May 11, 2018
A new initiative at Johns Hopkins Medicine is designed to ensure that patients receive all laboratory test results, normal or abnormal, within two weeks.
The commitment calls for doctors to communicate with patients by phone, a letter or the MyChart patient portal within 14 days after an outpatient visit at any Johns Hopkins-run office. Abnormal test results that require follow-up treatment are to be communicated sooner.
“Patients say if they haven’t heard from their provider that it must be good news,” says Steven Kravet, president of Johns Hopkins Community Physicians and vice president of the Office of Johns Hopkins Physicians (OJHP). “What we have tried to get across is that no news sometimes means just no news. Maybe the test results weren’t seen or communicated. We have set an expectation that every test, whether the results are normal or abnormal, and whether an abnormal result is actionable or not actionable, needs to be communicated.”
The effort, now in its second year and directed by the OJHP, stems from work with colleagues at Yale University, Columbia University, the University of Rochester, New York-Presbyterian hospital and Weill Cornell Medical College who are participating in a risk management consortium directed by insurer MCIC. The consortium’s office practice work group determined two years ago that reviewing and communicating abnormal test results was an area of significant risk to patients because of potentially missed or delayed diagnoses. Institutions have put their own performance improvement programs in place to make test follow-up better.
At Johns Hopkins, the OJHP ambulatory quality and analytics department, led by Jennifer Bailey, built report logic through the electronic medical records system to search for gaps in test result communication. The group looked at nine “high risk” tests, including those for sexually transmitted diseases, certain cancers, thyroid disease and medication levels, and what type of communication occurred after the tests. If no communication was documented within two weeks, the test was flagged and the group had the opportunity to try to follow what happened.
The investigators found just 43 high-risk test results that weren’t communicated after about 2 million outpatient visits. “That seems like a low number,” Kravet says. “But if you’re one of the 43, that’s all it takes for something devastating to happen.”
This year, with MCIC funding, OJHP hired a patient safety nurse, Joy Chiong, to review records. If she sees no communication, then there is a process to directly contact the ordering provider to be sure the loop is closed.
Along with the new test policy come a set of principles to help it operate, Kravet says. One proposed and advocated for by Stephen Sisson, executive director of ambulatory services for The Johns Hopkins Hospital, is: “If you order it, you own it.” In the academic environment, Kravet says, “We have situations where residents order tests and then it’s unclear who’s responsible for following up. It could be the attending. It could be another resident.” Now, whoever orders the test is responsible for communicating the results.
Other changes include altering the language in MyChart so patients better understand that their doctor — not the computer — is communicating the test results, as well as making sure physicians don’t wait until a patient’s next appointment to review results.