Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication

Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication.
Singh H, Wilson L, Petersen LA, et al. BMC Med Inform Decis Mak. 2009;9:49.

Technical problems with an electronic reminder system resulted in failure to follow up many abnormal fecal occult blood test results.


BMC Med Inform Decis Mak. 2009; 9: 49.
Published online 2009 December 9. doi: 10.1186/1472-6947-9-49. PMCID: PMC2797509

Copyright ©2009 Singh et al; licensee BioMed Central Ltd.
Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication
Hardeep Singh,1,2 Lindsey Wilson,1 Laura A Petersen,1,2 Mona K Sawhney,1 Brian Reis,1 Donna Espadas,1 and Dean F Sittig3

1The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication and the Houston VA HSR&D Center of Excellence at the Michael E DeBakey Veterans Affairs Medical Center, VA Medical Center (152) 2002 Holcombe Blvd, Houston, TX 77030, USA

2Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Michael E DeBakey Veterans Affairs Medical Center (MEDVAMC), HSR&D Center of Excellence (152) 2002 Holcombe Boulevard, Houston, TX 77030 USA

3The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, University of Texas School of Health Information Sciences and the UT-Memorial Hermann Center for Healthcare Quality & Safety, 6410 Fannin, UPB 1100 Houston, Texas 77030-3006, USA
Corresponding author.
Hardeep Singh: hardeeps@bcm.tmc.edu; Lindsey Wilson: lawilson@bcm.tmc.edu; Laura A Petersen: laurap@bcm.tmc.edu; Mona K Sawhney: sawhney@bcm.tmc.edu; Brian Reis: bareis@bcm.tmc.edu; Donna Espadas: despadas@bcm.tmc.edu; Dean F Sittig: Dean.F.Sittig@uth.tmc.edu

Received August 11, 2009; Accepted December 9, 2009.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background
Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response.

Methods
Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention.

Results
Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p < 0.01) and was sustained at month 4 following the intervention.

Conclusion
Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.

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Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication