Casalino LP, Dunham D, Chin MH, Bielang R, Kistner EO, Karrison TG, Ong MK, Sarkar U, McLaughlin MA, Meltzer DO. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results [Internet]. Arch Intern Med. 2009 Jun 22;169(12):1123-1129.[cited 2009 Jun 26 ]

This is a wonderful and well-timed study that has significant implications in the era of the Electronic Health Record and the Personal Health Record. As well done as it was, I would have loved a section of inquiry to be added about “the impact of patient and family access on test result notification.” Read on…

It’s impressive that in 2009, believe it or not, there really aren’t firmly established processes for handling information about test results. A lot of what is done today is bred from custom, such as the infamous “no news is good news,” which the authors found was the protocol in 8 out of 19 medical practices studied. Everyone who likes this approach to test result notification, please raise your hand….

With that background the study team started at a very low baseline, thinking about what kinds of test results patients should be informed about, in what period of time they should be informed about them, and then analyzed medical records (5305 in all) to see if theoretical best practices were carried out., and about 7.1% of the time, on average (up to 26.2% in one Academic Medical Center practice), information to patients was not furnished about their abnormal test results. We can imagine what that might mean in a practice whose policy is “no news is good news.”

The authors looked at the impact of having an electronic medical record and found that practices with a “full” electronic medical record were no more likely to have gaps than one without IF they had a good process for managing test results. So, process and workflow trumps technology in this case.


What’s missing in good process?

So, the number of abnormal test results in this study not communicated to patients is alarmingly high. At the same time, I immediately drifted to what’s missing in the process. The authors listed these steps as a good way to manage test results:

1. All results are routed to the responsible physician
2. The physician signs off on all results
3. The practice informs patients of all results, normal and abnormal, at least in general terms
4. The practice documents that the patient has been informed
5. Patients are told to call after a certain time interval if they have not been notified of their results.

Maybe this is good practice today, but what do our patients and families want in the era of the personal health record and full transparency (73 cents style)? How about this:

Good process for managing test results, patients and families at the center

1. All results are routed to the responsible physician and the patient and their proxies, if specified, at the same time
2. The physician and the patient and their proxies, if specified, sign off on all results (in a current PHR installation, this might mean verification that the patient has viewed the result…read on)
3. The practice informs patients and their proxies, if specified, of the meaning of all results, with specific recommendations to be made based on the information
4. The practice documents the shared decision made by the responsible physician and the patient based on the information obtained from results
5. Without 1-4 above, the practice reaches out to the patient via the most appropriate means (letter, telephone, secure e-mail) to achieve notification and shared decision-making.

If we think about it – in the era of the personal health record, do we really want to tell patients if they haven’t heard something within a certain time interval, they should call us?

Do we really want to continue a “no news is good news” policy, at the risk of “no news” meaning 7.1% of the time someone may be hurt in the process of care?

I think it’s important to remember that the ultimate reason a test of any kind is ordered in health care is for one reason – “to reduce uncertainty.”

It would be great in a future study to analyze the impact of patients having access to their test results in real-time or near-real time, to see what the rate of failure is, and also dig deeper, at the rate of understanding of what test results mean. This is the sweet spot for physicians and nurses, who excel at using test results to reduce uncertainty in the context of a patient’s overall health.

In terms of whether or not the new/improved “Good process” is more time intensive or not than the regular “Good Process,” I don’t think it is more time intensive. I think this is a great item for discussion in the comments. Let’s talk about the cost-benefit of doing things differently.

It’s worth noting that in the first quarter of 2009 alone, 5,078,442 test results were viewed by Kaiser Permanente patients and/o their proxy individuals on KP’s My Health Manager personal health record. In many of those instances, the test results were delivered to the patient at the same time as the physician. That’s a lot of experience both to tap into, and to understand that the old process is already changed forever for lots of Americans and the teams who care for them.

With thanks to the authors for a timely and useful investigation into an area of health care where we all want to improve.

• When Does a Social Media Policy Go Too Far? Ask the Associated Press – Associated Press is criticized for a too-far-reaching social media policy for its employees.

