Computerized Alerts Improve Outpatient Laboratory Monitorin of Transplant Patients

J Am Med Inform Assoc. 2008;15:324 –332. DOI 10.1197/jamia.M2608. ic.p.com jam ia/article-at/15/3/324/728650 by gest on 11 Jauary 2019 Background Especially for patients on anticoagulation, immunosuppression, and other therapies requiring ongoing monitoring, laboratory testing provides key information for clinical decision making. National patient safety efforts have targeted the need to improve communication about laboratory results. The 2005 Ambulatory Care National Patient Safety Goals of the Joint Commission stated that organizations should “assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results.” The Agency for Healthcare Research and Quality advises patients, “If you have had a test, don’t assume no news is good news.” New strategies for patient safety include communicating results of tests directly to patients. The plethora, diversity, and de-centralized nature of laboratories, data storage systems, and communication modes all Affiliations of the authors: Department of Biomedical Informatics, University of Utah School of Medicine (RSE, SMH, SPN, CJS, BHSCR), Salt Lake City, UT; Department of Medical Informatics (CJS, RSE, SMH, SPN), Intermountain Healthcare, Salt Lake City, UT; Liver, Kidney, Pancreas Transplant Program (JBS, JA), LDS Hospital, Salt Lake City, UT; Dr Staes and Dr. Narus are currently with the Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT; Dr. Sorensen is currently with the Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT. The authors thank the LDS Hospital transplant team, Intermountain Healthcare, and the National Library of Medicine (training grant #2T15LM07124) for their support with this project. Correspondence: Catherine J. Staes, BSN, MPH, PhD, Department of Biomedical Informatics, University of Utah, HSEB suite 5515E, 26 South 2000 East, Salt Lake City, Utah, 84112; e-mail: Catherine.Staes@hsc.utah.edu . Received for review: 08/30/07; accepted for publication: 01/22/08. complicate laboratory result communication. Clinicians communicate with multiple laboratories using faxes, phone, mail, and electronic systems that passively or actively report results. The heterogeneous nature of laboratory sources and reporting methods often leads to lost or delayed results and may impact patient outcomes. In a recent study, Smith et al. found that completed laboratory results were unavailable during 6% of all primary care outpatient visits. Clinicians indicated that missing information resulted in delayed care or duplicative medical services in 60% of the visits with missing clinical information. In another study, Lin et al. found that 46% of the resident physicians working in an outpatient clinic had seen a patient’s medical condition worsen due to a delay in test result follow-up. Several studies document physicians’ concerns about the availability and timeliness of results, the ability to detect patients overdue for follow-up, and the ability to prioritize and respond to abnormal (not critical) results. Clinicians at the liver transplantation program at LDS Hospital in Salt Lake City, Utah, have had similar concerns. LDS Hospital is part of the Intermountain Healthcare (Intermountain) enterprise. Liver transplant patients undergo periodic outpatient testing to identify clinical complications (such as deteriorating renal function and organ rejection) at the earliest possible time, and to monitor appropriateness of medication dose. At LDS Hospital, transplant patients have “standing orders” for laboratory testing to be performed at any laboratory from three times a week to every three months, depending on the patient’s status and the time from transplantation. To obtain laboratory results, nurses had to telephone the (possibly remote) laboratory that performed the tests, or log into a patient’s electronic health record (EHR), and also find any results that arrived on the fax/printer from a variety of laboratories internal and external to the Intermountain network. Since 2001, the InterJournal of the American Medical Informatics Association Volume 15 Number 3 May / June 2008 325 D ow naded rom http/academ ic.p.com jam ia/article-at/15/3/324/728650 by gest on 11 Jauary 2019 mountain EHR included all laboratory results generated from five Intermountain clinics and 17 hospitals (including LDS Hospital) located throughout Utah and southern Idaho, as well as other electronic patient data from multiple inpatient and outpatient sources. The clinicians, often unaware of new results saved to the EHR, depended on a phone call from the patient, a paper report, and their own memory to track all the liver transplant patients. The LDS transplant office staff and medical assistant manually sorted every laboratory report received. The medical assistant and the transplant nurses reviewed and transcribed results to paper flowcharts. A medical assistant often spent more than two hours each day sorting and transferring laboratory results from faxed reports to the flowchart. Clinicians at LDS Hospital used the paper flowchart as the primary longitudinal record for decision-making because it integrated laboratory results and medication dosages from all sources side by side. While clinicians had meticulously implemented this process, they feared they were missing results, and requested a better system for tracking laboratory data.