Here’s Why You Should Ask Your Doctor To Show You Any “Alerts” In Your Electronic Medical Record

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Electronic medical records (EMRs) make a lot of sense.  Ideally they capture, store, and report on all the pertinent information that’s floating around out there concerning your health.   One of the supposed advantages of EMRs is their ability to sort through vast quantities of health data to “alert” physicians to important gaps in your care.

Alerts are triggered when something in your EMR is flagged (think red flag) indicating that something that is supposed to happen to you has not yet happened….and vice versa    For example, EMRs can alert physicians when you are overdue for a screening test.  They can also alert physicians to lab and radiology test results that need to be followed up on.

It Is A Great Way To Engage Patients

Since everyone is so concerned about getting patients more engaged in their health care…why not start by turning the computer screen around and showing patients the “alerts” in their EMR.   I am sure that will get most patients’ attention.

Here’s why this is necessary

A study in a recent issue of the Journal of General Internal Medicine found that care gaps persisted among primary care physicians using EMRs and alerts.   Researchers found that:

  • Physicians failed to follow-up abnormal lab test results in a timely fashion (<30 days) in 7% to 62% of patients
  • Physicians failed to follow-up abnormal radiology test results in a timely fashion in 1% to 36% of patients.

Remember these where practices in which the EMR system was capable of generating electronic alerts telling the treating physicians that action was needed.  These follow-up rates are not all that different from similar studies of physician practices without EMRs.

The lack of timely follow-up by physicians reported in these studies resulted in otherwise preventable hospitalizations and delays in initiating time-sensitive cancer diagnosis and treatment.

In my wife’s case, her Non Small Cell Lung Cancer was identified in a hospital employee health screening when it was Stage 1… yet she was not told of the finding for some 5 years later at which time she was Stage 4.  This despite a “paper copy” of the radiologist report (chest X-ray) being sent to her PCP, OB-GYN and Employee Health Medical Director.

Why The Lack Of Timely Follow-Up?  

Researchers have found that primary care physicians in integrated delivery systems receive an average of 57 alerts per day.  Among the reason given for the lack of timely follow-up, despite the alerts, were the following:

  •  Physicians were found to be less likely to acknowledge alerts when they are behind schedule.
  • Physicians focused their attention on alerts concerning patients with greater “clinical burdens” (e.g., providers were more likely to acknowledge alerts about elderly or highly co morbid patients).
  • Physician lack of knowledge – physician knowledge of EMR alert-management features in one study ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two.  Put another way, many physicians don’t know how to use all the features of their EMR system.
  • Physicians ignored or turned the alert function off

The Take Away?

If you are a patient in a practice that uses an EMR, politely tell your physician that you would like to see any alerts that pertain to you.  If there aren’t any – fine.  If there are, simply ask your doctor what’s the plan for addressing the outstanding issue.  He or she may well have a good reason for ignoring the alert which I am sure they would be happy to explain to you.

If you are a patient in a “pencil and paper” practice, ask your physician what his/her policy is regarding test result notification, including timeliness.  Ask what their policies and procedures are to make sure that no one – particularly you – falls through the cracks.  Never leave your doctor’s office without a copy of all your test results!

If you are a physician with an EMR system…learn how to use the darn thing. Your patients will appreciate you for it and I dare say you prevent what happened to my wife and me.

That’s what I think.  What’s Your Opinion?

Sources:

Hysong, S.  et al.  Provider management strategies of abnormal test result alerts: a cognitive task analysis.  Journal American Medical Informatics  Association. 2010;17:71–77.

Singh, H. et al.  Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting.  Archives of Internal Medicine. 2009;169(17):1578-1586

Sittig, D. et al. Improving Test Result Follow-up through Electronic Health Records Requires More than Just an Alert.  Journal of General Internal Medicine. 2012 Oct;27(10):1235-7.

4 Comments

  1. tamsin franklin says:

    I am a family practitioner in Aus., and I have had the computer screen on display for my patients for about 4 years. I also allow all my patients access to all of their results as soon as I have seen them.

    Thanks for your article. If only more medical practitioners would open up to the realisation that open communication is clearly in everyone’s best interests, we could really make a difference to improving health care.

  2. I have installed and used 2 EMR systems in a group practice. Some things like lab tests are easy to generate an alert. Some things like the text of an x-ray report are quite difficult to extract an alert (so it does not happen). It is a hassle for patients to always ask for copies of their tests (but it is a good idea). Some EMRs have a patient portal to allow secure Internet access to copies of reports — this is a great convenience (it’s not a very expensive add-on for the practice). Another nice touch is if the provider will show the report to the patient on the computer screen at the time of a visit — it is a great teaching moment for both parties.

    Human error creeps into any system, even computer systems. Consider what happens when a provider is on vacation — the results are sent to someone else — that someone is busy and clicks “reviewed” and “forward”. The vacationing provider returns and thinks the problem was resolved and clicks “reviewed”. The abnormal test, x-ray or alert just fell through the cracks. I know about EMR systems and I always make sure I see my personal test results myself. There is a huge gap between what EMR makers claim and what actually happens. There are a lot of EMRs that don’t share data outside of the provider’s building — even when owned by a health system that could integrate the practice electronically but did not.

    Currently, the most helpful frequently used software is for drug prescribing — NEVER tell the provider to “just hand write the prescription” because that skips very valuable error, allergy and interaction checking. Many patients do ask for paper prescriptions to their detriment.

  3. Stephen,

    you raise an extremely important issue regarding EMR alerts. Your wife’s situation points out that this is an enormous patient safety issue. Certainly we need to hold ourselves as clinicians to be accountable to attending to the alerts being presented in our EMR’s.

    However, I would also like to call attention to the fact that far too little importance has been ascribed to the design of EMR’s in this critical area. All too often alerts are one or more clicks away from the screen where most of a clinician’s workflow is centered. All too often the accuracy of alerts being presented is variable, due to missing data. All too often there is no prioritization of alerts based on urgency or criticality.

    There is a need to incorporate lessons learned from industries such as aviation. If you’ve looked into a modern jet-liner’s cockpit recently, its obvious that there has been a trend toward simplifying the interface. Kahneman’s work so elegantly presented in his book, “Thinking Fast and Slow,” illustrates the problems with alerts that all too often require System 2 processing, slow and deliberative, and a break in flow from the usual System 1 mode of clinical decision making.

    So yes, we clinicians need to do a better job, but we also need tools that assist us better and more effectively. Most EMRs are not there yet.

    Don

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