While in active clinical practice, a typical day of seeing patients ended with completing dictations and reviewing test results. Result reports piled up quickly, and the first problem I had in dealing with them was coming up with a way to prioritize them for action. Eventually, I settled on using a spreadsheet to keep track of things. This addressed the tracking issues, but I still had to put in just as much time considering what to do about abnormal results.
Abnormal results often sparked a literature search or a textbook perusal. Impromptu calls to colleagues for a little advice were not out of the question. Consider the steps required to address an abnormal finding:
- Review chart
- If the result is as expected, stop
- If unexpected, decide on a course of action:
- Additional tests
- Another visit
- Change of diagnosis
- Change in management
- Proceed with plan of action
Typically, these steps occur outside of an actual patient visit, are essential for quality care, and require no less intellectual input than a visit.
The presence of an EHR does not automatically eliminate tracking issues or follow-up failures, nor does it reduce the number of clinician hours required to manage abnormal results (1, 2, 3). Even when EHRs do help with tracking headaches, the time and actions required to determine a course of action largely remain the same. Clinicians must still add on hours at the end of each day in order to manage results. The sticky notes and pile of charts waiting for review may be gone, but little else has changed. However, as the saying goes, “problems are just opportunities in disguise.”
It seems that results management brings together a few issues, which, if resolved, could provide a range of benefits to all involved. First, busy clinicians need help in creating processes for managing test results. Clearly, results management is an important clinical activity that requires a structured approach in order to be effective. Considering the importance of results management to the quality of care, why not make it a reimbursable activity? Doing so would acknowledge the value of results management as a key part of clinical work.
Secondly, results management is in accord with the precepts of Meaningful Use. Incorporation of clinical lab results into the EHR as structured data is an ongoing MU objective. This offers a good starting point for promoting results management features in EHRs. EHRs with bi-directional laboratory interfaces are becoming more prevalent, and this is an essential feature for managing the tracking aspects of results management. The next step is adding features that allow clinicians to document actions taken when managing test results, thereby providing a mechanism for justifying reimbursement. Since a chart review is frequently required (and possibly the first step) in managing abnormal results, one possibility would be to create a results management visit type that could be used as a basis for reimbursement.
Should the ONC take such an approach, it potentially creates a situation in which the interests of the ONC/CMS, vendors, and clinicians are aligned (something that is not always evident). For example, by making results management a part of MU and reimbursable, ONC/CMS would provide a positive incentive for having an EHR, thus further driving adoption. (Get an EHR or suffer penalties is not a positive incentive; get an EHR and receive pay for previously unreimbursed and unacknowledged work is.) Since Medicare patients, on average, have more tests than younger patients do, the impact of improved results management might well have an immediate effect on their care quality.
Vendors might benefit from results management reimbursement because documenting results management activities would be difficult without an EHR. Thus, adopting an EHR would offer a clear, calculable economic advantage to clinicians who are sitting on the fence, especially while EHR incentives are available. Finally, the R&D efforts that go into creating results management capabilities could spur innovation while improving patient safety, aiding in product differentiation, and increasing sales.
Results management happens in every practice every day, albeit with varying results. Why not elevate it to a cause célèbre and create a policy from which vendors, clinicians, ONC/CMS, and — most of all — patients can mutually benefit? Indeed, for everyone trying to bolster primary care, promote MU, increase EHR adoption, and improve the quality of care, reimbursing results management activities is a great place to start.
- Yackel TR, Embi PJ. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010 Jan-Feb;17(1):104–7.
- Hysong SJ, Sawhney MK, Wilson L, Sittig DF, Esquivel A, Singh S, Singh H. Understanding the management of electronic test result notifications in the outpatient setting. BMC Med Inform Decis Mak. 2011 Apr 12;11:22
- Elder NC, McEwen TR, Flach J, Gallimore J, Pallerla H. The management of test results in primary care: does an electronic medical record make a difference? Fam Med. 2010 May;42(5):327–33.