Laboratory Medicine Handoff Gaps Experienced by Primary Care Practices: A Report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP)

David R. West; Katherine A. James; Douglas H. Fernald; Claire Zelie; Maxwell L. Smith; Stephen S. Raab

doi:10.3122/jabfm.2014.06.140015

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Table 1. Laboratory Processes Explored

Process	Process Description
Test ordering	The clinician's decision process about which test(s) to order and the transmission of that information to personnel responsible for performing the test or obtaining the specimen
Test tracking	The clinic's internal monitoring and reconciliation processes for the expected transmission of results of tests ordered from laboratories
Test result notification	The processes by which a patient learns of test results and how recommendations for action are transmitted to the patient
Patient follow-up	The processes by which abnormal test results or results needing action by the patient are tracked until that action is taken or refused by the patient

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Table 2. Characteristics of Participating Primary Care Practices (n = 21)

Characteristic		Practices, n (%)
Electronic health record utilization		17 (81)
Disease registry utilization		20 (95)
Rural location		9 (43)
Practice patient volume
Small (<60 patient visits/day)		7 (33)
Medium (60–100 patient visits/day)		8 (38)
Large (>100 patient visits/day)		6 (29)
Medicaid and Medicare population/payer mix
>25% of patient population insured by Medicaid		14 (67)
>20% of patient population insured by Medicare		7 (33)
Past participation in formal practice improvement		17 (81)
On-site processes
Phlebotomy		14 (67)
Preparation of blood samples before transport to the laboratory		12 (57)
Collection of stool samples		20 (95)
Collection of urine samples		13 (62)
Clinical Laboratory Improvement Amendment–waived laboratories		13 (62)
Licensed laboratory as part of practice		5 (24)
Test result delivery method from external laboratories	Commercial Laboratory “A”	Commercial Laboratory “B”	Hospital
Fax	10 (48%)	8 (38%)	8 (38%)
Dedicated printer	1 (5%)	1 (5%)	4 (19%)
Directly downloaded to electronic heath record	10 (48%)	9 (43%)	8 (38%)
Other	1 (5%)	1 (5%)	6 (29%)

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Table 3. Reported Method of Communicating Normal/Clinically Insignificant Abnormal and Abnormal Laboratory Results to Patients, by Electronic Health Record (EHR)– versus Non-EHR-Enabled Practices^*

Method of Communicating Results^{^†}	Practices That Always/Often Use Method, n (%)^{^‡}
Method of Communicating Results^{^†}	Practices With EHR	Practices Without EHR
Normal and clinically insignificant abnormal results
Personal call from clinician	104 (41)	36 (32)
Medical assistant/nurse phone call to patient	137 (54)	36 (32)
Patient instructed to call	54 (22)	25 (23)
Patient to assume test is normal if not notified	68 (27)	30 (28)
Send personal note	68 (27)	19 (17)
Send form letter to patient	117 (46)	47 (42)
Mail copy of test results	108 (42)	39 (35)
Results available on secure website for patients to access	28 (11)	30 (27)
Results emailed to patients	9 (4)	6 (6)
Results available on automated phone-in system	2 (<1)	0 (0)
Results available during patient visit	139 (56)	55 (50)
Laboratory center directly notifies patient	5 (2)	0 (0)
Clinically significant abnormal results
Personal call from clinician	204 (81)	83 (75)
Medical assistant/nurse phone call to patient	136 (54)	33 (30)
Patient instructed to call	48 (20)	19 (18)
Send personal note	39 (16)	10 (9)
Results available on secure website for patients to access	22 (9)	25 (24)
Results emailed to patients	8 (3)	7 (7)
Results available on automated phone-in system	5 (2)	0 (0)
Send form letter to patient	55 (23)	26 (24)
Mail copy of test results	71 (29)	31 (29)
Results available during patient visit	110 (46)	50 (46)
Laboratory center directly notifies patient	6 (3)	1 (<1)

Bold indicates significant different between clinicians and staff and managers.
↵* Analysis was confined to responses from the 17 practices with an internal response rate of at least 70%, by role.
↵† Row percentage for each notification method could be <100% because not every respondent selected each method.
↵‡ Respondents to the survey (clinicians, staff, and managers) were able to select all notification methods that apply to their practice; therefore, percentages may be >100%.

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Table 4. Reported Method of Communicating Normal/Clinically Insignificant Abnormal and Abnormal Laboratory Results to Patients, by Urban versus Rural Practice Location^*

Method of Communicating Results^{^†}	Practices That Always/Often Use Method, n (%)^{^‡}
Method of Communicating Results^{^†}	Urban	Rural
Normal and clinically insignificant abnormal results
Personal call from clinician	127 (40)	22 (31)
Medical assistant/nurse phone call to patient	125 (40	56 (80)
Patient instructed to call	62 (20)	19 (27)
Patient to assume test is normal if not notified	94 (30)	11 (17)
Send personal note	72 (23)	17 (24)
Send form letter to patient	145 (46)	30 (43)
Mail copy of test results	138 (44)	15 (21)
Results available on secure website for patients to access	58 (19)	1 (1)
Results emailed to patients	15 (5)	0 (0)
Results available on automated phone-in system	2 (<1)	0 (0)
Results available during patient visit	153 (50)	53 (75)
Laboratory center directly notifies patient	4 (1)	1 (1)
Clinically significant abnormal results
Personal call from clinician	257 (82)	47 (67)
Medical assistant/nurse phone call to patient	124 (40)	53 (76)
Patient instructed to call	49 (17)	19 (28)
Send personal note	43 (14)	9 (13)
Results available on secure website for patients to access	47 (16)	1 (1)
Results emailed to patients	15 (5)	0 (0)
Results available on automated phone-in system	5 (1)	0 (0)
Send form letter to patient	65 (22)	20 (29)
Mail copy of test results	93 (31)	11 (16)
Results available during patient visit	124 (42)	45 (64)
Laboratory center directly notifies patient	5 (2)	2 (3)

Bold indicates significant different between clinicians and staff and managers.
↵* Analysis was confined to responses from the 17 practices with an internal response rate of at least 70%, by role.
↵† Row percentages for each notification method could be <100% because not every respondent selected each method.
↵‡ Respondents to the survey (clinicians, staff, and managers) were able to select all notification methods that apply to their practice; therefore, column percentages may be >100%.

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Table 5. Frequency With Which Practice Personnel Reported That the Practice Directly Notifies Patients of Laboratory Test Results (n = 384)

Result	Reported Patients Notified Directly, n (%)
Result	<96% of the Time	Between 96% to 100% of the Time
Normal	255 (66)	129 (34)
Clinically insignificant abnormal	220 (57)	164 (43)
Clinically significant abnormal	105 (27)	279 (73)