Test result communication in primary care: clinical and office staff perspectives

Notification of blood donors who test positive for transfusion-transmissible infections

BACKGROUND AND OBJECTIVES

Despite screening procedures, a few blood donors confirm positive for transfusion-transmissible infections and are deferred. Effective notification of laboratory results is essential to ensure that donors are advised of confirmed results and to seek medical care. Here we report results from post-notification interviews of Canadian Blood Services donors.

MATERIALS AND METHODS

Over 17 years, 2006-2022, all donors with confirmed positive results for hepatitis B virus (HBV), hepatitis C virus (HCV), human T-cell lymphotropic virus (HTLV) and syphilis were notified by registered mail of their result and advised to see a physician. In a separate communication, all donors were later invited to participate in a scripted interview asking whether they tested positive for an infection; if yes, which one, what their reaction was, whether they consulted a physician and whether public health contacted them. Frequencies of responses were calculated.

RESULTS

Of 2654 donors with confirmed positive test results, 876 (33%) participated; 90% said they were informed of a positive test result. Of these, about a quarter did not know for which infection they were positive. Most were surprised, and some were sad or disappointed. Most saw a physician after notification (77%). About two-thirds with HBV or HCV said they were contacted by public health, slightly fewer (58%) with syphilis, 27% of those with HTLV.

CONCLUSION

Most donors recalled being notified and were aware of their positive test, but details of the infection were sometimes not understood or recalled, and not all donors consulted a physician about the infection.

Communicating blood test results in primary care: a mixed-methods systematic review

BACKGROUND

Online records access, including test results, was rolled out as part of changes to the GP contract in England in 2023. Blood test result communication is important for patient-centred care, patient safety, and primary care workload. Evidence is needed to ensure that test results are communicated safely and efficiently to patients in primary care.

AIM

To summarise existing evidence for blood test result communication between primary care providers and their patients and carers.

DESIGN AND SETTING

A mixed-methods systematic review was undertaken.

METHOD

MEDLINE, Embase, PsycInfo (Ovid), CINAHL (EBSCOhost), and the Cochrane Library were searched from January 2013-September 2023. Qualitative or quantitative studies that provided information on the communication of blood test results by primary care staff to adult patients and carers were eligible for inclusion.

RESULTS

There were 71 included studies, including 10 experimental studies and no randomised controlled trials. Study quality was mostly poor and risk of bias was high, partly owing to a lack of reported information. The studies found that patients want more information about their blood test results, particularly in terms of 'what next', and prefer results to be provided quickly. Electronic methods, such as online access or text messages, were generally well accepted but not by everyone, and not for all results. Clinicians' opinions were mixed as to whether online direct release of test results to patients was beneficial or could cause problems, such as increased patient anxiety and increased workload.

CONCLUSION

A range of evidence has been identified on patient and clinician preferences, and barriers and facilitators to test communication, which is particularly important in the current NHS context of a move towards patient online access.

Stakeholders' perceptions and experiences of factors influencing the commissioning, delivery, and uptake of general health checks: a qualitative evidence synthesis

BACKGROUND

General health checks are integral to preventive services in many healthcare systems. They are offered, for example, through national programmes or commercial providers. Usually, general health checks consist of several screening tests to assess the overall health of clients who present without symptoms, aiming to reduce the population's morbidity and mortality. A 2019 Cochrane review of effectiveness studies suggested that general health checks have little or no effect on either all-cause mortality, cancer or cardiovascular mortality or cardiovascular morbidity. These findings emphasise the need to explore the values of different stakeholder groups associated with general health checks.

OBJECTIVES

To identify how stakeholders (i.e. healthcare managers or policymakers, healthcare providers, and clients) perceive and experience general health checks and experience influencing factors relevant to the commissioning, delivery and uptake of general health checks. Also, to supplement and contextualise the findings and conclusions of a 2019 Cochrane effectiveness review by Krogsbøll and colleagues.

SEARCH METHODS

We searched MEDLINE (Ovid) and CINAHL (EBSCO) and conducted citation-based searches (e.g. reference lists, effectiveness review-associated studies and cited references in our included studies). The original searches cover the period from inception to August 2022. The results from the update search in September 2023 have not yet been incorporated.

SELECTION CRITERIA

We included primary studies that utilised qualitative methods for data collection and analysis. Included studies explored perceptions and experiences of commissioning, delivery and uptake of general health checks. Stakeholders of interest were healthcare managers, policymakers, healthcare providers and adults who participate (clients) or do not participate (potential clients) in general health checks. The general health check had to include screening tests for at least two diseases or risk factors. We considered studies conducted in any country, setting, and language.

DATA COLLECTION AND ANALYSIS

We applied a prespecified sampling frame to purposefully sample a variety of eligible studies. This sampling approach allowed us to capture conceptually rich studies that described the viewpoints of different stakeholder groups from diverse geographical regions and different settings. Using the framework synthesis approach, we developed a framework representing individual, intervention and contextual factors, which guided data extraction and synthesis. We assessed the methodological limitations of each study using an adapted version of the Critical Appraisals Skills Programme (CASP) tool. We applied the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess our confidence in each finding.

