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ral
BMC Medical Informatics and
ssBioMed CentDecision Making
Open AcceResearch article
Improving follow-up of abnormal cancer screens using electronic
health records: trust but verify test result communication
Hardeep Singh*1,2, Lindsey Wilson1, Laura A Petersen1,2, Mona K Sawhney1,
Brian Reis1, Donna Espadas1 and Dean F Sittig3
Address: 1The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication and the Houston VA HSR&D Center
of Excellence at the Michael E DeBakey Veterans Affairs Medical Center, VA Medical Center (152) 2002 Holcombe Blvd, Houston, TX 77030, USA,
2Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Michael E DeBakey Veterans Affairs Medical Center
(MEDVAMC), HSR&D Center of Excellence (152) 2002 Holcombe Boulevard, Houston, TX 77030 USA and 3The Center of Inquiry to Improve
Outpatient Safety Through Effective Electronic Communication, University of Texas School of Health Information Sciences and the UT-Memorial
Hermann Center for Healthcare Quality & Safety, 6410 Fannin, UPB 1100 Houston, Texas 77030-3006, USA
Email: Hardeep Singh* - hardeeps@bcm.tmc.edu; Lindsey Wilson - lawilson@bcm.tmc.edu; Laura A Petersen - laurap@bcm.tmc.edu;
Mona K Sawhney - sawhney@bcm.tmc.edu; Brian Reis - bareis@bcm.tmc.edu; Donna Espadas - despadas@bcm.tmc.edu;
Dean F Sittig - Dean.F.Sittig@uth.tmc.edu
* Corresponding author
Abstract
Background: Early detection of colorectal cancer through timely follow-up of positive Fecal
Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive
FOBT results eligible for colonoscopy had no documented response by a treating clinician at two
weeks despite procedures for electronic result notification. We determined if technical and/or
workflow-related aspects of automated communication in the electronic health record could lead
to the lack of response.
Methods: Using both qualitative and quantitative methods, we evaluated positive FOBT
communication in the electronic health record of a large, urban facility between May 2008 and
March 2009. We identified the source of test result communication breakdown, and developed an
intervention to fix the problem. Explicit medical record reviews measured timely follow-up
(defined as response within 30 days of positive FOBT) pre- and post-intervention.
Results: Data from 11 interviews and tracking information from 490 FOBT alerts revealed that
the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not
configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon
correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to
5.4% (p < 0.01) and was sustained at month 4 following the intervention.
Conclusion: Electronic communication of positive FOBT results should be monitored to avoid
limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are
needed to achieve this. Our methods may be useful for others seeking to improve follow-up of
FOBTs in their systems.
Published: 9 December 2009
BMC Medical Informatics and Decision Making 2009, 9:49 doi:10.1186/1472-6947-9-49
Received: 11 August 2009
Accepted: 9 December 2009
This article is available from: http://www.biomedcentral.com/1472-6947/9/49
© 2009 Singh et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 7
(page number not for citation purposes)
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BMC Medical Informatics and Decision Making 2009, 9:49 http://www.biomedcentral.com/1472-6947/9/49Background
Fewer than 75% of patients with abnormal cancer screen-
ing examinations receive follow-up diagnostic care subse-
quent to the initial screening [1-5]. This inadequate
follow-up of abnormal cancer screens compromises the
benefits of population-based screening programs [6-9].
For instance, the rate of follow-up for positive fecal occult
blood test (FOBT) results in the Veterans Affairs health
care system is low; more than 40% of veterans with posi-
tive FOBTs may not be receiving timely diagnostic colon-
oscopies [10,11]. Lack of timely follow-up has also been
documented outside the VA system [12,13].
An important, largely preventable but relatively unex-
plored reason for lack of follow-up is a problem in com-
munication of the positive test result from the laboratory
to the clinician who ordered it [14,15]. The use of elec-
tronic health records, especially those that utilize such fea-
tures as automated communication of abnormal results
from laboratories to clinicians, can potentially improve
follow-up of abnormal cancer screens [16-19]. Electroni-
cally "alerting" the ordering provider about an abnormal
test result such as positive FOBT can improve the availa-
bility of vital information at the point of care [18]. As one
of several multifaceted interventions to improve follow-
up of positive FOBTs, our institution previously imple-
mented standard operating procedures for the electronic
health record's test result communication system [19],
including the transmission of a mandatory alert to the
patient's clinician for every positive FOBT result. This pro-
cedure was expected to reduce breakdowns in communi-
cation between the laboratory and clinicians.
A significant increase in timely responses to positive FOBT
notifications (defined as a documented response within
two weeks of the test) followed implementation of this
and several related interventions. However, we found that
40% of automated notifications of FOBT results had no
documented response by a treating clinician at two weeks
even though all of the patients with these positive FOBT
tests were eligible to receive a diagnostic colonoscopy.
Our research question was to determine why a large
number of FOBT alerts were not followed by clinician
response at 2-weeks and to investigate if technical and
workflow-related aspects of automated communication in
the electronic health record were responsible. We also
sought to implement and evaluate a potential solution to
the issue(s) we identified.
