Results and expectations: Test follow-up and the office-based family physician

In brief

• Patient harm can result when test follow-up systems fail or are non-existent.
• Office-based family physicians frequently receive patient complaints related to this aspect of practice, and criticisms often focus on inadequate test follow-up procedures and communication with the patient.
• Among other measures, designing and implementing an effective system of test follow-up procedures and encouraging patient collaboration can help improve patient care.

Communicating test results is a critical part of patient care. Test results that are not attended to in a timely and effective manner can lead to serious patient harm or death.

To better understand gaps in test result follow-up in the Canadian context, CMPA conducted a review of College complaints and legal cases related to the management and communication of non-urgent and urgent test results. Specifically, we reviewed 268 legal and medical regulatory authority (College) cases closed between 2019 and 2023 involving test result follow-up by office-based family physicians.

Our review indicated three key factors contributed to patient safety incidents in these cases:

• a failure to follow or maintain clearly outlined test follow-up procedures
• documentation issues
• communication problems with the patient, family members, or a substitute decision maker.

Of the 268 cases reviewed, patient harm occurred in 250 cases, with one in five cases resulting in severe harm or death.

Case example: Diagnostic delay of an adenocarcinoma

Having not seen their physician for two years, a patient arrives at a small office practice for the resumption of routine visits. The physician orders blood tests and a urinalysis, and asks the patient to return for a digital rectal exam in a week’s time. The patient does not attend the follow-up appointment. When the patient’s blood test arrives several days later, it indicates an elevated PSA level. The physician attempts to inform the patient but is unable to reach them. The contact information on file is out of date.

Eighteen weeks later the patient returns. A digital rectal exam is performed, and a nodule is discovered. The patient undergoes surgical resection for an adenocarcinoma of the prostate and recovers well. In their complaint, the patient asserts that the physician delayed their cancer diagnosis by failing to contact them about the test result showing an elevated PSA level. The College supports the care provided but criticizes the physician for not maintaining up-to-date contact information, not documenting their attempts to contact the patient, and not maintaining a systematic approach to test follow-up.

Documentation and test result follow-up procedures

In 125 of 268 (47%) of the College and legal matters reviewed, peer experts noted documentation as a contributing factor. Tests ordered, reviewed, and plans for follow-up should be clearly documented to facilitate their management and to demonstrate that reasonable efforts were made to contact the patient, should care be questioned. Most EMRs have the capacity to track tests and generate reminders and can be a useful resource for organizing this information.

Evidence also suggests that having well-defined systems, policies, and procedures for following up on test results improves effectiveness. In 31% of cases, physician providers were criticized for procedural flaws involving test result follow-up, such as failing to read or review the patient’s results, failing to advise the patient in a timely manner, or failing to have an adequate process in place for reviewing results.

In the cases reviewed, peer experts indicated clear expectations around the design of test follow-up systems. In addition to specific procedures for record-keeping, requisition tracking, and patient communication, experts recommended that systems include provisions for flagging significant test results, generating reminders (e.g. test receipt and review, informing patients, confirming referrals), and integrating safeguards (i.e. back-up strategies and procedures anticipating system failures).

Communication with the patient

Our review indicated that breakdowns in patient communication were the most common contributing factor in test follow-up matters. Of 268 College and legal matters, 104 (39%) involved communication problems with patients, family members, or substitute decision makers.

One promising strategy for addressing this gap is patient engagement. In Canada, tools and networks such as Québec’s Health Booklet, MyHealthRecords in Alberta, and MyChart in Ontario and British Columbia have, for several years now, established patient portals that provide patients online access to common lab tests, imaging, and vaccination records. Alberta is also rolling out MyAHS Connect that will give patients access to their health information stored in Connect Care, a centralized and standardized provincial system that allows healthcare providers to access patient information from a single source.

While physicians are responsible for communicating and following up on test results, encouraging a mutual sense of responsibility for follow up with the patient may contribute to the development of a safer and more reliable test follow-up system. However, it remains important for physicians to communicate directly and promptly with patients when a test result is significant or where it may be difficult for the patient to comprehend its meaning. This is the case despite the patient’s ability to access their test results via an online portal. Patient portals also do not indicate to the patient why a particular test was ordered in the first place. Communicating at the outset with the patient about the importance of a particular test is a central aspect of fostering patient engagement in the testing and follow up process.

Additional reading

• Closing the loop on effective follow-up in clinical practice
• Managing stress when transitioning to new electronic record systems

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.