Diagnostic Test Tracking: A Common Source of Claims

Diagnostic testing is a foundation of the healthcare encounter. The Centers for Disease Control and Prevention estimates that 70% of medical decisions are based on laboratory test results. These tests are routinely performed in both inpatient and outpatient settings. The Agency for Healthcare Research and Quality estimates that 40% of patient encounters in the primary care office setting involve diagnostic testing. 

While technological advances have streamlined diagnostic testing orders, improper test result management is a frequent source of patient harm and liability. Systems to track tests and follow up with patients and practitioners vary from practice to practice and sometimes even among physicians within a practice. 

Diagnostic error resulting from mismanagement of test results is a significant contributor to patient harm. For this article, Coverys has analyzed 1,622 diagnosis-related claims that were closed from 2018-2022 to better understand the factors contributing to those claims. While this data is not absolute, it provides valuable signals that can lend insight into existing vulnerabilities and allow practitioners and organizations to implement proactive risk strategies. Below are some key insights gleaned from that data: 

Mismanagement of test results is a frequent contributor to diagnostic error claims. 

 

Claims resulting from diagnostic error can be serious. 

Over half of the events that give rise to diagnostic error claims occur in the office setting or in the emergency department.

Practitioners face the challenge of accommodating an ever-growing number of patients in a decreasing amount of time. Most of these patients will require diagnostic testing and follow-up at some point in the care continuum. Despite patients’ increased involvement in their own care, the burden remains on practitioners to ensure that no patient “slips between the cracks” after leaving the office or hospital. Well-designed clinical systems and a proactive risk management strategy are essential in reducing the risk of error related to the management of test results. 

Risk Management Recommendations

Mitigate risks associated with improper test result management by standardizing and improving clinical systems and communication. Continuous monitoring for systems issues and variances is important in maintaining high compliance levels. Consider the following strategies when reviewing your organization’s test tracking process: 

• Establish a standardized test-tracking system. Design test-tracking systems to ensure proper transmission, receipt, and interpretation of test results, as well as timely follow-up. Work with a multidisciplinary team to design a system that decreases the risk of overlooked test results.  Implement a systemwide, standardized process for managing test results. Essential tracking system elements include:
  • Expectations regarding timely practitioner follow-up.
  • A process for managing non-critical results received by phone.
  • A process for practitioners to review, sign, and date test results and consult reports.
  • Expectations regarding communication of test results to patients.
  • Requirements for documentation of all communications and notifications.
  • A process to ensure patient follow-through with recommendations made regarding test result follow-up.

Centralized follow-up allows other practitioners to provide patient care if the primary practitioner is away. Keep and monitor a tracking log to screen for unreturned results or reports. Conduct regular test-tracking audits and follow-up as part of the organization’s performance improvement process. 

• Manage critical results. Develop and implement a critical values policy that specifies: 
  • Persons who transmit and receive critical values results.
  • Verification process.
  • Time limit for reporting critical results.
  • Time frame for follow-up with final report.
  • Person(s) who receives results when the ordering/managing practitioner is unavailable.
  • Dissemination of results to practitioners and patients after hours.
  • Requirements for documentation of critical values in the medical record.
  • Process for following up with patients regarding critical values results following their discharge from the emergency department. 
• Manage incidental findings. Develop and implement a system for managing test results that are electronically received by a non-ordering physician. Ensure that all practitioners, regardless of whether they ordered the study, address any electronically received abnormal test result, communicate the test result to the ordering practitioner and/or the patient, and document these details in the patient’s medical record accordingly.
• Involve patients. When ordering tests, set expectations with patients regarding follow-up. Instruct patients to call the office if they have not received their test results within a certain time frame. Empower patients to access their test results via the patient portal and to call the office with any questions. Request notification, not only when a patient receives the test result, but when the patient does not open the test result within a certain period. Use an alternate method, such as certified mail, to notify patients of test results if the patient does not use the portal or you cannot reach the patient by telephone. 
• Leverage EHR capabilities. While the electronic health record (EHR) provides a platform for comprehensive medical information management, many of its capabilities are not fully understood or utilized. The computerized physician order entry (CPOE) simplifies the test ordering process and helps practitioners ensure correct test ordering. Work with vendors and your information technology department to optimize CPOE use, clinical decision support tools, automated processes, and reminder technologies. Establish queries or run reports that identify the patient’s name, test performed, lab used, date the report is received, practitioner review, and patient notification. Train practitioners on these EHR capabilities and how they can ensure loop closure on test result follow-up. 
• Follow up consistently. Develop a policy for communicating test results to patients that includes the person responsible for notification, notification time frames, and methods to ensure that the patient knows/understands the result. Schedule follow-up appointments after ordering a test, after abnormal results, and when repeat or deferred testing is suggested. Document all communications with patients regarding test results, all efforts to reach the patient or reschedule appointments, and all missed, cancelled, or “no-show” appointments. Identify at-risk patients who require periodic monitoring and have a system in place for ensuring that these patients make and keep appointments. If unable to reach a patient who has an abnormal result or high-risk condition, consider sending a letter by certified and regular mail. 
• Monitor results. Ongoing monitoring of test tracking and follow-up processes is an integral component of a successful quality improvement program. Self-assessment and regular compliance audits can alert you to workflow issues, workarounds, and other process obstacles that can contribute to diagnostic error. 

Mismanagement of test results is a major contributor to diagnostic error. Regardless of whether a tracking system involves manual tracking or sophisticated EHR capability, a well–designed system can reduce the likelihood of diagnostic error and enhance patient safety.
 

Additional Resources

• A Dose of Insight: Diagnostic Accuracy Room For Improvement
• RisKey: Effective Communication of Incidental Findings: Vital for Patient Safety