GRAPEVINE, TEX. – E-mailing the results of tests still pending at patient discharge is a feasible solution to the "I never got this message" scenario.
Such a pilot project performed well for hospitalists and primary care doctors in the Partners HealthCare System’s "partners.org" database, Dr. Anuj K. Dalal said at the annual meeting of the Society of Hospital Medicine.
However, he warned, unless system bugs are hunted down and exterminated before deployment, one inaccurate discharge entry could set up a domino-effect deluge of e-mails to peeved primary care physicians.
"One unit clerk inadvertently ‘discharged’ a patient on day 4 of a 10-day hospital stay," he said. "The system then detected 510 pending tests at discharge, which resulted in nine e-mails to one very frustrated physician. I can’t tell you how important it is to have the process crisp before you jump into something like this. You have to remember the computer adage, ‘Garbage in, garbage out.’ "
He points to the not-uncommon scenario of patients who are discharged before all the lab results come back. Those results are returned to the physician who ordered them – most likely the hospitalist – and frequently stop there. "No one ever communicates the results to the PCP [primary care physician], and the attendings don’t review them," because the patient is no longer under their care, said Dr. Dalal, a hospitalist at Brigham and Women’s Hospital in Boston.
To address the problem, he conceived of and helped create a computer algorithm that automatically detects incoming test results and generates a single e-mail to the patient’s hospital attending and primary care physician. The system updates at midnight and keeps generating one e-mail a day to each provider until all results are finalized.
"Every e-mail has the date it was generated, the patient’s name, name of the discharging attending physician, the day of discharge, and the results of each test," Dr. Dalal said.
While the system is feasible in a large, interconnected health care system, it isn’t foolproof, he added. Sometimes, physicians outside the Partners e-mail system admit a patient; in that case only the hospitalist gets the e-mail. "But it always has the phone number of the primary care doc, so the hospitalist can call and relay the results."
The 1-month pilot period included chemistry/hematology, radiology/pathology, and microbiology results. It was tested on 83 discharges – including the one that caused the electronic mayhem. After excluding that one, Dr. Dalal said, the computer program found 405 pending tests, most of which (55%) were chemistry, while the remainder were hematology; 18% were abnormal. This generated 136 e-mails – about 1.7 per patient, although 34% of the patients had 2 or more e-mails sent. Aside from complaints about the inaccurate discharge, only three physicians (two PCPs and one hospitalist) said they received incorrect e-mails.
A survey of 70 physician users found that 84% were satisfied or very satisfied with the system, while 6% were neutral and 10% dissatisfied or very dissatisfied.
Comments from both sides of the issue included remarks such as "I found this extremely useful, knowing the final results of tests, both those that are positive as well as negative," and "Test was not needed and not ordered by me."
Dr. Dalal also presented a poster that examined the system’s 6-month outcomes among 36 discharging physicians who got the e-mails and 43 who did not. Physicians who got the e-mails were six times more likely to be aware of the results of any pending test, and five times more aware of any pending tests that required action on their part.
They were also significantly more likely to be satisfied with the automatic notification system than with the usual care system (84% vs. 21%).
In considering the impact of this novel collaboration on patient care, Dr. Dalal said, "I would challenge you on the thought that our responsibility as hospitalists ends when the patient is discharged. Does it really, especially as we are doing all this work on care transition and decreased readmission? We are going to become the care transition experts; we need to think of whether we are responsible for these results."
Dr. Dalal reported having no financial disclosures.