Methods
The study was conducted at the Michael E. DeBakey Veter-
ans Affairs Medical Center and its satellite clinics and was
approved by the local institutional review board. We used
ysis [20] to uncover potential workflow or technical rea-
sons for lack of clinician response to positive FOBT
results. We conducted eleven semi-structured interviews
with key informants from the laboratory, primary care,
and information technology sections to gather details
related to FOBT alert generation, transmission, and
receipt. Concurrently, we obtained quantitative data to
track the alert receipt and follow-up actions by providers.
Clinicians in the VA health care system receive notifica-
tions of high-priority information such as abnormal test
results in a "View Alert" window of the electronic health
record. To understand the technical issues surrounding
electronic communication, we analyzed and mapped the
associated system-level processes involved. We discovered
that the FOBT alert communication system is driven by an
underlying component of the electronic health record that
continually monitors test order and result entry. Alerts are
automatically generated and recipients selected based on
a set of predefined rules and parameters. For instance,
entry of a test result such as positive FOBT (which was pre-
determined to be a high-priority test result) will generate
an automated notification to one or more clinicians. The
proper recipients for this notification are chosen based on
the setting of certain system parameters. After delivery to
recipients, alerts stay active in the clinician's inbox up to
two weeks, or until acknowledged.
Using the alert tracking system of the electronic health
record, we identified all positive FOBT alerts transmitted
daily during our study period. Approximately three weeks
after alert generation, a trained physician reviewed the
electronic health record for evidence of timely FOBT fol-
low-up using a standardized data collection form that had
been pilot tested in previous work [19]. Any documented
response to the FOBT, such as colonoscopy referral,
patient notification, or mention of exclusion criteria for
colonoscopy, was considered timely follow-up. If no fol-
low-up action was documented, an additional investiga-
tor confirmed the findings and called the ordering
clinician (usually the primary care practitioner-PCP). If
the clinician gave convincing information to support any
undocumented actions, we considered this response as
evidence of timely follow-up as well. We also recorded cli-
nicians' comments and actions.
Following a trail of positive FOBTs that were found to
have lack of timely follow-up, we used purposeful sam-
pling and snowball techniques to identify our study sub-
jects [21]. We initially purposefully sampled three PCPs
whose FOBT results were found on chart review to have
not received follow-up. Information from these PCPs led
to further interviews with 1 additional provider (a subspe-Page 2 of 7
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a mixed methods approach analogous to root cause anal- cialist) and representatives that were involved with FOBT
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performance (laboratory personnel) and FOBT reporting
(laboratory and Information Technology personnel).
Additionally, 3 institutional representatives from leader-
ship and administration that oversee workflow related to
FOBT results were also interviewed.
We gathered data from interviews, clinicians' comments
and FOBT tracking to uncover reasons for lack of timely
follow-up (Figure 1). Using themes generated from this
data, we found that five steps contributed to the problem,
one of which was a software configuration error in the
alert communication system. The latter step was the most
significant one in the final common pathway and most
amenable to a systems based intervention to improve
communication and follow-up of positive FOBTs. To
assess effect of the intervention we implemented, we com-
pared rates of follow-up of positive FOBTs pre- and post-
intervention using a Z test of two proportions.
Results
Problem Identification
Data from PCP interviews and reported comments sug-
gested that PCPs were not receiving positive FOBT alerts
consistently, leading us to further investigate the processes
associated with FOBT alert generation. Workflow analysis
revealed that a large number of patients who are given
FOBT cards never return them to the lab for processing,
and therefore an order for the test (through a computer-
ized order-entry system) is only placed upon receipt of the
card by the lab. However, in the absence of a provider-
generated computerized order, the ordering provider is
not easily identifiable unless written on the card. Because
lab technicians use a different order-entry system, it is dif-
ficult for them to identify the ordering provider (and
hence the primary recipient of the alert).
Further analysis of alert generation revealed that, regard-
less of an identifiable ordering provider in the system, the
alert management software is designed to communicate
all high priority alerts to the PCP as long as a primary alert
recipient is identified. We discovered that in positive
FOBTs where the ordering provider was not identified, a
laboratory staff member served as the designated "order-
ing" provider, i.e. the primary recipient for the alert. This
workaround (nonstandard procedures typically used
because of deficiencies in system or workflow design) [22]
was intended to enable the completion of the order and
subsequent transmission of any alert generated to the
patient's PCP; a fail-safe or safety-net mechanism
designed to prevent loss of FOBT follow-up.
However, additional technical analysis of the alert track-
ing data revealed that in all cases where the designated lab
the lab provider was receiving the positive FOBT results
and had no knowledge of this technical problem. We cat-
egorized such alerts as designated lab provider alerts and
found that lack of timely follow-up was much more prev-
alent in this subgroup of alerts (29.9% vs. 4.5% in non-
designated lab provider alerts).
