Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems

doi:10.1016/S1386-5056(03)00133-3

International Journal of Medical Informatics

Volume 71, Issues 2–3, September 2003, Pages 137-149

https://doi.org/10.1016/S1386-5056(03)00133-3 Get rights and content

Abstract

Objectives: Failures to follow-up abnormal test results are common in ambulatory care. Information systems could assist providers with abnormal test result tracking, yet little is known about primary care providers attitudes toward outpatient decision support systems. Methods: A cross-sectional survey of 216 primary care physicians (PCPs) that utilize a single electronic medical record (EMR) without computer-based clinical decision support. Results: The overall response rate was 65% (140/216). Less than one-third of the respondents were satisfied with their current system to manage abnormal laboratory, radiographs, Pap smear, or mammograms results. Only 15% of providers were satisfied with their system to notify patients of abnormal results. Over 90% of respondents felt automated systems to track abnormal test results would be useful. Seventy-nine percent of our respondents believed that they could comply better with guidelines through electronic clinical reminders. Conclusions: Most PCPs were not satisfied with their methods for tracking abnormal results. Respondents believed that clinical decision support systems (CDSS) would be useful and could improve their ability to track abnormal results.

Introduction

Failure to follow-up on abnormal tests and failure to comply with guidelines are common quality concerns in primary care. The increases in diagnostic testing options and patient volumes have made failure to follow-up one of the fastest growing area of malpractice litigation in outpatient medicine [1], [2], [3], [4], [5], [6]. In an analysis of office-based claims of a single large malpractice carrier from 1989 to 1998, 27% of all diagnostic-related claims were related to systems errors, with poor tracking of diagnostic tests, inadequate patient monitoring, and failure of patient notification representing the most common types of claims [7]. In one cross-sectional survey, one-third of physician respondents reported no reliable methods to ensure that tests were completed and adequate follow-up had been performed [8].

In addition, clinical practice often lags behind the best available evidence, [9], [10] and failure to comply with national guidelines has become another key concern regarding quality of care. Physicians fail to provide preventative services, such as mammograms, pap smears, influenza vaccinations, and age and gender appropriate screening for a disturbing fraction of patients [11]. For example, one study demonstrated that only 46% of diabetics had had an annual ophthalmologic examination and only 16% had annual hemoglobin A1c levels [12]. While numerous guidelines for patient care exist, they are often complex and difficult to integrate into a provider’s routine clinical workflow.

One means of approaching these issues is electronic medical records (EMRs) with computer-based clinical decision support systems (CDSS) [13]. Much effort has been devoted to the development of CDSS [14] and data support their effectiveness for changing provider behavior [15], [16], [17]. CDSS could be designed that would automatically capture abnormal test results, store them, and then present them to the provider at the appropriate time. Patient specific, evidence-based reminders could also be integrated into the clinical encounter. However, despite these potential benefits, ambulatory computer-based CDSS have not yet been widely adopted.

Several barriers to adoption exist. Clearly, the costs of these systems are an issue. However, it is important to determine if physician factors are also contributing to the slow adoption. First, it is unclear if primary care physicians (PCPs) are dissatisfied with their current methods for tracking abnormal test results or adhering to patient care recommendations. Their level of satisfaction could influence their desire to adopt new approaches. Secondly, PCP’s overall attitude towards CDSS has been not been well studied. Attitudes towards computer-based CDSS could be influenced by prior experiences with EMRs. Third, while patient case mix may influence physician perceptions of CDSS [18], it is unknown how a physician’s workload and patient volume might influence their attitudes towards computer-based CDSS, particularly given concerns that these systems could impact negatively on workflow [19].

The goals of this study were to (1) evaluate PCPs’ satisfaction with their current systems for tracking abnormal tests results and managing patient care recommendations; (2) assess PCP’s usage of an internally-developed EMR and attitudes concerning outpatient CDSS; (3) to assess the influence of experience and satisfaction with an EMR on attitudes concerning outpatient CDSS; and (4) evaluate the influence of provider productivity and patient volume on attitudes towards the EMR and CDSS.