• Group Health Cooperative: Reinventing Primary Care by Connecting Patients with a Medical Home – Report from Commonwealth Fund on Group Health Medical Home

• What’s Needed Next: A Culture of Candor – HBR.org – We’ll tackle upward communication first. Consider the results of an intriguing, relatively obscure study from the 1980s, in which organizational theorists Robert Blake and Jane Mouton examined NASA’s findings on the human factors involved in airline accidents. NASA researchers had placed existing cockpit crews—pilot, copilot, navigator—in flight simulators and tested them to see how they would respond during the crucial 30 to 45 seconds between the first sign of a potential accident and the moment it would occur. The stereotypical take-charge “flyboy” pilots, who acted immediately on their gut instincts, made the wrong decisions far more often than the more open, inclusive pilots who said to their crews, in effect, “We’ve got a problem. How do you read it?” before choosing a course of action.

• D.C. Summer Jobs Contractor Fired for Posts on Twitter – washingtonpost.com – I believe this speaks to having a good policy and guiding use of social media rather than not permitting it all.

I was honored (truly) to represent The Permanente Federation as a guest last week at a summit held by Veterans Health Administration Primary Care in Washington, DC, to review work done to date inside and outside of VHA, for the purpose of continuing to provide the best overall care for our veterans.

The summit included a review of the latest efforts of the Patient Centered Medical Home, given personally by Paul Grundy, MD, from IBM, and Michael Barr, MD, from the American College of Physicians, as well as information given by VHA experts in primary care leadership operations, quality, and across disciplines, including physicians and nurses.

The day and a half-summit included a healthy (in my opinion) amount of introspection that included the best results for our veterans, as well as areas for improvement. As I expected, this group of nursing and physician leaders are incredibly bright and committed to understanding the strengths and weakness of the system they support, to a humbling degree.

This is impressive to see in a system (VHA) that is regarded by many in health care as an example to others as what world class health care should be, and at the same time what I am familiar with in systems like this – an ongoing, healthy dissatisfaction with the status quo.

What I could also relate to in my role is the serious interest, especially in a highly-regarded system, in making sure that primary care is all that it can be, not just in medical offices but wherever patients/people/veterans live, work, and play (and I learned about the existence of the care coordination services – telehealth program). And, as at Kaiser Permanente, the VHA has a commitment to a robust internet portal for veterans, MyHealtheVet. I think the era of the personal health record is a great one for primary care, and vice versa.

In terms of connection to the patient centered medical home, I really liked how this concept was used not so much as a bar to reach, but as a guide and stimulus to create a whole new bar. Systems like VHA and Kaiser Permanente by virtue of their emphases on whole-body, total care, may be more likely to experience challenges faced by primary care across our profession(s) (nursing and medicine) sooner than the rest of health care and therefore be faced with the urgency of solving those challenges sooner as well. Both systems also support multi-specialty care, so there’s good understanding that great specialty care goes hand in hand with great primary care – both are necessary.

My hope is that the solutions they create for veterans will support strong primary care for all Americans, and I am confident that they will. Thanks to the primary care leadership, physicians and nurses alike, for allowing me to observe their work on behalf of our veterans.

This week’s photograph was taken at a regular gathering of some of Washington, DC’s most thoughtful health information technology professionals, known collectively as Clinovations. The group gets together to share cross-disciplinary expertise in implementation, policy, and local and national approaches to promoting a better health care system through technology. On this evening, we were briefed on the efforts of Chesapeake Regional Information Systems for our Patients , based in Maryland.

The venue in which the gathering was held, is unique to Washington, DC – it’s the Edward Marc Chocolatier sales office, which is opened to community organizations for events (a little chocolate was included…).

From left to right, top photograph: Joel Selz, Ike Brenner, John Kontor, Anita Samarth, Jeremy Wong, Luana Lewis, Jamie Marraccini, Steve Zlotkus, Gaurov Dayal, Brenda Wright

From left to right, bottom photograph: Jeremy Wong, Luana Lewis, Jamie Marraccini, Steve Zlotkus, Danny Rosenthal

A little while ago, I wrote about the experience of a patient, Fred Holliday, whose wife Regina Holliday stimulated a discussion about patient access to recorded health information. Fred Holliday died on June 17, 2009 .

