Managing Patient Information Longitudinally
Commentary about Management of Laboratory Test Results in Family Practice
Between competing feelings of fatigue and satisfaction from a busy day of helping others, I am occasionally unsettled by a gnawing distraction: Did I miss anything today?
Most of us accept that some inherent uncertainty exists in the practice of medicine. Family physicians depend on minor obsessive-compulsive rituals to prevent subtle mistakes that may result in catastrophe. The Institute of Medicine released a report last year highlighting the large number of medical errors that shorten lives in the United States. However, family physicians are less likely to commit overt errors of commission, mistakenly taking a wrong action. Our errors are more subtle acts of omission: We forget, lose, misplace, or simply do not prioritize some piece of information that, in retrospect, should have changed our approach to a patient problem.
Optimal patient care requires the right action at the right time. Researchers in the United States spend significant resources attempting to decipher the right action for a multitude of health problems but fail to examine patient management issues in the context of longitudinal care for individuals. Errors occasionally occur because we do not take the right action, but more often we do not take the action at the right time, especially for chronic diseases.
Two recent studies provide evidence of potential primary care errors where the sense of immediacy may have been blunted by the steady march of time. Schootman and colleagues3 found that 14% of abnormal findings on breast cancer screening had inadequate follow-up. McBride and coworkers4 showed that documentation of appropriate management for cardiovascular disease risks (such as management of cholesterol >200mg/dL) was found in approximately 65% of charts. Although these studies do not specifically address medical errors in primary care practices, they do suggest that we should strengthen our office management procedures to reduce potential errors, especially those relating to follow-up of potential health problems.
In this issue of the Journal, Mold and colleagues5 report their examination of methods for managing laboratory information and offer an interesting glimpse into how practice-based research can be used to investigate common primary care problems where errors may occur. Ordering a laboratory test is the inciting event for cascading actions and reactions intended to provide clinical clarity, better patient health, and a satisfied clinician. However, too often we must contend with inadequate specimens, reports that do not return in their usual time frame, or the wrong laboratory test being done. In spite of these potential traps, we remain trusting of our abilities to avoid catastrophic medical outcomes.
Mold and coworkers explored the management and reporting of laboratory tests with the goal of finding best practices. The greatest asset of this study is its description of real world practice. The authors did not test for best practices. To test, one must rigidly control extraneous variables and compare a practice with other known strategies. The importance of this study lies in the direction it points and its intended destination. Mold and colleagues asked an important question, examined practices, and sought improvement through practice-based research.
Laboratory management
Mold and coworkers examined 4 steps in the management of laboratory testing. The first step is tracking tests until results are received. Developing a system that tracks physician orders, specimen collection, specimen transport and receipt, and return of results over time is vital to effective quality monitoring. The complex portion of this task appears to be what happens between the day of collection and receipt of results. The optimal practice in this study used a log in the laboratory with a second registry using billing data.
However, logbook information is isolated from the medical record and devoid of the pertinent patient information found there. Laboratory information management is really patient information management. The process of tracking information in the form of a question until it becomes an answer is a complex task. Seamless information systems that can link our office notes and plans to laboratory and radiological assessments are eagerly sought improvements to clinical practice.
Tracking information over time is difficult because no standard formats exist for how information should be organized. Laboratory management is similar to other pieces of data that we attempt to track. Examples include disease-specific measures, such as diabetic flow sheets and preventative strategies such as Papanicolaou tests, lipid testing, or documentation of smoking status. The problem is that tracking tools can distance us from patient-specific data that provide useful cues to improve effective care. Practicing primary care clinicians must eventually develop patient-specific information that is accessed at the right time.
Notifying patients of results is the second step in laboratory management. Mold and coworkers found that laboratory results can be most simply explained with a note on the laboratory report mailed to the patient. Patients expect information to be in the form of clear answers. Unfortunately, information obtained from laboratory testing may not always clarify a condition, and ambiguous laboratory results may confuse patients. Further research in primary care should seek to elucidate the determinants of high-quality communication. We should test other strategies for communicating results to patients. Allowing them an opportunity to participate in their own medical decisions has been shown beneficial.6 Despite these complexities, this study encourages us to simplify our processes to ensure that patients are notified.