Section snippets

Setting and participants

Partners HealthCare System is a large healthcare network that includes the Brigham and Women’s Hospital (BWH) and the Massachusetts General Hospital (MGH) and provides primary, secondary, and tertiary care in Boston, MA and surrounding areas. In July 2000, Partners HealthCare began implementing the longitudinal medical record (LMR) in its primary care clinics. The LMR is an internally-developed, Windows-based, fully integrated electronic ambulatory medical record that allows for visit note

Response rate

Two hundred and sixteen housestaff and attending PCPs were eligible for inclusion. The overall response rate was 65% (140/216). The response rate for housestaff physicians was 49% (50/103) and for attending PCPs was 80% (90/113). Of the 140 respondents, 88 considered themselves to be experienced with the LMR, while 52 considered themselves inexperienced. Table 1, Table 2 describes respondent demographics and LMR usage characteristics stratified by self-reported LMR experience level.

There were

Discussion

High quality health care requires systems to be in place to ensure adequate patient safety and quality [22]. Even though the primary care providers were already using an EMR and receiving some paper-based decision support, most physicians surveyed were not happy with their current systems for managing abnormal test results or patient care recommendations and wanted more support from the EMR. It is striking in particular that less than one in five PCPs were satisfied with their system to notify

Acknowledgements

This research was supported by a RO1 #1 U18 HS11046 grant from the Agency for Healthcare Research and Quality.

References (38)

A. Karcz
Massachusetts emergency medicine closed malpractice claims: 1988–1990
Ann. Emerg. Med.
(1993)
R.A. Rusnak
Litigation against the emergency physician: common features in cases of missed myocardial infarction
Ann. Emerg. Med.
(1989)
T.E. Kottke
Delivery rates for preventive services in 44 midwestern clinics
Mayo Clin. Proc.
(1997)
J.M. Teich
The Brigham integrated computing system (BICS): advanced clinical systems in an academic hospital environment
Int. J. Med. Inf.
(1999)
B.D. McCarthy
Inadequate follow-up of abnormal mammograms
Am. J. Prev. Med.
(1996)
G. Harris
Early diagnosis of breast changes. Risk management and quality of care approach
J. Fla. Med. Assoc.
(1996)
R.L. Kravitz et al.
Omission-related malpractice claims and the limits of defensive medicine
Med. Care Res. Rev.
(1997)
J.R. Osuch et al.
Primary care guide to managing a breast mass: a legal perspective on risk management
Medscape Womens Health
(1998)
D.B. Troxel et al.
Problem areas in pathology practice. Uncovered by a review of malpractice claims
Am. J. Surg. Pathol.
(1994)
M. Schaefer, Reducing office practice risks, in: Forum,...

E.A. Boohaker

Patient notification and follow-up of abnormal test results. A physician survey

Arch. Intern. Med.

(1996)

P.J. Greco et al.

Changing physicians’ practices

N. Engl. J. Med.

(1993)

J. Lomas

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians

N. Engl. J. Med.

(1989)

J.P. Weiner

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes

JAMA

(1995)

D.W. Bates

Reducing the frequency of errors in medicine using information technology

J. Am. Med. Inform. Assoc.

(2001)

E.H. Shortliffe

Computer programs to support clinical decision making

JAMA

(1987)

S. Shea et al.

A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting

J. Am. Med. Inform. Assoc.

(1996)

M.E. Johnston

Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research (see comments)

Ann. Intern. Med.

(1994)

D.L. Hunt

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review

JAMA

(1998)

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Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems

Abstract

Introduction

Section snippets

Setting and participants

Response rate

Discussion

Acknowledgements

Ann. Emerg. Med.

Ann. Emerg. Med.

Mayo Clin. Proc.

Int. J. Med. Inf.

Am. J. Prev. Med.

Early diagnosis of breast changes. Risk management and quality of care approach

J. Fla. Med. Assoc.

Omission-related malpractice claims and the limits of defensive medicine

Med. Care Res. Rev.

Primary care guide to managing a breast mass: a legal perspective on risk management

Medscape Womens Health

Problem areas in pathology practice. Uncovered by a review of malpractice claims

Am. J. Surg. Pathol.

Patient notification and follow-up of abnormal test results. A physician survey

Arch. Intern. Med.

Changing physicians’ practices

N. Engl. J. Med.

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians

N. Engl. J. Med.

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes

JAMA

Reducing the frequency of errors in medicine using information technology

J. Am. Med. Inform. Assoc.

Computer programs to support clinical decision making

JAMA

A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting

J. Am. Med. Inform. Assoc.

Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research (see comments)

Ann. Intern. Med.

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review

JAMA