MAIN RESULTS

One hundred and forty-six studies met the inclusion criteria, and we sampled 36 of these for our analysis. While most of the studies were set in high-income countries in Europe, nearly a third (11/36) were set in culturally diverse middle-income countries across Eastern Europe, South and Southeast Asia, and Latin America. Sixteen sampled studies were conducted in primary and community healthcare settings, four in workplace settings and four in community settings. Included studies explored the perceptions and experiences of clients (n = 25), healthcare providers (n = 15) and healthcare managers or commissioners (n = 9). We grouped the findings at the individual level, intervention level and surrounding context. The findings at the individual level mainly reflect the client's perspective. General health checks helped motivate most clients to change their lifestyles. They were trusted to assess their health objectively, finding reassurance through professional confirmation (moderate confidence). However, those who feared negative results or relied on symptom-based care were more reluctant to attend (moderate confidence). Perceptions of disease, risk factors and prevention affected uptake (high confidence). Some clients felt an obligation to their families and society to maintain and improve their health through general health checks (moderate confidence). Healthcare providers played a crucial role in motivating participation, but negative experiences with unqualified providers discouraged attendance (moderate confidence). The availability and accessibility of general health checks and awareness systems played significant roles in clients' decision-making. Factors such as time and concerns that health insurance may not cover potential treatment costs influenced attendance (moderate confidence). The findings at the intervention level drew on the perspectives of all three stakeholder groups, with a strong focus on the healthcare provider's perspective. Healthcare providers and clients considered it essential that general health check providers were skilled and culturally competent (high confidence). Barriers to delivery included time competition with curative care, staff changes and shortages, resource limitations, technical issues, and reimbursement challenges (moderate confidence). Stakeholders thought innovative and diverse settings might improve access (moderate confidence). The evidence suggests that clients appreciated a comprehensive approach, with various tests. At the same time, healthcare providers deemed individualised approaches tailored to clients' health risks suitable, focusing on improving rather than abandoning general health checks (low confidence). The perspectives on the effectiveness of general health checks differed among healthcare commissioners, managers, providers, and clients (moderate confidence). Healthcare providers and clients recognised the importance of information, invitation systems, and educational approaches to create awareness of general health check availability and their respective advantages or disadvantages (moderate confidence). Clients considered explaining test results and providing recommendations as key elements of general health checks (low confidence). We have low or very low confidence in findings related to the contextual level and reasons for commissioning general health checks. The evidence suggests that cultural background, social norms, religion, gender, and language shape the perception of prevention and disease, thereby influencing the uptake of general health checks. Policymakers thought that a favourable political climate and support from various stakeholders are needed to establish general health checks.

AUTHORS' CONCLUSIONS

Despite the lack of effectiveness in the quantitative review, our findings showed that general health checks remain popular amongst clients, healthcare providers, managers and policymakers across countries and settings. Our data did not offer strong evidence on why these are commissioned, but it did point to these interventions being valued in contexts where general health checks have long been established. General health checks fulfil specific wants and needs, and de-implementation strategies may need to offer alternatives before a constructive debate can take place about fundamental changes to this widely popular or, at least, accepted service.

Impact of the clinically oriented roles of a general practice receptionist: a systematic review with narrative synthesis

BACKGROUND

Modern general practice is characterised by increased demand and growing multidisciplinarity, including ring-fenced funding for additional non-clinical roles. For practice receptionists, however, training has remained unchanged for decades despite primary care being under greater pressure than ever, with receptionists becoming a growing focal point for abuse and unprecedented numbers leaving the role.

AIM

To present the evidence of the range of tasks that receptionists continue to perform, describing their impact on primary care delivery and how the role might be better supported.

DESIGN AND SETTING

Systematic review of research conducted in the UK.

METHOD

A systematic review of evidence contained in the major medical databases (MEDLINE/PubMed, CINAHL, ASSIA, Cochrane Library, and Embase) from January 2000 to March 2024 was conducted, including hand searches of the bibliographies of included studies.

RESULTS

In total, 29 studies were identified that grouped into three themes: service delivery, patient attitudes, and receptionist experience. The theme 'service delivery' confirms the continuing role of receptionists in providing administrative support alongside the clinical tasks of prioritising patients for consultations, facilitating repeat prescriptions, and communicating blood test results. The theme 'patient attitudes' describes how patients lacked trust in receptionists, who were viewed as unqualified and unnecessarily obstructive. Finally, in considering receptionist experience, the contrast between their confidence in performing administrative roles and the anxiety induced from the clinically related tasks was described, particularly the mounting pressure from patients to meet their preferences for clinician appointments.

CONCLUSION

Although confident performing administrative tasks, receptionists described uncertainty and anxiety when providing clinically oriented support or managing patients when their requests for appointments could not be met. More appropriate training or professionalisation might improve staff retainment.

Patient safety in actioning and communicating blood test results in primary care: a UK wide audit using the Primary care Academic CollaboraTive (PACT)

BACKGROUND

Errors associated with failures in filing, actioning and communicating blood test results can lead to delayed and missed diagnoses and patient harm. This study aimed to audit how blood tests in primary care are filed, actioned and communicated in primary care, to identify areas for patient safety improvements.

METHODS

UK primary care clinicians were recruited through the Primary Care Academic CollaboraTive (PACT). PACT members audited 50 recent sets of blood tests from their practice and retrospectively extracted data on blood test result coding, actioning and communication. PACT members received a practice report, showing their own results, benchmarked against other participating practices.