Intervention
We surmised that a lack of PCP awareness (in over a third
of cases with positive FOBTs) contributed substantially to
the prevalence of FOBT results with no documented fol-
low-up, and that a software configuration error was the
root of the problem. Once the electronic health record
determines the need to generate an alert, proper recipients
are selected based on their relationship to the patient (i.e.,
ordering provider, PCP, etc.). We found an improper con-
figuration of the parameter that defines these default
recipients, such that the PCP was not selected as a recipi-
ent for designated lab provider alerts (i.e. when PCPs were
not listed as ordering providers). However, we could not
determine when and how this error occurred in the sys-
tem. Nevertheless, we posited that a problem-specific fix
of this incorrect software configuration would reduce the
risk of loss of follow-up for these alerts. The solution to
this problem, an addition of a code to link patients to
their PCP for tests ordered by others, was implemented on
November 28, 2008 (date of intervention).
Evaluation
We reviewed 360 alerts (117 designated lab provider
alerts) pre-intervention and 130 alerts (55 designated lab
provider alerts) post-intervention. Figure 2 shows the
monthly prevalence of designated lab provider and non-
designated lab provider alerts without timely follow-up
pre- and post-intervention. Pre-intervention, lack of
timely follow-up was observed for 29.9% of the desig-
nated lab provider alerts and 4.5% of non- designated lab
provider alerts group. However, in the time period follow-
ing the intervention, the percentage of designated lab pro-
vider alerts without timely follow-up decreased to 5.4% (p
< 0.01) and was not statistically significantly different
from that of non- designated lab provider alerts (6.6%; p
= 0.9). This rate decrease occurred immediately following
the intervention and remained stable (i.e. lower than pre-
intervention levels) in the subsequent four months (Fig-
ure 2). Post-intervention tracking data confirmed that
alerts assigned to the designated lab provider were now
also being transmitted to the patient's PCP.
Discussion
We investigated reasons why follow-up actions on a large
proportion of positive FOBT results that needed a diag-
nostic colonoscopy were not documented by cliniciansPage 3 of 7
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provider was alerted as the "ordering" provider, there was
no concomitant alert transmission to the PCP. Thus, only
despite the use of a system to electronically communicate
positive results. In addition to order-entry workarounds in
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Workflow and technical analysis to investigate root cause of high rates of non- response to positive FOBT (fecal occult blood test)Figure 1
Workflow and technical analysis to investigate root cause of high rates of non- response to positive FOBT
(fecal occult blood test). Contributing steps 1-5 identified.
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the electronic health record, we discovered that the com-
munication system intended to alert PCPs of positive
FOBT results was not configured correctly, leading to cer-
tain situations in which PCPs never received the test
result. Upon correction of the software configuration
error, the percentage of positive FOBT results lacking fol-
low-up were dramatically reduced. Although the rate did
not drop to zero, it was comparable to the rate of lack of
timely follow-up we found for other types of non-life
threatening, high-priority lab notifications in the same
system [23]. Our findings suggest that communication of
cancer-related test results in the electronic health record
must be monitored to avoid compromising the promise
of cancer screening programs.
Of the over 800 patients each year who have positive
FOBTs at our institution, about 10-15% of them are even-
tually diagnosed with some form of colon disease (includ-
ing cancer). None of the patients in our study had any
delay in cancer diagnosis or related harm. Although it is
possible that follow-up may have occurred beyond our 30
day "timely response" window had we not intervened,
previous work suggests that many of these findings would
ultimately never be followed-up [10,11,19]. Thus, our
seemingly small intervention could potentially have a
large impact on decreasing time to referral for colonos-
copy, thereby reducing the risk of a missed or delayed
diagnosis of colorectal cancer, a common reason for
ambulatory malpractice claims [24-26]. Previous litera-
ture has highlighted the need for system-based interven-
tions to improve follow-up of positive cancer screens and
Our findings also highlight how electronic health record
use can have dramatic effects on follow-up care of
patients. Electronic health records have potential to
address the fragmented and discontinuous care that usu-
ally characterizes care in the outpatient setting. Critical
information flow between different practitioners, settings
and systems of care is essential to high quality care.
Through good decision support systems, transmission of
information to the right provider at the right time is
within the reach of integrated electronic health records.
However, as we find, electronic health record use must
take into account the effect electronic communication will
have on workflow and vice versa. Not doing this correctly
would lead to circumstances that reduce the situational
awareness of providers and perhaps other unintended
adverse effects.
A limitation of our study was a lack of comparable data
from other VA or non-VA facilities. However, our work
illustrates how electronic test result communication sys-
tems are susceptible to errors that may limit their
intended outcomes. Furthermore, it should be noted that
other VA investigators [10,11] have demonstrated high
rates of lack of positive FOBT follow-up, so it is possible
that this problem exists at other VA sites. We are currently
investigating whether this problem exists in other VA facil-
ities or if this was an isolated event. Additionally, in this
study we did not address many other systems issues that
should be considered to address follow-up of abnormal
test results in addition to provider, technology and work-
flow. In our work, we are now using a socio-technical
Follow Up of Positive Fecal Occult Blood Tests Pre- and Post-Intervention to Correct Software Configuration Errorigure 2
Follow Up of Positive Fecal Occult Blood Tests Pre- and Post-Intervention to Correct Software Configuration
Error.Page 5 of 7
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our study is one of few that contributes to this body of
knowledge [6].
model that accounts for many other systems issues
beyond the responsible provider, including the role of
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