One of the key areas of laboratory to physician communication is that of reporting critical values. Since regulators and accreditation organizations define critical values as abnormal test results that are potentially life threatening and require a rapid response from caregivers, any steps taken to improve this process impacts the quality of patient care. This not only refers to the timeliness of reporting test results, but ensuring that these results reach the intended physicians no matter where they are and that the information sent and received is secure.
Thanks to the rapid spread of mobile technology, including mobile phones, pagers, pads, and computers linked to electronic health records, new more secure messaging systems to report critical values are available. These allow for more options and richer features far beyond that of current pager systems or traditional telephone communication. These systems offer security that normal cellphone text messaging lacks, and their two-way capabilities automate the kind of closed-loop system that patient safety experts have advocated. These mobile-friendly applications can keep critical results from falling through the cracks. They create an audit trail of message sending, delivery, and receipt, and labs can configure software that escalates an alert when the initial caregiver does not respond in a timely manner.*
Another new application of mobile technology is in real-time patient monitoring using wearables, such as watches and wrist bands synced to mobile phones. In these cases, if critical values are detected, these values can be immediately transmitted to the laboratory’s electronic health records system (EHR), and the physician notified immediately.
However, along with these advances have come issues of information overload which can act as a counter-force to the progress that these devices provide. In the same way that laboratories often feel frustrated when they are not able to reach physicians to release critical results, physicians increasingly feel overwhelmed with the high volume of alerts, calls, and other messages that they are receiving. These alerts came from test results, referrals, notes, order statuses, patient change statuses, and incomplete task reminders.**
As a result, even with the increasing number of high-tech tools available, labs often struggle to optimize critical value reporting. Realistically, this cannot be solved unilaterally by the laboratory. There must be active ongoing collaboration with physicians to identify problem areas, and seek solutions through mutually agreed upon strategies. The problem with information overload is how to distinguish laboratory alerts from all the other alerts that are coming in as well. This collaboration should produce uniform policies applicable to all physicians on staff, not customized for individual physicians.
Just one example of this approach is to consider utilization of computerized provider order entry (CPOE) systems and improved EHR software to help solve problems with tracking and feedback. According to Hardeep Singh, MD, MPH, a researcher at the Houston Veterans Affairs Health Sciences Research and Development Service, and a co-author of the recent study on EHR alerts, “Using CPOE to order lab tests is the way to go. You can have all sorts of fancy processes in place, but unless the results get back to the right person, you’re not going to have any follow-up on it. CPOE is the beginning point of getting the results into a trackable coded fashion that is recognized by the computer so that the communication loop can be closed.”***
Of course, many laboratories still utilize the basic manual system of calling or paging the ordering physician directly whenever a critical value is reported, and documenting these contacts either electronically or on paper. However, the same principle of collaboration and mutually agreed upon policies and procedures for critical values reporting applies. The bottom line is that these results must get to the right person, as quickly as possible, so that the patient receives the highest quality of care regardless of new or traditional obstacles.
* B. Malone. The Dilemma Surrounding Critical Value Reporting. Dec. 1 2012. AACC. Clinical Laboratory News. https://www.aacc.org/publications/cln/articles/2012/december/critical-value-reporting.aspx