RESULTS

PACT members from 57 general practices across all four UK nations collected data on 2572 patients who had blood tests in April 2021. In 89.9% (n=2311) they agreed with the initial clinician's actioning of blood tests; 10.1% disagreed, either partially (7.1%) or fully (3.0%).In 44% of patients (n=1132) an action (eg, 'make an appointment') was specified by the filing clinician. This action was carried out in 89.7% (n=1015/1132) of cases; in 6.8% (n=77) the action was not carried out, in 3.5% (n=40) it was unclear. In the 117 cases where the test result had not been actioned 38% (n=45) were felt to be at low risk of harm, 1.7% (n=2) were at high risk of harm, 0.85% (n=1) came to harm.Overall, in 47% (n=1210) of patients there was no evidence in the electronic health records that results had been communicated. Out of 1176 patients with one or more abnormal results there was no evidence of test communication in 30.6% (n=360). There were large variations between practices in rates of actioning and communicating tests.

CONCLUSION

This research demonstrates variation in the way blood test results are actioned and communicated, with important patient safety implications.

Medical Doctors Approaches and Understanding of Health Literacy: A Systematic Literature Review

A physician's role is critical in fostering patient health literacy (HL) and influencing various aspects, including patient-physician communication and treatment effectiveness. The purpose of this systematic literature review is to analyze physicians' perspectives, comprehension, and management of HL. The focus of this review is on physicians' views, opinions, experiences, and strategies related to HL. We conducted comprehensive searches across seven databases, including PubMed, Scopus, ProQuest, Science Direct, Web of Science, The Cochrane Library, and Google Scholar. Original research articles published between January 1, 2009, and July 31, 2020, were considered for inclusion. This literature review incorporates qualitative studies and mixed-methods studies, with a focus on extracting qualitative data. Among the 22 articles included in our review, we employed the method of inductive thematic analysis for data analysis. A detailed description of the review methodology can be found in a previously published protocol available through PROSPERO (CRD42020212599). The themes that emerged from the thematic analysis include: (a) physicians' perception and management of HL; and (b) barriers. The results of the systematic review reveal that healthcare professionals exhibit varying perceptions of patients' HL levels and ascribe different meanings to it. However, none of them employ a specific measuring tool. While there appears to be no uniform approach to managing patients with low HL, some prioritize certain communication strategies, such as repetition, simplified language, and providing written instructions, among others. Most physicians cited multiple barriers that impede the development of patients' HL, including dysfunctions within the healthcare system, staff shortages, managing a large number of patients, limited time, work-related stress, cultural and socio-economic barriers, medical jargon, and language barriers. Considering the pivotal role of physicians in fostering patient HL, it is crucial to enhance medical education in addressing and managing HL, both within academic curricula and through continuing education seminars. Furthermore, there is a pressing need to improve healthcare professionals' working conditions, ensuring that each physician can allocate the necessary time to each patient based on their individual needs, without being hindered by stress-inducing work environments.

Blood test result communication in primary care: mixed-methods systematic review protocol

BACKGROUND

After testing, ensuring test results are communicated and actioned is important for patient safety, with failure or delay in diagnosis the most common cause of malpractice claims in primary care worldwide. Identifying interventions to improve test communication from the decision to test through to sharing of results has important implications for patient safety, GP workload, and patient engagement.

AIM

To assess the factors around communication of blood test results between primary care providers (for example GPs, nurses, reception staff) and their patients and carers.

DESIGN & SETTING

A mixed methods systematic review including primary studies involving communication of blood test results in primary care.

METHOD

The review will use a segregated convergent synthesis method. Qualitative information will be synthesised using a meta-aggregative approach, and quantitative data will be meta-analysed or synthesised if pooling of studies is appropriate and data are available. If not, data will be presented in tabular and descriptive summary form.

CONCLUSION

This review has the potential to provide conclusions about blood test result communication interventions and factors important to stakeholders, including barriers and facilitators to improved communication.

Greek medical professionals approaches and understanding of health literacy: a qualitative study

BACKGROUND

Health literacy holds significant importance for medical professionals, as it is widely acknowledged as a key element in enhancing health promotion and overall well-being. The primary objective of this study is to explore Greek physicians' comprehension of health literacy, the significance they attribute to it, their strategies for addressing patients with low health literacy, and the potential barriers they face while striving to enhance a patient's health literacy. In this context, we examine the communication methods employed by physicians as an integral part of their approach to improving a patient's health literacy.

METHODS

A qualitative study was conducted between April 29, 2021, and February 17, 2022, utilizing in-depth, semi-structured interviews with 30 Greek medical professionals, of whom 15 were university professors. The research sample selection methodology employed in this study was purposive sampling. Data analysis was conducted using inductive thematic analysis.

RESULTS

The majority of physicians were not familiar with the concept of health literacy. The most significant barriers to the development of health literacy among physicians are a lack of time, issues within the healthcare system, and interference from third parties, although they acknowledge that a significant portion of the responsibility lies with them. Effective communication with patients is important for all physicians, as it plays a crucial role in the therapeutic process. When they realize that their patients are not understanding them, they employ communication methods such as using plain language, providing numerous examples, incorporating visuals like pictures and even using drawings.

CONCLUSIONS

The findings of this study underscore the importance of implementing targeted initiatives to promote health literacy within the Greek medical and academic community. Integrating health literacy training for physicians into the educational and training curriculum is essential. To accomplish this goal, it is imperative to first address the shortcomings within the healthcare system and improve the working conditions for physicians.

'I guess I'll wait to hear'- communication of blood test results in primary care a qualitative study

BACKGROUND

Rates of blood testing in primary care are rising. Communicating blood test results generates significant workload for patients, GPs, and practice staff.

AIM

To explore GPs' and patients' experience of systems of blood test communication.

DESIGN AND SETTING

Qualitative interviews with patients and GPs in UK primary care in both urban and rural practices in the West of England.

