

13

Standard policies and procedures (%)

Agree

Disagree

Neither



Perceptions of missed test

results

19.2

26.9

53.9

In the past year I have missed an abnormal result that led to delayed

patient care

Yes (%)

No (%)

Don't know (%)

38.5

11.5

50

In the past year a colleague has missed an abnormal results that

led to delayed patient care

Yes (%)

No (%)

Don't know (%)



Who is responsible for notifying

the patient of a test result?

65 65

43

35

3

15

0

32

42

0

10

20

30

40

50

60

70

Doctor who ordered thetest

Primary care doctor It is not always clear whoshould notify patients

Agree (%)

Disagree (%)

Neither agree nor disagree (%)



Are you comfortable with

patients receiving direct

notification of test results

(%)?

39

54

7

Yes

No

Don't know

Main concerns regarding direct

notification of results to

patients

85

92 90

15

8 10

0

20

40

60

80

100

Patient anxiety about

test result

Patient confusion

about test result

Patient lacks

expertise to interpret

result

Yes (%)

No (%)



Delivering safe and effective test result

communication, management and follow-up

• National Health & Medical Research Council

partnership grant (APP1111925)

• Partners:

• South Eastern Area Laboratory Services

• Australian Commission on Safety and

Quality in Health Care

• Royal College of Pathologists of

Australasia (Pathology Information,

Terminology and Units Standardisation)

• Health Consumers NSW

• Australian Association of Clinical

Biochemists

• Centre for Health Systems & Safety

Research, Australian Institute of Health

Innovation, Macquarie University



Aims of the project

Establishment of effective test result

management systems in hospitals• Clear processes of communication, responsibility and

accountability

• Guidelines and standards for safe test result follow-up

Harnessing health information

technologies (IT)

• Informing and monitoring test result management

Enhancing the contribution of consumers

• What do consumers want?

• Establishing patient-centred health care



Thank youEmail: [email protected]

Website: www.aihi.mq.edu.au

Twitter: @AGeorgiouMQ

mailto:[email protected]

http://www.aihi.mq.edu.au/

professor andrew georgiou - macquarie university

Health & Medicine