Introduction
It's 6:00
pm. You've seen all your patients, answered your messages, completed
your prescription refill requests, and faxed back your last work release.
The only task remaining is to review the laboratory test results that
came back during the afternoon. This job--acting on abnormal test results
and communicating findings--is a critically important part of the care
we deliver and can occupy a substantial portion of a physician's day.
I have
personally been interested in how we manage our lab results and have
surveyed internists and family practitioners in the KP Southern California
Region for their thoughts on this topic. Most have reported that they
spend about one hour each day managing laboratory test results. In this
article, I share some lab management techniques which may help you streamline
your day.
The Electronic Medical
Record
In the
KP Southern California Region, we have yet to implement the electronic
medical record (EMR); therefore, I have written this article from the
perspective of the "EMR- naïve" practitioner. I hope,
however, that even those physicians who currently use the EMR will find
this discussion useful. In this article, I discuss functions not usually
provided by a computer: selecting the most appropriate lab tests, managing
patient demands for tests, communicating with patients about test results,
and organizing your nursing staff to support you in these lab management
tasks.
Evidence-Based Ordering
Of Laboratory Tests
Ordering
laboratory tests sensibly is probably the most important aspect of efficiently
managing laboratory test results. The inevitable false positive results
of unnecessary tests consume much valuable time, whether a clinician
spends this time explaining the results to concerned patients or requesting
additional tests. To paraphrase an old saw, "Order all the necessary
tests and not one test more." In practice, achieving this goal
is difficult because of many considerations (in addition to the patient's
medical history and physical examination findings) that factor into
our patterns of ordering laboratory tests. When we order these tests
simply because we believe the patient will leave our office more satisfied,
we may be the ones disappointed. Contrary to what some may believe,
a study from the KP Northern California Region showed that, when controlled
for other variables, even a dramatic increase in ordering laboratory
tests or imaging would not produce a meaningful change in patient satisfaction
scores. (Kristen Hannum Gregory, PhD, unpublished data, May 1999).a
Moreover, ordering more laboratory tests compounds a doctor's workload
by inviting more messages from patients about test results (S Winarko,
MD, unpublished data, 1998).b In my experience, the most
unnecessary increase in workload is imposed by healthy ("worried
well") patients who are seen for a routine visit or physical examination
and leave the office clutching a long list of lab orders. Fortunately,
at least for these healthy patients, we can benefit from a wealth of
data on the laboratory screening tests appropriate for each interval
of life. The US Preventative Services Task Force Recommendations and
KP's clinical practice guidelines are particularly helpful in this regard.
For patients without risk factors who are seeing their doctor for a
routine periodic health examination, only the following five screening
tests (excluding radiologic, nuclear, and endoscopic procedures) are
supported by either "good" or "fair" evidence:
- Measurement
of fasting blood glucose level every five years starting at age 45;1
- Measurement
of blood cholesterol level once between age 20 and 25 years and then
every five years, starting at age 35 for men and at age 45 for women);1,2
- Annual
chlamydia testing for sexually active females age 25 and younger;1,2
- Annual
fecal occult blood testing (as an option or in addition to periodic
sigmoidoscopy) starting at age 50;1,2 and
- Pap
smear testing every three years after two normal annual Pap smear
test results in females who are or have been sexually active.1,2
What To Do When Patients
Demand Tests
The challenge
for physicians with demanding patients is to balance their expectations
with the requirements of evidence-based medicine. Contrary to what many
doctors believe, I find that most patients readily accept an office
visit without an accompanying trip to the phlebotomist if I first explain
to them that no blood testing is indicated. Patients who nonetheless
desire laboratory testing or who demand a specific test must be managed
carefully because abruptly denying their request may alienate these
patients. Instead of bluntly responding "No, I will not order that
test," a clinician is more likely to invite rational discussion
by saying "Let me tell you my thoughts" if the requested testing
is poorly advised or "I'd be glad to order that test, but first
let's talk" if the testing is a reasonable option. Asking the reasons
behind a request might also provide valuable information and clues on
how to address the patient's concerns specifically. Sometimes a third
person--someone behind the scenes--orchestrates the demand for testing;
in those cases, a discussion with that person (with the patient's consent)
may better satisfy all parties.
Managing Your Results
Because
primary care practitioners are ultimately responsible for managing laboratory
results, we all justifiably concern ourselves with careful review and
follow-up of abnormal test results. For example, we all live in fear
of the positive stool occult blood test result that falls through the
cracks. Each of us has set up our own system to guide patients with
abnormal results through telephone discussion and repeat testing, a
second discussion, and perhaps additional testing, treatment or consultation
with a specialist. More often than not, test results pile up on our
desk, remain there for long periods, and risk being misplaced. Better
management of this process requires a sophisticated laboratory system
and active involvement of the nursing staff and even of the patients
themselves.
Laboratory Capability
Most laboratories
already streamline evaluation of abnormal test results by reflexively
repeating the test or administering an alternative confirmatory test.
For example, an abnormal level of thyroid-stimulating hormone (TSH)
triggers testing of the same blood sample for free T4; The patient,
unaware of this additional test, is spared a phone call from the doctor
and a second trip to the laboratory. Your evaluation of a laboratory
result can be further assisted if it is accompanied by contextual information.
For example, a notation that the patient is receiving a particular antibiotic
is helpful for evaluating a culture and sensitivity result. In a more
advanced clinical system, the physician might also be provided historical
information such as diagnoses or prior test results for comparison.