METHOD

A total of 28 patients and 19 GPs from six practices were recruited, with a range of socioeconomic and demographic characteristics. Patients were interviewed at two time points: a) at or soon after their blood test and b) after they had received their test results. The GPs who requested the tests were also interviewed (they could complete a maximum of two interviews about different patients). Eighty qualitative interviews were undertaken; 54 patient interviews and 26 GP interviews.

RESULTS

Methods of test result communication varied between doctors and were based on habits, unwritten heuristics, and personal preferences rather than protocols. Doctors expected patients to know how to access their test results. In contrast, patients were often uncertain and used guesswork to decide when and how to access their tests. Patients and doctors generally assumed that the other party would make contact, with potential implications for patient safety. Text messaging and online methods of communication have benefits, but were perceived by some patients as 'flippant' or 'confusing'. Delays and difficulties obtaining and interpreting test results can lead to anxiety and frustration for patients.

CONCLUSION

Current systems of test result communication are complex and confusing, and mostly based on habits and routines rather than clear protocols. This has important implications for patient-centred care and patient safety.

Why test study protocol: a UK-wide audit using the primary care academic collaborative to explore the reasons for primary care testing

BACKGROUND

The number of blood tests done in primary care has been increasing over the last 20 years. Some estimates suggest that up to a quarter of these tests may not have been needed. This could lead to a cascade effect of further investigations, appointments, or referrals, as well as anxiety for patients, increased workload and costs to the health service. To better understand the impact and sequelae of blood tests on patients, we need to know why blood tests are requested and what is done with the results.

AIMS

To explore who orders blood tests and why, and how test results are actioned in primary care.

DESIGN & SETTING

Retrospective audit of electronic health records in general practices across the UK.

METHOD

The Primary care Academic CollaboraTive (PACT), a UK-wide network of primary care health professionals, will be utilised to collect data from individual practices. PACT members will be asked to review the electronic health records of 50 patients who had recent blood tests in their practice, and manually extract anonymised data on who requested the test, the indication, the result, and subsequent actions. Data will also be collected from PACT members to assess the feasibility of the collaborative model.

CONCLUSION

PACT offers a unique opportunity to extract clinical data which cannot otherwise be obtained. Understanding the indications for tests will help identify priority areas for research to optimise testing and patient safety in primary care.

Understanding consumer perceptions of frailty screening to inform knowledge translation and health service improvements

BACKGROUND AND OBJECTIVES

despite growing support for the clinical application of frailty, including regular frailty screening for older adults, little is known about how older adults perceive frailty screening. The purpose of this study was to examine older adults' perspectives on frailty screening to inform knowledge translation and service improvements for older adults with frailty.

RESEARCH DESIGN

interpretive descriptive qualitative design.

PARTICIPANTS

a total of 39 non-frail (18%), pre-frail (33%) and frail or very frail (49%) South Australian older adults aged 62-99 years, sampled from community, assisted living and residential aged care settings.

METHODS

seven focus groups were conducted and analysed by two independent investigators using inductive thematic analysis.

RESULTS

three themes were identified. First, older adults question the necessity and logic of an objective frailty measure. Second, older adults believe any efforts at frailty screening need to culminate in an action. Third, older adults emphasise that frailty screening needs to be conducted sensitively given negative perceptions of the term frailty and the potential adverse effects of frailty labelling.

DISCUSSION AND IMPLICATIONS

previous screening experiences and underlying beliefs about the nature of frailty as inevitable shaped openness to, and acceptance of, frailty screening. Findings correspond with previous research illuminating the lack of public awareness of frailty and the nascent stage of frailty screening implementation. Incorporating consumer perspectives, along with perspectives of other stakeholder groups when considering implementing frailty screening, is likely to impact uptake and optimise suitability-important considerations in person-centred care provision.

CASNET2: evaluation of an electronic safety netting cancer toolkit for the primary care electronic health record: protocol for a pragmatic stepped-wedge RCT

INTRODUCTION

Safety-netting in primary care is the best practice in cancer diagnosis, ensuring that patients are followed up until symptoms are explained or have resolved. Currently, clinicians use haphazard manual solutions. The ubiquitous use of electronic health records provides an opportunity to standardise safety-netting practices.A new electronic safety-netting toolkit has been introduced to provide systematic ways to track and follow up patients. We will evaluate the effectiveness of this toolkit, which is embedded in a major primary care clinical system in England:Egerton Medical Information System(EMIS)-Web.

METHODS AND ANALYSIS

We will conduct a stepped-wedge cluster RCT in 60 general practices within the RCGP Research and Surveillance Centre (RSC) network. Groups of 10 practices will be randomised into the active phase at 2-monthly intervals over 12 months. All practices will be activated for at least 2 months. The primary outcome is the primary care interval measured as days between the first recorded symptom of cancer (within the year prior to diagnosis) and the subsequent referral to secondary care. Other outcomes include referrals rates and rates of direct access cancer investigation.Analysis of the clustered stepped-wedge design will model associations using a fixed effect for intervention condition of the cluster at each time step, a fixed effect for time and other covariates, and then include a random effect for practice and for patient to account for correlation between observations from the same centre and from the same participant.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the North West-Greater Manchester West National Health Service Research Ethics Committee (REC Reference 19/NW/0692). Results will be disseminated in peer-reviewed journals and conferences, and sent to participating practices. They will be published on the University of Oxford Nuffield Department of Primary Care and RCGP RSC websites.

TRIAL REGISTRATION NUMBER

ISRCTN15913081; Pre-results.

