Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup
Research Activities, November 2010, No. 363
The electronic medical record (EMR) can do a great deal to improve office-based care, including reducing medical errors. However, while physicians believe that the EMR will greatly impact test result procedures, this is not always the case. A recent study found that while the EMR does increase the documentation of patient test results, it still falls short when it comes to notifying patients, documenting the interpretation of results, and following up on abnormal test results.
Researchers examined patient charts from eight primary care offices in Ohio. They reviewed a total of 461 test results in 200 charts. Of these, 274 were managed by EMR at 4 offices, with the others managed by standard paper-based procedures. There were significant differences between EMR vs. paper charts in the way test results were documented. Both did well at ensuring that the results were in the proper location in the chart. However, while 86 percent of paper test results had a clinician signature, all of the EMR results did. Also the EMR was better at documentation of test result interpretation and patient notifications. However, the success rate declined greatly for both EMR and paper charting when it came to writing a results interpretation in the chart and documenting patient notification. There were also low rates of documentation regarding needed followup of abnormal test results for both the EMR and paper systems.
The researchers concluded that the EMR is not being used to its fullest potential when it comes to steps involving the active input of staff and clinicians. They note that an important unresolved issue is whether an EMR really increases test result management quality or just documentation. The study was supported in part by the Agency for Healthcare Research and Quality (HS13914).
See "The management of test results in primary care: Does an electronic medical record make a difference?" by Nancy C. Elder, M.D., M.S.P.H., Timothy R. McEwen, M.S., John Flach, Ph.D., and others in the May 2010 Family Medicine 42(5), pp. 327-333.