These "smart" laboratory results could be a great timesaver
and can be particularly useful to any physician covering for you who
is unfamiliar with your patients.
Nursing Support
Your nursing
staff also should be enlisted to support you in managing laboratory
test results. However, a call from your nurse to a patient with a mildly
abnormal test result might save you time initially but could raise more
questions later from your justifiably concerned patient. To avoid this
situation, prepare your patients in advance to expect a call from your
nurse if a test result is abnormal: Tell your patients that the nurse
will call them about any abnormal results and will convey your personal
instructions about what action to take. During the visit, try to give
patients specific information, such as "I will prescribe potassium
for you in case your potassium level is low." This may allay their
fears and increase compliance when the nurse does call. If the abnormality
is serious, however, nothing should substitute for a personal call from
the physician. Many KP departments use clinical practice algorithms
that allow registered nurses to manage specific illnesses. The protocol
for urinary tract infection (UTI) exemplifies use of such an algorithm:
The nurse obtains the patient's medical history and symptoms from the
patient over the phone while filling out a preprinted questionnaire.
A urine culture is seldom necessary and is ordered only if the patient
meets certain criteria. The physician then reviews the questionnaire,
prescribes appropriate antibiotic therapy, and the nurse makes all the
necessary arrangements.
Feedback
During
the past few years, I have increasingly found patients to be interested
in obtaining precise numeric results of their laboratory tests. These
patients are not satisfied with being told simply, "we'll call
you if the results are abnormal." Automated programs have been
developed to give confidential results by telephone, but many patients
are reluctant to try this technology or find it difficult to use. Of
the doctors I surveyed, about half use various approaches to relay all
or most normal test results to patients. Some doctors send a copy of
all laboratory test results directly to the patient's home. This process
can be simplified by folding the test report into a window envelope
so that the patient's name and address are clearly visible. Other doctors
send postcards or prewritten documents with a personal comment added
or educational material attached. By all accounts, patients genuinely
appreciate this information. Contrary to the fear expressed by many
doctors--that they will need to field countless calls from alarmed patients--the
doctors I queried stated that informing patients of all test results
prompted fewer (not more) telephone calls. Other doctors take a different
approach: They simply ask their patients to take their prescribed laboratory
tests shortly before the next scheduled appointment so that the results
can be discussed in person at the visit.
Tracking The Critical
Tests
To ensure
that patients follow-up with their requested tests, some physicians
find a "tickler file" to be most useful. In my case, I have
an accordion file with sections labeled for each month of the year.
When I request a particularly critical test or consultation, I simply
place a note or a copy of the request into the file under the month
I expect to receive the report. Once or twice each month, I look in
the corresponding section of the file to confirm that the test was properly
completed. An electronic version of this same strategy using your desk
or handheld computer also could be used.
Patient Accountability
Enlisting
patients in their own follow-up is a final step in managing abnormal
test results. Asking patients to call when they complete any retesting
not only increases their compliance but also ensures that I review and
discuss their case whether the final result is normal or abnormal. Perhaps
most importantly, asking patients to make this phone call reinforces
the modern proposition that patients must take some responsibility for
their own health.
Conclusion
Managing
laboratory test results is a time-consuming yet critically important
aspect of any physician's work. A surprising fact, however, is that
little research has been done on this topic; moreover, physicians seldom
discuss their practice strategies with each other. New physicians, in
particular, could benefit from having discussion of this topic included
in their orientation. Five items are most important to emphasize:
- Order
screening laboratory tests in an evidence-based manner;
- Maximize
nursing support for communicating with patients and use clinical practice
algorithms that include nursing support;
- Give
routine feedback to patients about normal laboratory test results
(this practice is highly valued by many patients can reduce the number
of messages that you receive from patients);
- Encourage
patients to take responsibility for their health and test results;
- Discuss
helpful techniques with other physicians so that "best practices"
of test result management can be shared for the benefit of clinicians
and patients.
With all
the pressures on primary care practitioners, each of us must develop
an efficient, reliable system for optimizing management of laboratory
test results. Such a system can make this important task a more satisfying
part of our day and not simply a burden that keeps us late in the office.
a
Manager, TPMG Access and Service Assessment, Kaiser Permanente of
California, Oakland, CA.
b
Family Practice, Kaiser Permanente of California, Pasadena, CA.
Acknowledgments
Maureen
Spell, MD, FACP, Chief of Internal Medicine, and James Evans, MD,
of Internal Medicine, reviewed the manuscript and provided valuable
suggestions.
The
General Internists at the Kaiser Permanente Los Angeles Medical Center
and members of the Southern California Permanente Medical Group Regional
General Internal Medicine Committee shared with me their thoughts
about laboratory management.
References
1. Kaiser
Permanente Southern California. Clinical practice guidelines. Preventive
services for adults (age 18-64) and older adults (age 65+). Available
from: http://pkc.org (accessed
September 23, 2003); under "Clinical Guidelines," click on
"Southern California Guidelines;" under "Family Practice/Internal
Medicine," click on "Preventive Services for Adults (18-64)
and Older Adults (65+)."
2. US
Preventive Services Task Force. Guide to clinical preventive services:
report of the US Preventive Services Task Force. 2nd ed. [Washington
(DC)]: US Department of Health and Human Services; 1996. Available from:
http://odphp.osophs.dhhs.gov/pubs/guidecps/pcpstoc.htm
(accessed September 23, 2003).
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