Enabling Laboratory Medicine in Primary Care Through IT Systems Use

Important problems remain regarding the efficiency and quality of laboratory testing in primary care. In view of this, a significant function of electronic medical record (EMR) systems is to enable the practice of laboratory medicine by primary care physicians. The present study aims to deepen our understanding of the nature and extent of physicians' use of EMR and other laboratory information exchange systems for patient management and care within the laboratory testing process. We conducted a survey of 684 Canadian family physicians. Results indicate that physicians use 84 percent of the laboratory functionalities available in their EMR system. The two most important impacts are the ability to gain time in the post-analytical phase and to take faster action in this same phase as they follow-up on their patients' test results. Physicians who perceive to benefit most from their EMR use are those who make the most extensive use of their system. Extended use of an EMR system allows primary care physicians to better ascertain and monitor the health status of their patients, verify their diagnosis assumptions, and, if their system includes a clinical decision support module, apply evidence-based practices in laboratory medicine.

Communication of cancer screening results by letter, telephone or in person: A mixed methods systematic review of the effect on attendee anxiety, understanding and preferences

Attending and receiving a result from screening can be an anxious process. Using an appropriate method to deliver screening results could improve communication and reduce negative outcomes for screening attendees. Screening programmes are increasingly communicating results by letter or telephone rather than in-person. We investigated the impact of communication methods on attendees. We systematically reviewed the literature on the communication methods used to deliver results in cancer screening programmes for women, focusing on screening attendee anxiety, understanding of results and preferences for results communication. We included qualitative and quantitative research. We searched MEDLINE, PsycINFO, CINAHL, Cochrane Library and Embase. Results were analysed using framework synthesis. 10,558 papers were identified with seven studies meeting the inclusion criteria. Several key ideas emerged from the synthesis including speed, accuracy of results, visual support, ability to ask questions, privacy of results location and managing expectations. Verbal communication methods (telephone and in-person) were preferred and facilitated greater understanding than written methods, although there was considerable variability in attendee preferences. Findings for anxiety were mixed, with no clear consensus on which method of communication might minimise attendee anxiety. The low number of identified studies and generally low quality evidence suggest we do not know the most appropriate communication methods in the delivery of cancer screening results. More research is needed to directly compare methods of results communication, focusing on what impact each method may have on screening attendees.

Content analysis of 50 clinical negligence claims involving test results management systems in general practice

Background and aims

Laboratory test results management systems are a complex safety issue in primary care settings worldwide. Related failures lead to avoidable patient harm, medicolegal action, patient complaints and additional workload to problem solve identified issues. We aimed to review and learn from 50 clinical negligence cases involving system failures related to the management of test results.

Methods

The Medical Protection Society database was searched and a convenience sample of 50 claims identified from a 3-year period covering 2014–2016. A content analysis of documentation was undertaken to quantify and theme data, aided by a Risk Assessment Matrix and the Yorkshire Contributory Factors Framework. Quantitative data were subjected to simple descriptive statistical analysis.

Results

14/50 cases (28%) involved a delay in diagnosis or treatment of a patient with cancer. 15 cases were judged to be ‘never events’ (30%) and 85 distinct system issues were identified. Just under half of cases involved a failure to notify patients of an abnormal test result (n=24, 48%), while 18 cases (36%) involved a test result not being actioned by a doctor. The most frequently occurring contributory factors (n=30, 60%) were related to local working conditions, for example, unclear professional responsibilities with regards to test result review or follow-up or lack of patient care continuity.

Conclusion

This small study highlights why test result management systems fail and contribute to future litigation, providing new insights in this area. Most claims involved avoidable harm to patients and preventable organisational risks. The findings point to the inadequate design of practice systems and the need for proactive strategies to improve the management of test results in order to reduce patient harm.

The impact of status and social context on health service co-design: an example from a collaborative improvement initiative in UK primary care

BACKGROUND

Increasingly, collaborative participatory methods requiring open and honest interaction between a range of stakeholders are being used to improve health service delivery. To be successful these methodologies must incorporate perspectives from a range of patients and staff. Yet, if unaccounted for, the complex relationships amongst staff groups and between patients and providers can affect the veracity and applicability of co-designed solutions.

METHODS

Two focus groups convened to discuss suggestions for the improvement of blood testing and result communication in primary care. The groups were mixed of patients and staff in various combinations drawn from the four participating study practices. Here we present a secondary mixed-method analysis of the interaction between participants in both groups using sociogrammatic and thematic analysis.

RESULTS

Despite a similar mix of practice staff and patients the two groups produced contrasting discussions, seemingly influenced by status and social context. The sociograms provided a useful insight into the flow of conversation and highlighted the dominance of the senior staff member in the first focus group. Within the three key themes of social context, the alliances formed between participants and the fluidity of the roles assumed manifested differently between groups apparently dictated by the different profile of the participants of each.

CONCLUSIONS

For primary care service improvement attention must be paid to the background of participants when convening collaborative service improvement groups as status and imported hierarchies can have significant connotations for the data produced.

Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families

Objective

We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner.

Methods

Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days.

Results

Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period ( P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children’s study results.

Discussion

Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner.

Implications for Practice

With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea.

