AN electronic discharge summary that includes tests pending when patients leave hospital is a good idea, but first the problem of test results disappearing into hospital “black holes” has to be solved, says Dr Mukesh Haikerwal, a national e-health leader and practising GP.

Dr Haikerwal, national clinical lead for the National E-Health Transition Authority, said that, in Australia, hospitals were the stumbling block to the implementation of an electronic test management and discharge summary system.

He was commenting on a systematic review by Australian researchers which showed failure to follow up test results for hospital patients is a substantial problem.

The paper, published online in BMJ Quality and Safety, found the lack of follow-up of laboratory or radiology test results for inpatients ranged from 20.04% to 61.6%, and for patients treated in emergency departments, ranged from 1.0% to 75%, when calculated as a proportion of tests.(1)

The two areas most lacking were reporting of critical results of tests and results for patients moving between healthcare settings.

The findings, based on analysis of 12 studies, showed in some cases the lack of follow-up resulted in: inappropriate or unnecessary antibiotics being prescribed; missed diagnoses of hypothyroidism, hyperthyroidism and osteoporosis; a missed positive test for chlamydia (where the patient subsequently developed pelvic inflammatory disease); missed cancer diagnoses; and death.

The systems used to manage follow-up of test results included paper-based and electronic systems and hybrids of both types.

“An electronic test management and discharge summary system which provided secure access for health professionals, both in hospital and in the community, could facilitate the follow-up of test results pending at discharge,” the authors said.

Dr Haikerwal said that, currently in Australia, electronic information from private laboratories was sent to GPs, but the missing links were hospital diagnoses and “results that we cannot get access to”.

“Hospitals talk about funding and other things and say they haven’t the facilities to do it but they can do it. They can send a bloody fax so why can’t they do it? They just need to press a button to send electronically.”

Dr Haikerwal said e-health records could be useful, but only as tools to support good practice.

He said that with electronic systems a balance had to be struck between what was possible with what was safe, acceptable to patients and achievable by health professionals.

However, he said it was still important for the hospital to ring the patient and the doctor and remind them about follow-up.

Dr Haikerwal said patients could leave hospital without knowing who to ring for results and results were not automatically sent to the GP.

“Improving business practice will help, and e-health is part of that,” he said. “But saying we will have an e-health record which is going to save the world — that ain’t going to happen.”

Dr Michael Smith, senior medical advisor to the Australian Commission on Safety and Quality in Health Care, said the Commission was working on a number of areas relating to safer handover of clinical care between practising clinicians.

It was also supporting the development of structured electronic requesting and reporting of laboratory tests in health care-associated infections.

“The specific question of clinician follow-up of test results in radiology and pathology is, however, not part of the current work plan of the Commission,” he said.

The authors of the paper said the World Alliance for Patient Safety recently identified poor test follow-up as one of the major processes contributing to unsafe patient care, increasing the risk of missed or delayed diagnoses, with potential medicolegal implications.

Ms Georgie Haysom, solicitor with Avant Law, said failing to follow up test results performed in hospital could have devastating consequences for patients, leaving both the hospital and the doctor who ordered them vulnerable to a claim or complaint.

– Cathy Saunders

1. BMJ Qual Saf 2011; 20: 194-199 doi:10.1136/bmjqs.2010.044339.

 

Posted 14 February 2011

8 thoughts on “Discharge summaries in a “black hole”

  1. woolly says:

    The trouble is the frequent change over of junior staff, use of locums, and shift work. I get a pile of radiology reports several inches high on our desk in the emergency dept after each weekend. It is not a pleasant or rewarding job going over huge number of reports of patients that I know nothing about and trying to chase patients up via phone to deal with possible subtle missed fractures that the radiologist is unsure about or tiny possible lung nodules that usually amount to nothing ( “suggest MRI scan” – yeah, easy to arrange over the phone for a patient you’ve never seen).
    And what the blazes am I supposed to do about someone’s high WCC or slightly abnormal LFTs, after the patient was discharged??
    There needs to be a better system, otherwise staff just lose interest.

  2. Dr Chris Henderson says:

    There’s all this fuss about residents not writing discharge summaries, but I haven’t yet seen the best system – which worked when I was a resident years ago.
    We used to get paid for filling out the cremation forms (about 5 quid, perhaps $25 these days). Cash in hand.
    The result – whatever else didn’t get done, cremation forms did.
    Every time, no exceptions.

