Step 2: Patient Notification
Twenty patients who had been seen by the physician 2 weeks to 3 months earlier and who had laboratory tests ordered were chosen at random by the research assistant. A letter and a return postcard were sent to each of the patients asking whether they remembered having the test done, whether they were notified of the results, how soon they were notified, whether they were satisfied with the method used to notify them, and whether they had any suggestions for improving the notification process. No attempt was made to contact nonresponders.
Step 3: Documentation of Notification
The research assistant, using the same selection process as for Step 2, reviewed the patients’ charts for evidence of documentation that the results of tests ordered at the index visit had been communicated to the patients.
Step 4: Follow-Up Tracking
Twenty patients who had been seen by the physician 2 to 3 months earlier, who had abnormal test results, and for whom follow-up recommendation had been made, were identified from billing records and encounter forms by the research assistant. Patients asked to follow up at some point beyond the audit date were excluded. Charts were reviewed for evidence that the patients had either followed up as recommended or that the clinic had recognized their failure to follow up and had made an attempt to contact them.
Analysis
We tabulated the audit results. For each step, the 2 methods were compared with each other and with the following performance criteria: (1) >90% satisfactory accomplishment of the step; (2) for step 2, >90% patient notification rate within 2 weeks; and (3) for step 2, >90% patient satisfaction. It was possible to identify effective methods for the first 3 steps in the laboratory test management process. At that point, the research assistant went back to the practices using the more effective methods and observed the time and material costs of implementing each component of the strategy (time-motion study). Each step was directly observed and timed for 5 consecutive sets of laboratory tests for 5 patients seen on the same day. The results were averaged.
Results
Twenty-three of 24 physicians (96%) responded to the questionnaire. A summary of the results is shown in [Table 2]. Eleven of 23 physicians (48%) said that they had a method that worked well for at least 1 of the 4 management steps. Four respondents reported having an effective method for step 1 (tracking test results). All reported using either a laboratory test log, billing slips, or a computerized system. Ten respondents reported having an effective method for step 2 (patient notification of test results). Of these, 5 had their nurse call the patient with test results or discussed the results at a follow-up appointment, and 3 sent the laboratory result with a hand-written note from the physician with or without an additional explanatory form. One mailed a patient-friendly form without the actual test results, and 1 did not elaborate on his method. Ten respondents reported having an effective method for step 3 (documentation of patient notification). The method that all of them reported using for this step was documentation on the laboratory sheet. Only 3 of the respondents reported having an effective method for step 4 (follow-up tracking). Of these, 2 relied on attempts to call no-shows to their offices, and 1 did not elaborate on his method.
Practice Audits
Step 1: Test Tracking At the first practice chosen to evaluate this step, a manifest logbook was used to record all tests sent to an outside laboratory. The nurse who drew the blood was responsible for entering the information in the logbook. In-house laboratory tests were not recorded, as they were generally completed while the patient was in the office. The nurse checked the book daily and marked any outstanding test results with colored self-adhesive notes. When the results came in, the same nurse initialed and dated the entry in the book and removed the note. If the test results were not back within the expected time period (dependent on the test ordered), the nurse called the laboratory and notified the physician if the specimen needed to be obtained again. The nurse initialed laboratory test reports as they came in and took them to the physician for review.
The audit of this method revealed that 15% of the laboratory tests ordered were not recorded in the manifest logbook (the nurse said she must have forgotten to do so), and 5% of the tests sent to outside laboratories were marked received on the log but were not found in the chart. In addition, at least 1 in-house test result was missing from the charts of 15% of patients for whom these tests were ordered.