Test results management and distributed cognition in electronic health record-enabled primary care

Managing abnormal test results in primary care involves coordination across various settings. This study identifies how primary care teams manage test results in a large, computerized healthcare system in order to inform health information technology requirements for test results management and other distributed healthcare services. At five US Veterans Health Administration facilities, we interviewed 37 primary care team members, including 16 primary care providers, 12 registered nurses, and 9 licensed practical nurses. We performed content analysis using a distributed cognition approach, identifying patterns of information transmission across people and artifacts (e.g. electronic health records). Results illustrate challenges (e.g. information overload) as well as strategies used to overcome challenges. Various communication paths were used. Some team members served as intermediaries, processing information before relaying it. Artifacts were used as memory aids. Health information technology should address the risks of distributed work by supporting awareness of team and task status for reliable management of results.

Laboratory testing in primary care: A systematic review of health IT impacts

INTRODUCTION

Laboratory testing in primary care is a fundamental process that supports patient management and care. Any breakdown in the process may alter clinical information gathering and decision-making activities and can lead to medical errors and potential adverse outcomes for patients. Various information technologies are being used in primary care with the goal to support the process, maximize patient benefits and reduce medical errors. However, the overall impact of health information technologies on laboratory testing processes has not been evaluated.

OBJECTIVES

To synthesize the positive and negative impacts resulting from the use of health information technology in each phase of the laboratory 'total testing process' in primary care.

METHODS

We conducted a systematic review. Databases including Medline, PubMed, CINAHL, Web of Science and Google Scholar were searched. Studies eligible for inclusion reported empirical data on: 1) the use of a specific IT system, 2) the impacts of the systems to support the laboratory testing process, and were conducted in 3) primary care settings (including ambulatory care and primary care offices). Our final sample consisted of 22 empirical studies which were mapped to a framework that outlines the phases of the laboratory total testing process, focusing on phases where medical errors may occur.

RESULTS

Health information technology systems support several phases of the laboratory testing process, from ordering the test to following-up with patients. This is a growing field of research with most studies focusing on the use of information technology during the final phases of the laboratory total testing process. The findings were largely positive. Positive impacts included easier access to test results by primary care providers, reduced turnaround times, and increased prescribed tests based on best practice guidelines. Negative impacts were reported in several studies: paper-based processes employed in parallel to the electronic process increased the potential for medical errors due to clinicians' cognitive overload; systems deemed not reliable or user-friendly hampered clinicians' performance; and organizational issues arose when results tracking relied on the prescribers' memory.

DISCUSSION

The potential of health information technology lies not only in the exchange of health information, but also in knowledge sharing among clinicians. This review has underscored the important role played by cognitive factors, which are critical in the clinician's decision-making, the selection of the most appropriate tests, correct interpretation of the results and efficient interventions.

CONCLUSIONS

By providing the right information, at the right time to the right clinician, many IT solutions adequately support the laboratory testing process and help primary care clinicians make better decisions. However, several technological and organizational barriers require more attention to fully support the highly fragmented and error-prone process of laboratory testing.

Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of International Cancer Benchmarking Partnership data

BACKGROUND

It is unclear to what extent primary care practitioners (PCPs) should retain responsibility for follow-up to ensure that patients are monitored until their symptoms or signs are explained.

AIM

To explore the extent to which PCPs retain responsibility for diagnostic follow-up actions across 11 international jurisdictions.

DESIGN AND SETTING

A secondary analysis of survey data from the International Cancer Benchmarking Partnership.

METHOD

The authors counted the proportion of 2879 PCPs who retained responsibility for each area of follow-up (appointments, test results, and non-attenders). Proportions were weighted by the sample size of each jurisdiction. Pooled estimates were obtained using a random-effects model, and UK estimates were compared with non-UK ones. Free-text responses were analysed to contextualise quantitative findings using a modified grounded theory approach.

RESULTS

PCPs varied in their retention of responsibility for follow-up from 19% to 97% across jurisdictions and area of follow-up. Test reconciliation was inadequate in most jurisdictions. Significantly fewer UK PCPs retained responsibility for test result communication (73% versus 85%, P = 0.04) and non-attender follow-up (78% versus 93%, P<0.01) compared with non-UK PCPs. PCPs have developed bespoke, inconsistent solutions to follow-up. In cases of greatest concern, 'double safety netting' is described, where both patient and PCP retain responsibility.

CONCLUSION

The degree to which PCPs retain responsibility for follow-up is dependent on their level of concern about the patient and their primary care system's properties. Integrated systems to support follow-up are at present underutilised, and research into their development, uptake, and effectiveness seems warranted.

Benefit-risk of Patients' Online Access to their Medical Records: Consensus Exercise of an International Expert Group

Background:  Patients' access to their computerised medical records (CMRs) is a legal right in many countries. However, little is reported about the benefit-risk associated with patients' online access to their CMRs.

Objective:  To conduct a consensus exercise to assess the impact of patients' online access to their CMRs on the quality of care as defined in six domains by the Institute of Medicine (IoM), now the National Academy of Medicine (NAM).

Method:  A five-round Delphi study was conducted. Round One explored experts' (n = 37) viewpoints on providing patients with access to their CMRs. Round Two rated the appropriateness of statements arising from Round One (n = 16). The third round was an online panel discussion of findings (n = 13) with the members of both the International Medical Informatics Association and the European Federation of Medical Informatics Primary Health Care Informatics Working Groups. Two additional rounds, a survey of the revised consensus statements and an online workshop, were carried out to further refine consensus statements.

Results:  Thirty-seven responses from Round One were used as a basis to initially develop 15 statements which were categorised using IoM's domains of care quality. The experts agreed that providing patients online access to their CMRs for bookings, results, and prescriptions increased efficiency and improved the quality of medical records. Experts also anticipated that patients would proactively use their online access to share data with different health care providers, including emergencies. However, experts differed on whether access to limited or summary data was more useful to patients than accessing their complete records. They thought online access would change recording practice, but they were unclear about the benefit-risk of high and onerous levels of security. The 5-round process, finally, produced 16 consensus statements.