On June 16, 2009, the HIT Policy Committee produced its first recommendations of what Meaningful Use should be. I of course am looking at the proposal from the perspective of patient and family involvement in care, and I think in many ways it is impressive.

It’s useful to think about the HIT Policy Committee recommendation in the context of what the law as written says, which is as follows (page 355-356):

‘(2) MEANINGFUL EHR USER.— ‘‘(A) IN GENERAL.—For purposes of paragraph (1), an eligible professional shall be treated as a meaningful EHR user for an EHR reporting period for a payment year (or, for purposes of subsection (a)(7), for an EHR reporting period under such subsection for a year) if each of the following requirements is met: ‘‘(i) MEANINGFUL USE OF CERTIFIED EHR TECHNOLOGY.—The eligible professional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period the profes- sional is using certified EHR technology in a meaning- ful manner, which shall include the use of electronic prescribing as determined to be appropriate by the Secretary. ‘‘(ii) INFORMATIONEXCHANGE.—The eligible profes- sional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as pro- moting care coordination. ‘‘(iii) REPORTING ON MEASURES USINGE HR.—Subject to subparagraph (B)(ii) and using such certified EHR technology, the eligible professional submits information for such period, in a form and manner specified by the Secretary, on such clinical quality measures and such other measures as selected by the Secretary under subparagraph (B)(i).

That’s the complete definition in the law.

With that in mind, the thinking of the HIT Policy Committee is inclusive of a policy priority they call “Engage patients and families,” with a fairly reasonable (based on what I know the technology can do) set of objectives and measures for 2011-2015. The way I interpret the thinking in this set, it is that in 2011, patients will begin to read their records online, in 2013 they will begin to write their records online, including via secure messaging with their providers, and in 2015, there will be full real-time access to a personal health record populated with their data.

The measures in 2011 include the use of an after visit summary, which I’ve written about previously, and is relatively easy to measure (and produce, in my opinion).

I think the measures are a nice compromise between what leading edge health care systems can do today versus where all health care systems should be in the future. I’ll also say that this component of meaningful use is likely to help all of the other components be more successful, because they will cause health care systems and providers to see the impact of what they do, through patient reaction. To the patients out there, what do you think?

While speaking at the Institute for the Future’s Health Horizons’ Spring 2009 Conference (LiveTweets here and more organized here) about Combinatorial Innovation, with William Ruh, Vice President, Cisco Systems, Larry Tessler, from 23andMe, and Mike Liebhold, Senior Researcher from IFTF, I had a great opportunity to have my words documented graphically, by a very talented visual recording artist.

You could look at the product and get a sense of what I was speaking about on behalf of Kaiser Permanente – member/patient as the hub of health care, engaged doctors with their patients, moving ahead together in the interest of those they serve.

Seeing the documentation is also a great check on accuracy – and in fact, it showed an error in my discussion – the “$5 billion Project” attributed to Kaiser Permanente HealthConnect is actually $4.2 billion, which is a big difference in discussing the investment of a non-profit health system in leading edge technology.

I think (and thought) this was a great opportunity. How can a person tell what the audience feels after they tell a story about something like patient empowerment using technology? Extrapolating to the patient-physician encounter, how does a patient know if their physician understood the significance of their story? Seeing the documentation is very powerful, and a visual check on creating the right impression of the work is very innovative, in my opinion.

Thanks a ton to Institute for the Future for hosting a great discussion, and for allowing me to touch base again wtih two of my favorite leaders in the universe, Karl Hoover and Diana Elser, both from Group Health Cooperative, and as of the date of this discussion, now on Twitter (Follow them here: @kmhoover @dlelser and please encourage them to share their experience in this medium…) Welcome aboard!

• Airforceblog – Blog Assessment Flowchart – A very comprehensive view of managing organizational viewpoint in the blogosphere. In Air Force style.