At the second practice, an internal referral form was used to track patients referred within the practice for follow-up of abnormal results. When patients failed to show up for a scheduled follow-up appointment, attempts are made to contact them, and these attempts were recorded on the internal referral form. If several unsuccessful attempts were made to contact the patient, the form came back to the physician. If a patient did not show up for an outside consultation, the consultant usually notified the physician. The results of the audit revealed that 35% of the patients whose charts were reviewed had not followed up as recommended in 3 months, and 10% followed up much later than recommended. None of the charts of those patients who followed up late or not at all contained documentation of attempts to contact the patient. We did not believe that the other physicians’ practices were sufficiently different from these 2 approaches to warrant audit.
Combined Best Method
Considering effectiveness, efficiency, and ease of use, we concluded that a combination approach using the methods from the second practices audited for steps 1, 2, and 3 represented the best method that we could identify within our network for managing those steps. We were not happy with either method audited for step 4. The combined method for steps 1 to 3 is summarized in [Table 3]. The results of the time-motion studies are shown in [Table 4].
Discussion
This is the first attempt that we are aware of to describe an effective method for the comprehensive management of laboratory test results in the primary care setting. The results of the physician survey (Table 3) demonstrate the diversity of methods being used by practicing physicians. Laboratory test results are handled differently by individual practices and by physicians within the same practice. By self-report, a substantial percentage of these physicians fall short of optimal performance in this area.
The method that we propose on the basis of our findings involves a dual registry of tests ordered and returned (laboratory logbook and nurse billing slip copy) and a uniform system for patient notification and documentation. It is possible that in some practices a single-entry system may work, especially if there is a paid laboratory technician who is held accountable to manage this. However, our findings agree with 2 British studies6,7 that also suggest that a single-entry system often does not work adequately. We believe that it is important to have a uniform system with very little decision making required on the part of staff. We also think it important to provide patients with their actual results, not just a report stating they were normal.
We were unsuccessful in identifying a method that is effective for the follow-up of abnormal laboratory test results. Our guess is that this will require some kind of tickler file system with postcards sent to patients who appear to have not followed up as suggested. It may also be that methods could be developed, such as the one described by Del Mar and Wright10 in which the outside laboratory participates in the follow-up process.
We do not claim that our best method is the only method that will work. The number of clinicians surveyed and audited was small, they all practice in the same geographic area, and many of them were trained in the same institution. The response rates on the patient audits for step 2 were only 65% and 45%, raising the possibility that those who did not respond were unhappy with the methods used. Anecdotally, however, we have subsequently implemented steps 2 and 3 in one of our University-based clinics, and they seem to work extremely well. Our nurse loves it, and we have had no patient complaints.
Telephonic methods of managing laboratory test results are now available. These allow physicians to dictate personalized messages to patients about their results. Patients access the information by calling a designated number and using their own personal identification code. Reports are generated for the physician indicating which patients called for results so that another notification method could be used for those who did not. These services typically do not address steps 1 and 4, and it was the feeling of the clinicians in our network who had tried them that the services failed for enough patients that a back-up method was necessary.
The largest portion (43%) of the cost of the method is physician time. In theory this portion is billable within the evaluation and management (E/M) codes. Most practices also charge a laboratory collection fee. Our experience has been that on average a practice can collect approximately $3.00 of an $11.00 collection fee billed to patients’ insurance. This varies by insurance carrier and does not apply to capitated systems. This must cover the costs of test result management and the venopuncture, packaging, and labeling of specimens as well. We estimate that primary care physicians who manage test results lose approximately $5.00 on each set of tests sent out on an individual patient unless they properly incorporate the costs into the E/M charge for the visit.