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Closing the Loop on Test Results to Reduce Diagnostic Errors


By Sue Sheridan, MIM, MBA, DHL, director of Patient Engagement, Society to Improve Diagnosis in Medicine, and Hardeep Singh, MD, MPH, chief of Health Policy, Quality & Informatics Program, Center for Innovations in Quality, Effectiveness and Safety based at Michael E. DeBakey VA Medical Center and Baylor College of Medicine, and director of Houston DISCovery (Diagnosis Improvement Safety Center)

Diagnostic errors affect 1 in 20 adult patients in outpatient settings and can result in harm from delayed testing and treatment. In 2015, the National Academy of Medicine (formerly known as the Institute of Medicine) developed a patient-centered definition of diagnostic error as a failure to:

  • establish an accurate and timely explanation of the patient’s health problem
  • communicate the explanation to the patient

One type of diagnostic error occurs from the failure to communicate important test results to patients.  To address this important and common problem, the Joint Commission issued Quick Safety 52: Advancing Safety with Closed Loop Communication of Test Results with input from the Society to Improve Diagnosis in Medicine (represented by author SS) and the research community (represented by author HS). While in 2005, the Joint Commission identified the timely reporting of critical test and diagnostic procedure results as a National Patient Safety Goal (NPSG.02.03.01), implementation has been inconsistent so far. Additionally, this goal does not address the risk related to communicating “sub-critical” test results that are not life threatening and are often communicated through nonverbal channels.

Failure Points Are System-wide
Closed loop communication requires that every test result is:

  • sent (e.g. from the lab or radiologist to the referring clinician)
  • received (e.g. received electronically by the referring clinician’s electronic medical record)
  • acted upon ( e.g. patient is notified of test result and next step)

These processes are essential in reducing diagnostic error and require coordination between multiple parties to:

  • hand off tests
  • interpret results
  • communicate results in a language that patients can understand

But patients may not be informed about an abnormal result in a timely manner. In fact, a systematic review reported that 6.8 to 62% of laboratory results and anywhere from 1 to 36% of radiology results are not communicated, which sometimes leads to missed cancer diagnoses. This occurs despite patients’ preferences for having all results—normal and abnormal—communicated to them. Workflow factors and confusion about who is responsible for following up with patients can lead to some of these communication breakdowns.

Failure to close the communication loop is also among the contributing factors for high-severity medical malpractice claims. 

Role of the Electronic Health Record
The electronic health record (EHR) should help avert these communication lapses, but results have been mixed. Almost 8% of abnormal outpatient test results transmitted as EHR-based asynchronous notifications lacked follow-up at four weeks.

Several non-technical factors affect the use of the EHR in closing the follow-up loop, including:

  • user behaviors
  • EHR usage practices
  • policies and procedures related to communication and follow-up
  • training issues
  • organizational practices
  • workflow-related issues

Online patient portals have made it easier for patients to access test results, although some studies suggest they don’t present information in a way that is meaningful. Not all patients use portals. Some patients prefer person-to-person communication to discuss results or have other reasons for not accessing the patient portal. Even when patients use the portals to check results, many do not receive any contextual information to understand the meaning of these test results.

Several suggested practices to improve patient portals include:

  • ensuring accessibility on mobile and large-format computer platforms
  • providing and promoting patient access to the EHR, optimally including real-time clinical notes and diagnostic testing results
  • explaining test results directly in the portal
  • providing easy access to support services and contextual information for next steps
  • creating consensus and standards on timing for the portal’s release of normal and abnormal test results

Safety Actions 
Several safety actions can help clinicians and health care organizations get the correct test information to the right individual, including the patient, to close the loop.
1. Identify workflows particularly vulnerable to mishandling of test results (such as results ordered by trainees or covering clinicians) and develop back-up procedures to ensure results are received by someone responsible for the affected patient’s care. Implement procedures to address handoffs and care transitions.
2. Establish consistent processes to ensure results are communicated to the clinician responsible for follow-up care.
3. Notify patients and providers of life-threatening test results verbally and ensure positive confirmation of receipt.
4. Forward or escalate to an alternative responsible provider any abnormal test results that remain un-received or unacknowledged after a pre-specified time period.
5. Keep contact information for providers updated and ensure that test results are communicated to a back-up provider if the ordering provider is not available. Timeliness is dependent upon the significance of the test result.
6. Optimize your organization’s IT capabilities to improve communication of test results (see ONC SAFER Guides).
7. Improve your organization’s online patient portals to help patients access test results and track medical histories.

Several other resources for improvement are mentioned in the Quick Safety. In the era of information technology and process improvement, we should build systems that make communication of test results fail-safe. Thanks to research in this area, we now know how to do better. The time to act is now. 

Hardeep Singh is a professor of medicine at the Center for Innovations in Quality, Effectiveness and Safety based at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX. He leads a portfolio of multidisciplinary patient safety research in improving the use of health information technology and reducing diagnostic errors. His research has informed several national and international patient safety initiatives and policy reports, including those by the National Academies, CDC, NQF, AMA, AHRQ, OECD and the WHO.  He has received several prestigious awards for pioneering work in the field, including the AcademyHealth Alice S. Hersh New Investigator Award in 2012, the Presidential Early Career Award for Scientists and Engineers (PECASE) from President Obama in 2014 and the VA Health System Impact Award in 2016.
Susan E. Sheridan, MIM, MBA, DHL, currently serves as the Director of Patient Engagement for the Society to Improve Diagnosis in Medicine (SIDM). Prior to her work at SIDM, Sheridan served as patient and family engagement adviser at the Centers of Medicare and Medicaid Services (CMS), director of patient engagement for PCORI and was the external lead of the Patients for Patient Safety program at the World Health Organization (WHO).  She cofounded and is past president of Parents of Infants and Children with Kernicterus (brain damage from jaundice), and is also the cofounder of Consumers Advancing Patient Safety, which helps organizations engage patients as partners in developing patient-safety solutions.