By Deborah Borfitz
September 17, 2019 | Widespread adoption of electronic health records (EHRs) has led to some disturbing communication snafus in the pathology results reporting process that some provider organizations are actively working to mitigate. Getting test results back to the right physician and responding in a timely manner to messages from referring physicians are among the chief challenges, according to Vinita Parkash, M.D., associate professor in the department of pathology at Yale University School of Medicine, and Andrea Lynne Barbieri, M.D., an assistant pathology professor.
The communication glitches can affect the reporting of new pathology results, addendums and amendments, says Parkash, as well as contribute to diagnostic errors—the top safety concern for healthcare organizations for two years running, based on surveys by the ECRI Institute. It is not always easy for clinicians to even choose the appropriate diagnostic test, given the proliferating number of options available.
Five years ago, Parkash published an eye-opening study on the difficulties in getting amended surgical pathology reports to the correct responsible care provider. Even in these high-penalty situations, more than 10% of reports had discrepancies between the ordering and treating physician both because they failed to follow the patient’s chain of referrals and EHR systems weren't sending alerts to clinical teams.
As with pathology reporting in general, results typically get sent to the ordering physician because that's the listed contact point, Parkash says. Mix-ups are most likely in cases where a biopsy specimen is taken by an interventionalist, who is not typically the one managing the patient's disease. "The clinician and/or the patient would have to stay on top of things to make sure that a worrisome result gets to the right physician."
EHR Messaging
A separate paper published in 2017 looked at the challenges faced by referring physicians in communicating with pathologists via EHR inbox messaging. One of the partnering institutions on the study had "completely inactivated" messaging functionality for pathologists, says Barbieri, and in the other two settings EHR messaging had fallen out of favor if pathologists were even aware it existed in the first place.
"Some of it is inherent to pathology," Barbieri says. "Many of us have separate software systems for exchanging patient information, so we don't necessarily access an EHR with the regularity of someone who is writing progress notes on patients."
As a direct result of that study, Barbieri and Parkash began educating their colleagues about the availability of messaging functionality in the Epic EHR system. The institutional IT team also worked with them to create an opt-in alert for pathologists whenever they receive a message via the EHR, so they would know to log on and read it. The alert persists until the message has been marked as read in Epic, Parkash notes. The alert feature has worked well, in part because pathologists’ message volume is light.
Of the more than seven billion tests done annually in the US, pathology is responsible for only about 5% of them, says Parkash. That puts pathologists at much lower risk of alert fatigue relative to radiologists and those working in lab medicine. Clinicians, who might have 50 or more patient-related reports added to their inbox each day, are at high risk—making it easier to understand how a single, critical message might get overlooked.
Report Format
Recognizing the daily deluge of messages facing physicians, and the complexity of managing and interpreting study results, pathologists at Yale routinely talk about how to make their reports "more streamlined and uniform," Barbieri adds. They also endeavor to make addendums easy for busy physicians to interpret.
Parkash thinks 80% of reports can be standardized using a discrete data format in lieu of descriptive terms, so clinicians can get the answers they need in a glance. The problem, she adds, is that the human brain is not wired to read every single word on a page like a computer. In cases where the diagnosis is not clear-cut, the ambiguities would also be hard to communicate—resulting in "incredibly long reports" where vital information might go unnoticed.
"I imagine that we will increasingly move to discrete data entry," Parkash says. "But the loss of unstructured information doesn't necessarily improve understanding. I'm not sure there is a universal solution, since patients are different, and diseases are different, and we're dealing with an EHR... that has become so unwieldy that we don't know where to find the information we're looking for."
All of this "makes the issue of communication that much more important in medicine now than it used to be," says Parkash.
Reducing Misunderstandings
Weak links exist in the process of getting pathology results reports back to care providers, whether institutions use the integrated lab information system (LIS) that EHR vendors provide (e.g., Epic Beaker) or a standalone LIS, Parkash says. The biggest advantages with the former are that specimens can be easily tracked, and information doesn't have to be repeatedly entered, avoiding mix-ups.
"The downside is that EHR vendors have not given a huge amount of attention to the needs of anatomic pathology," Parkash continues. Beaker software originally "piggybacked" on Epic's clinical lab information system that was optimized for short, numeric-based reports. Reports from anatomic pathology labs are more consultative and conversational. She expects the features of different laboratory information systems to better align with future iterations of both.
Yale's pathology department has opted to use a standalone LIS that electronically communicates with Epic "in a way that would be best for patients," says Parkash. "We're a unique department in that we have our own mini lab information group, allowing us to customize our system with a lot of quality improvement functionality," including monitoring day-to-day and sometimes hour-to-hour workflow.
Among the procedures that hospital pathology labs offer is rapid intraoperative consultation, aka frozen section, which renders preliminary results with "reasonably high" accuracy in 20 minutes and helps direct surgical decisions in the moment. At most institutions, pathologists would communicate with surgeons via the phone, Parkash says. But physicians aren't always able to get to the phone or use the intercom system—and having a nurse relay the information opens the door for mistakes.
The answer at Yale was to display the lab's written diagnosis on the screen in the operating room suite, which surgeons can read by merely lifting their head, says Parkash. "If necessary, we layer direct conversation on top of that." It's a closed loop communication system that requires the surgeon to acknowledge the diagnosis has been received.
It was a labor of love for Director of Anatomic Pathology John Sinard, M.D., Ph.D., who is also medical director of pathology informatics at Yale, says Parkash. "He has done a huge amount of work to customize our system so we can reduce the number of misunderstandings that traditional systems have not yet addressed."
Preventing Diagnostic Errors
Errors in pathology reports are particularly concerning when cancer is missed, says Parkash, but also when it's over-diagnosed and patients get treated for a non-growing or slow-growing cancer that would never cause harm. That has given birth to the idea of diagnostic management teams (DMTs) for eliminating some of the guesswork. The concept brings together the pathologist and lab scientist to the bedside, helping physicians order the correct test and use the results to select the most appropriate treatment.
DMT was the brainchild of Michael Laposata, M.D., Ph.D., professor and chair of the department of pathology at the University of Texas Medical Branch. He has spearheaded the development of DMTs at multiple institutions and demonstrated their ability to improve patient outcomes and shorten hospital stays, Parkash says.
Most institutions have multidisciplinary tumor board conferences where patients with cancer are discussed, she says, but the idea is now migrating to other disease areas. It's a collaborative approach, with radiologists, pathologists, treating physicians and other experts all sitting at the table.
"I'd eventually like to see direct-to-patient communication of results by pathologists, radiologists and lab physicians," Parkash says, adding that efforts to implement such a strategy have been met with a "lot of pushback."
It may only be a matter of time. Pennsylvania passed a law earlier this year requiring radiologists to directly notify patients of significant and unexpected findings, Parkash says. Federal law has for the past two decades required radiologists to directly communicate mammography results to patients and delays in diagnosing breast cancer have fallen significantly as a result.