Conclusion:  Patients' online access to their CMRs should be part of all CMR systems. It improves the process of health care, but further evidence is required about outcomes. Online access improves efficiency of bookings and other services. However, there is scope to improve many of the processes of care it purports to support, particularly the provision of a more effective interface and the protection of the vulnerable.

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action

Nurses have always been involved in the diagnostic process, but there remains a pervasive view across physicians, nurses, and allied health professionals that medical diagnosis is solely a physician responsibility. There is an urgent need to adjust this view and for nurses to take part in leading efforts addressing diagnostic errors. The purpose of this article is to define a framework for nursing engagement in the diagnostic process that can serve as a catalyst for nurses to engage in eliminating preventable harms from diagnostic error. We offer a conceptual model to formalize and expand nurses’ engagement in the diagnostic process through education, maximize effectiveness of interprofessional teamwork and communication through culture change, and leverage the nursing mission to empower patients to become active members of the diagnostic team. We describe the primary barriers, including culture, education, operations, and regulations, to nurses participating as full, equal members of the diagnostic team, and illustrate our approach to addressing these barriers. Nurses already play a major role in diagnosis and increasingly take ownership of this role, removing barriers will strengthen nurses’ ability to be equal, integral diagnostic team members. This model should serve as a foundation for increasing the role of the nurse in the diagnostic process, and calling nurses to take action in leading efforts to reduce diagnostic error.

Use of text messaging in general practice: a mixed methods investigation on GPs' and patients' views

BACKGROUND

Text messaging has become more prevalent in general practice as a tool with which to communicate with patients.

AIM

The main objectives were to assess the extent, growth, and perceived risks and benefits of text messaging by GPs to communicate with patients, and assess patients' attitudes towards receiving text messages from their GP.

DESIGN AND SETTING

A mixed methods study, using surveys, a review, and a focus group, was conducted in both urban and rural practices in the south-west of Ireland.

METHOD

A telephone survey of 389 GPs was conducted to ascertain the prevalence of text messaging. Subsequently, the following were also carried out: additional telephone surveys with 25 GPs who use text messaging and 26 GPs who do not, a written satisfaction survey given to 78 patients, a review of the electronic information systems of five practices, and a focus group with six GPs to ascertain attitudes towards text messaging.

RESULTS

In total, 38% (n = 148) of the surveyed GPs used text messaging to communicate with patients and 62% (n = 241) did not. Time management was identified as the key advantage of text messaging among GPs who used it (80%; n = 20) and those who did not (50%; n = 13). Confidentiality was reported as the principal concern among both groups, at 32% (n = 8) and 69% (n = 18) respectively. Most patients (99%; n = 77) were happy to receive text messages from their GP. The GP focus group identified similar issues and benefits in terms of confidentiality and time management. Data were extracted from the IT systems of five consenting practices and the number of text messages sent during the period from January 2013 to March 2016 was generated. This increased by 40% per annum.

CONCLUSION

Collaborative efforts are required from relevant policymakers to address data protection and text messaging issues so that GPs can be provided with clear guidelines to protect patient confidentiality.

Adaption, implementation and evaluation of collaborative service improvements in the testing and result communication process in primary care from patient and staff perspectives: a qualitative study

Background

Increasing numbers of blood tests are being ordered in primary care settings and the swift and accurate communication of test results is central to providing high quality care. The process of testing and result communication is complex and reliant on the coordinated actions of care providers, external groups in laboratory and hospital settings, and patients. This fragmentation leaves it vulnerable to error and the need to improve an apparently fallible system is apparent. However, primary care is complex and does not necessarily adopt change in a linear and prescribed manner influenced by a range of factors relating to practice staff, patients and organisational factors. To account for these competing perspectives, we worked in conjunction with both staff and patients to develop and implement strategies intended to improve patient satisfaction and increase efficiency of existing processes.

Methods

The study applied the principles of ‘experience-based co-design’ to identify key areas of weakness and source proposals for change from staff and patients. The study was undertaken within two primary practices situated in South Birmingham (UK) of contrasting size and socio-economic environment. Senior practice staff were involved in the refinement of the interventions for introduction. We conducted focus groups singly constituted of staff and patients at each practice to determine suitability, applicability and desirability alongside the practical implications of their introduction.

Results

At each practice four of the six proposals for change were implemented these were increased access to phlebotomy, improved receptionist training, proactive communication of results, and increased patient awareness of the tests ordered and the means of their communication. All were received favourably by both patients and staff. The remaining issues around the management of telephone calls and the introduction of electronic alerts for missing results were not addressed due to constraints of time and available resources.

Conclusions

Approaches to tackling the same area of weakness differed at practices and was determined by individual staff attitudes and by organisational and patient characteristics. The long-term impact of the changes requires further quantitative evaluation.

Improving Timely Resident Follow-Up and Communication of Results in Ambulatory Clinics Utilizing a Web-Based Audit and Feedback Module

BACKGROUND

Failure to follow up and communicate test results to patients in outpatient settings may lead to diagnostic and therapeutic delays. Residents are less likely than attending physicians to report results to patients, and may face additional barriers to reporting, given competing clinical responsibilities.

OBJECTIVE

This study aimed to improve the rates of communicating test results to patients in resident ambulatory clinics.

