Closing the loop on effective follow-up in clinical practice

Consider this scenario and how it might have turned out differently with better follow-up.

A 53-year-old man sees a general surgeon for a colonoscopy, after having received a positive fecal occult blood test and noted to have a hemoglobin of 72 g/L. The colonoscopy is difficult and is terminated without the surgeon being able to fully visualize the colon. The surgeon orders a CT colonography to rule out a tumour. Unfortunately, the requisition gets lost and the patient never undergoes the procedure. Months later, the patient returns to the emergency department with symptoms of a bowel obstruction. At surgery, a large obstructive tumour is identified. Despite treatment, the patient dies and his family initiates a legal action alleging negligent delay in diagnosis due to the surgeon’s lack of follow-up on the investigation she ordered.

Following up is a professional obligation

Many factors may lead to a diagnostic delay, such as failing to inform a patient of a test result. Physicians can reduce the likelihood of such delays by targeting improvement efforts on their system for following up on laboratory tests, diagnostic imaging, and consultations.

Many provincial and territorial regulatory authorities (Colleges) have policies that set their expectations of physicians for following up on test, imaging, and consultation requests and results. Indeed, having a reasonable system in place to achieve this goal is a professional obligation of physicians. While some types of tests are subject to established follow-up programs (e.g. Papanicolaou smear, fecal occult blood test, mammogram screening), in most other instances the responsibility for following up rests with the ordering physician.

Toward a reliable follow-up system: Getting started

Developing or improving a follow-up system may seem difficult, but the system need not be complicated. A follow-up system should be sufficiently robust so that test requisitions and results are reviewed and acted on in a reasonable period of time.

Start by understanding your practice. Determine what tests you typically order that would have a high likelihood of resulting in harm if mishandled. For example, if you regularly order tests to investigate malignancies (chest X-rays, CT scans, ultrasounds, mammograms, prostate-specific antigen) or coagulopathies (CBCs, INRs), you could focus your initial efforts on establishing or improving a formal system focused on these types of tests.

Don’t stop improving your process after an early success: continuous improvement is key to building a reliable system. When you spot a problem area, use a collaborative approach with other parties involved in the testing process (including nurses, reception staff, lab staff, and consultant physicians) to arrive at a mutually agreeable solution.

Suggested steps in a follow-up system

In a review of CMPA family practice medical-legal cases in which a follow-up issue was found to contribute to a patient safety incident, more than half (60%) of the cases involved a deficiency in one step of the follow-up process while the remaining 40% involved deficiencies across multiple steps.

The diagram below, adapted from the Agency for Healthcare Research and Quality (AHRQ) in the United States, conceptualizes the process of test result follow-up as a series of steps. ¹ Improvements in one or more steps may reduce the risk of failures. A reliable follow-up system includes safeguards at each step so that there is redundancy of defences. If one step fails, another step later in the process ideally compensates for the oversight.

For each step, a potential problem area is described, followed by suggested mitigation solutions. 

1. Test ordered
   Problem: Some tests are ordered incorrectly or unnecessarily. Requisitions are mislabelled, or the physician later does not remember ordering the test or the reason for it.
   Suggested solutions:
   • Order only relevant and necessary testing. ²
   • Minimize variability by using the same ordering process for a given type of test.
   • Train staff to confirm the patient’s and next-of-kin’s contact information when patients register at your office, before you order any testing.
   • In clinics, employ a system that requires each ordering physician to use the correct requisition.
2. Test performed
   Problem: Some patients neglect to have the test performed or experience a long wait time between the test being ordered and performed.
   Suggested solutions:
   • Identify a reasonable deadline date by which you wish to receive the results, taking your practice context into account. Contact patients whose results are not back by that date to remind them to have the test performed.
   • Foster patient engagement in managing their health and following through with testing. Explain the importance of the test and ask patients whether they understand.
3. Result generated / tracked
   Problem: Some critical test results do not receive the needed attention.
   Suggested solutions:
   • Consultants, clearly mark “ABNORMAL RESULT” or “WARNING – UNEXPECTED FINDING” at the top of all abnormal or unexpected results.
   • Verbally notify the requesting physician of critical or unexpected results.
   • If you receive an abnormal result you did not order, ask yourself who the most responsible physician is, who should act on the test result, and consider whether other physicians in the circle of care should be notified.
4. Result returned
   Problem: Some test results do not make it back to the ordering physician.
   Suggested solutions:
   • Set up an electronic reminder (in your EMR or calendar) to check that you received a pending test result by a specified date.
   • Tell your patients they should expect to receive a call from your office prior to the specified date and to call your office if they have not been contacted by then. Explain that this is a safeguard against occasional loss of test results.
   • Instruct locum physicians to keep a list of pending results. Upon your return, review the list and assume responsibility for following up on these results.
   • If you work at many sites, consider how often you visit each location and whether you are able to perform a timely review of test results.
   • If practical, link your billing to the receipt of test results—no test results, no billing.
5. Result reviewed
   Problem: The test result has been returned but the physician did not see it.
   Suggested solutions:
   • Review test results regularly to keep your inbox manageable.
   • Designate and train staff to review test results and flag abnormal ones.
   • Do not click “Reviewed” or “OK” on results you have not reviewed as a means of “getting rid” of an EMR alert or reminder message.
6. Result documented and filed
   Problem: The test result gets filed before the physician has reviewed it.
   Suggested solutions:
   • Train staff not to file reports that you have not reviewed and for which you have not created an action plan.
   • Sign off the results and make a brief note of the action taken.
7. Patient notified of result
   Problem: The patient is not informed of the result or of the required action.
   Suggested solutions:
   • Use telephone prescription refill requests as a trigger to review whether a result is pending, prior to reordering the medication.
   • Set a policy on the number of follow-up phone calls to a patient your office will make concerning a specific test requisition, and when and how to use alternative methods for follow-up (e.g. with prior consent, contacting the patient’s next-of-kin).
   • Create an alert for the issue, which you and your staff will see at the next contact with the patient.
8. Patient monitored through follow-up
   Problem: The physician does not take action on a test result.
   Suggested solutions:
   • If a follow-up investigation is warranted, order it right away where possible (do not wait).
   • Include test results with consultation requests to facilitate prioritization by the consultant.
   • If you are uncertain about a follow-up plan, contact other physicians in the circle of care to verify who is taking action.

Learn more

Visit Workshops to learn more about test result follow-up systems.

• Register for an upcoming CMPA workshop near you: “Is no news good news? Build a more reliable follow-up system for test results.”
• Listen to the CMPA podcast “Creating a reliable system for the follow-up of test results,” and access other useful resources by the CMPA and other organizations.

References

1. 1. 
   Agency for Healthcare Research and Quality [Internet]. Rockville (MD): AHRQ; reviewed 2018 Jan. Improving Your Laboratory Testing Process [cited 2018 Dec]. Available from: https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-care/labtesting-toolkit.html
2. 2. 
   For more information about appropriate use of clinical tests and treatments, visit Choosing Wisely Canada at www.choosingwiselycanada.org 

DISCLAIMER: This content is for general informational purposes and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. Your use of CMPA learning resources is subject to the foregoing as well as CMPA's Terms of Use.