  3. Michael Rice says:

    Queensland Health has an excellent system in place to send pathology to GPs by putting the local doctor on the path request from; results go directly from the lab by secure electronic transfer (or post or fax) just like private-sector path results.
    It means that GPs aren’t chasing overworked ED or path lab staff for results by phone when the patient rolls up a few days later; and while it doesn’t relieve the requesting doctor of their duty of care to follow-up abnormal results, it does at least provide an additional level of safety.
    The only problem lies in persuading the hospital staff to USE this system. It’s been extraordinarily difficult to persuade people with tertiary degrees and postgraduate fellowships that the “copy to” box is provided for a reason, and that it works (and works really well).
    Excuses range from “we don’t do that here” and “is that what that’s for?” through “that doesn’t work” to “we don’t want the GP to get the histology before we do, they might inform the patient”
    Anybody got any ideas to change the culture?

  4. Shyan Goh says:

    I dont think some of us get the point about the discharge summaries.
    Hospitals have changing terms of junior doctors all the time (registrars and residents). The issue of including any investigation with results pending, (an initiative as a part of the revamping the design of the original discharge summary form when I got involved with the design committee in my state) was to ask the general practitioner to be aware of the tests that was done in the hospital to which not all are available at the time of discharge.
    We were asking the GPs to chase the results if they did not receive them automatically by the pathology service. While it is often ‘easy’ to include the GP’s details in the form (which in many hospital are still paper based) there is no way we can be sure the GPs actually got the reports from the pathology service, short of someone sitting down all day faxing the report themselves and calling the practice to make sure they received it. Even the treating consultant may not know which investigation has their results overdue.
    The worst thing that the health system is doing now is making junior doctors do an electronic discharge summary without actually learning how to communicate effectively. We all have plenty of example when we received a 10 page summary but still have no idea what is going on and what needs to be done by the GP. All the JMO did was to write a short paragraph and then cut and paste all the reports without commenting on what the treating consultant response to the results.
    Like it or not this problems is not new. Until it is fixed and for the sake of the patients, the GPs will still need to actively chase some of the results themselves.

  5. Jim Goding says:

    One of my most vivid memories of my time as a medical student nearly 40 years ago concerned a young man who came in to hospital in a hypertensive crisis. When his history was retrieved from medical records it was found that on a previous visit it was suspected that he had a pheochromocytoma, and a urinary VMA had been ordered. The test had been done, and was strongly positive. The result was filed away in the history where it lay with no action until his current admission when we were astonished to see it. Fortunately he had surgery and made an excellent recovery.

  6. Peter B says:

    Both Drs Rice and Goh, above have hit the nail on the head. On the one hand, the system is there in place for us to all receive tests and imaging done in hospitals, but they seldom remember to put our name in the copy box, or if they do, the lab or imaging dept fails to act on it. Dr Goh & Woolly also illustrate the point that hospital staff fail to activate this excellent potential communications system because they can’t quite believe it works. Well guys it does. The private labs and imaging services have been using it and trusting it for years now, and so have we GPs, and it works brilliantly. So just do it. Ask who the patient’s GP is, and put their name in there. Most hospitals now have a list of the contact details of their local GPs for electronic send of these results. Sure some don’t, nothing is perfect, but it would be heaps better than what is being done (or rather not done) at present. And over time…. who knows…? If it became the norm, then we might be at the threshold of the magic national electronic health record…? Have you any idea what a time-wasting rigamarole it is for us to access these now if they are not sent? Most hospitals will no longer give them over the phone – we have to send in faxed requests signed by the patient – it’s crazy stuff now.

  7. Ryan Spencer says:

    In reply to Michael Rice you could try what we do, just make all tests done in hospital automatically go to the GP whether the treating team CC them or not. It was the main way the local GP knew the patient had been admitted to hospital as they started getting reams of test results in their inbox (now we email them when they’re admitted).
    And Jim, a carbon copy of your case happened within the last 12 months at a Victorian hospital, and luckily again the patient survived.

  8. Alison Rose says:

    I agree that sending copies of test results automatically to the GP is a good idea; however if a patient has a prolonged admission do we really want pages and pages of daily FBCs, INRs etc ? There is a danger of the important result getting overlooked amongst pages of these routine results.
    What I find most helpful is those discharge summaries that include the relevant direct phone numbers for path or x-ray departments, so that I can contact them straight away without the time-wasting of looking through hospital directories or the hospital switchboard.

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