METHODS

We performed an internal medicine, residency-wide, pre- and postintervention, quality improvement project using audit and feedback. Residents performed audits of ambulatory patients requiring laboratory or radiologic testing by means of a shared online interface. The intervention consisted of an educational module viewed with initial audits, development of a personalized improvement plan after Phase 1, and repeated real-time feedback of individual relative performance compared at clinic and program levels. Outcomes included results communicated within 14 days and prespecified "significant" results communicated within 72 hours.

RESULTS

A total of 76 of 86 eligible residents (88%) reviewed 1713 individual ambulatory patients' charts in Phase 1, and 73 residents (85%) reviewed 1509 charts in Phase 2. Follow-up rates were higher in Phase 2 than Phase 1 for communicating results within 14 days and significant results within 72 hours (85% versus 78%, P < .001; and 82% versus 70%, P = .002, respectively). Communication of "significant" results was more likely to occur via telephone, compared with communication of nonsignificant results.

CONCLUSIONS

Participation in a shared audit and feedback quality improvement project can improve rates of resident follow-up and communication of results, although communication gaps remained.

Patient perspectives on test result communication in primary care: a qualitative study

BACKGROUND

Although the number of blood tests ordered in primary care continues to increase, efficient systems for the communication of blood test results to patients are lacking. This is a concern in terms of both patient safety and patient satisfaction.

AIM

To gain an understanding of patient perspectives on organisational and technological aspects of current and prospective systems for communicating laboratory test results in primary care, and the influences that impact patients' preferred methods for receiving results.

DESIGN AND SETTING

Qualitative study using patient focus groups in four primary care practices in Birmingham, UK.

METHOD

The primary care practices were purposively selected to ensure they varied in size, socioeconomic environment, and the default pathways they used to communicate test results. A total of 26 patients from the four practices who had had a recent blood test were recruited. Over a 6 month period in 2011, six, 1-hour focus groups were conducted at the four practices involved in the study.

RESULTS

Patients expressed a preference for receiving results from the ordering GP or a clinically qualified member of staff. Suggestions for refining current systems included improved access to phlebotomy appointments, better management of patient telephone calls, and a clear, accessible protocol for the communication of results.

CONCLUSION

Despite the testing and result communication process being a core activity in primary care, it was found that practices could improve their service in a number of areas. Patients described frequent delays and inconsistency in both the level of information and the method of communication, as well as dissatisfaction with non-clinical staff relaying results. Patient preferences for result communication based on their experience of current systems have produced practical suggestions to improve processes.

Test result communication in primary care: a survey of current practice

Background

The number of blood tests ordered in primary care continues to increase and the timely and appropriate communication of results remains essential. However, the testing and result communication process includes a number of participants in a variety of settings and is both complicated to manage and vulnerable to human error. In the UK, guidelines for the process are absent and research in this area is surprisingly scarce; so before we can begin to address potential areas of weakness there is a need to more precisely understand the strengths and weaknesses of current systems used by general practices and testing facilities.

Methods

We conducted a telephone survey of practices across England to determine the methods of managing the testing and result communication process. In order to gain insight into the perspectives from staff at a large hospital laboratory we conducted paired interviews with senior managers, which we used to inform a service blueprint demonstrating the interaction between practices and laboratories and identifying potential sources of delay and failure.

Results

Staff at 80% of practices reported that the default method for communicating normal results required patients to telephone the practice and 40% of practices required that patients also call for abnormal results. Over 80% had no fail-safe system for ensuring that results had been returned to the practice from laboratories; practices would otherwise only be aware that results were missing or delayed when patients requested results. Persistent sources of missing results were identified by laboratory staff and included sample handling, misidentification of samples and the inefficient system for collating and resending misdirected results.

Conclusions

The success of the current system relies on patients both to retrieve results and in so doing alert staff to missing and delayed results. Practices appear slow to adopt available technological solutions despite their potential for reducing the impact of recurring errors in the handling of samples and the reporting of results. Our findings will inform our continuing work with patients and staff to develop, implement and evaluate improvements to existing systems of managing the testing and result communication process.

Communication of Pulmonary Function Test Results: A Survey of Patient's Preferences

Introduction

Physician-patient communication in patients suffering from common chronic respiratory disease should encompass discussion about pulmonary function test (PFT) results, diagnosis, disease education, smoking cessation and optimising inhaler technique. Previous studies have identified that patients with chronic respiratory disease/s often express dissatisfaction about physician communication. Currently there is a paucity of data regarding patient awareness of their PFT results (among those who have undergone PFTs previously) or patient preferences about PFT result communication.

Methods

We undertook a three-month prospective study on outpatients referred to two Pulmonary Function Laboratories. If subjects had undergone PFTs previously, the awareness of their previous test results was evaluated. All subjects were asked about their preferences for PFT result communication. Subjects were determined to have chronic respiratory disease based on their past medical history.

Results

300 subjects (50% male) with a median age (±SD) of 65 (±14) years participated in the study. 99% of the study participants stated that they were at least moderately interested in knowing their PFT results. 72% (217/300) of the subjects had undergone at least one PFT in the past, 48% of whom stated they had not been made aware of their results. Fewer subjects with chronic respiratory disease preferred that only a doctor discuss their PFT results with them (28% vs. 41%, p = 0.021).

Conclusion

Our study demonstrates that while almost all subjects want to be informed of their PFT results, this does not occur in a large number of patients. Many subjects are agreeable for their PFT results to be communicated to them by clinicians other than doctors. Further research is required to develop an efficient method of conveying PFT results that will improve patient satisfaction and health outcomes.