This guidance explores clinical responsibility for acting upon test results when using electronic systems. There is no simple solution and therefore it is important that you consider the challenges highlighted and decide upon a strategy which works best for your team or organisation.
Electronic reporting of results can:
- offer significant benefits - they enable fast access to results to inform patients' ongoing care, results may be less likely to go astray and they can be simultaneously made available to multiple clinicians.
- raise patient safety issues if not implemented properly - holding paper test results can serve as a physical prompt that you are responsible for reviewing those results and taking action. With potentially multiple users viewing results it can easily become confusing where the responsibility for action lies.
We would be interested in receiving examples of good practice when dealing with electronic test results. Please tell us about your experiences at info.nhs-[email protected]
Receiving and viewing results ordered by another clinician
Who is responsible for action?
Traditionally a clinician who orders a test is responsible for receiving and acting upon the results once available. This may require direct action by the clinician or a transfer of responsibility to another clinician, for example a consultant writing to the patient's GP with the details of the results and any action that is required1. Likewise, if tests are required as a pre-requirement for a hospital referral a GP would be responsible for making the hospital aware of the relevant results as part of the referral process.
Until an explicit code of practice is agreed, clinicians should assume that the ordering clinician is responsible for receiving and acting upon results and should not assume that others who can view the result will take action.
Pulling down results
Allowing others involved in a patient's care, to view or at times act upon test results prior to the results being communicated by the 'ordering' clinician can offer benefits. If a patient attends a GP practice shortly after being discharged and prior to the test results being formally communicated by the requesting consultant, 'pulling' down and viewing the relevant test results may help the GP decide how to care for the patient.
Automated feed of results
Test results can also be automatically sent or 'pushed' to GP practices. Although the ordering clinician retains ultimate responsibility as described above, an automated feed of test results can blur the lines of clinical responsibility because once you receive a test result you may also assume clinical responsibility to act upon it or ensure that it is actioned even if it was ordered by another clinician and you are unsure whether any action has been taken.
A test result may reveal the need for urgent intervention and if, once viewing the test result, no action was taken and a patient came to harm a clinician could potentially be held accountable even if they did not order the test. In light of this we recommend that systems which automatically send or 'push' test results to clinicians who have not ordered the test, for example the patient's GP practice should be approached with caution.
Accident and Emergency
Similar situations also arise in secondary care for example if a patient is admitted following a visit to A and E, the consultant now caring for the patient may wish to view the results of test ordered by colleagues in A and E. In such circumstances there need to be clear local protocols about who is responsible for taking action.
Instructing another clinician to take action upon a result
Sometimes a patient will have left your care when test results become available. In most cases it is appropriate for the ordering clinician to review test results and forward the results with advice and comments to the treating clinician.
There may be times when you order a test but require another clinician or team to take direct action. A consultant may discharge a patient when test results are pending and wish the results to be sent directly to the GP practice or an A and E consultant may instruct a patient to be transferred to another department and want any test results to follow the patient.
This could be enabled in system design but would only be appropriate if:
- It is clear which individual or team will be caring for the patient once the test results are available. For transfers within hospitals this may rely on colleagues updating
promptly on systems the location of the patient so that results can be transferred to the appropriate department.
- There is no need for the ordering clinician to review the results prior to them being sent to another clinician. Care should be taken to ensure that electronic reporting does
not affect the quality of communications and handover between clinicians.
- The receiving clinician has access to the relevant clinical information to place the test results in context. For internal transfers in hospitals, systems should be designed so
that the patient's clinical information is readily accessible from the test results screen.
- There is a clear instruction that the receiving clinician needs to take action. You should not assume that because a clinician can view a result he/she knows that action is
required; the ordering clinician will retain responsibility until there is an instruction otherwise. This could be enabled in the design of clinical systems for example by allowing the ordering clinician to request that results are sent to another clinician who is prompted when the results are available with clear instructions that action is required. The ordering clinician should also be sent a copy of the results and could send a reminder to the receiving clinician as an extra precaution if felt necessary.
- It is clear who is responsible for chasing or following up if the results do not arrive. If the receiving clinician is located in a different organisation it may not be possible for him or her to track the results down, in which case it would be better for the ordering clinician to receive the results which can then be forwarded as necessary.
Electronic results and hospital teams
Increasingly hospital junior doctors and consultants are working as flexible teams to manage patient care. This presents some challenges with the review of patient results and requires good communication and clarity around roles and responsibilities (see note 2).
The use of paper based results can ensure that the result is viewed and that an audit trail in the form of a signature on the result exists. Electronic systems need to offer the same, if not better safeguards i.e. results need to be available to all those involved in a patient's care, clearly marked with who ordered them, who currently has responsibility for them, who has looked at them and who has signed them off. It also requires systems which allow users to log on as an individual but still have access to all the relevant results for checking and cross checking.
It is particularly important for flexible hospital teams to ensure a clear policy relating to both the review of electronic results and any subsequent action. Primarily the ultimate responsibility will lie with the consultant responsible for the patients' care (see note 3). Any delegation of this responsibility must be clear, result in an appropriate audit trail and be flexible enough to manage planned and unplanned absences of various team members including the responsible consultant.
There will also be situations in hospitals, particularly in A and E Departments where clinicians will need to make an initial decision on a patient's care prior to results such as reports from the radiologist being available. It is important that once the report is available, processes are in place to ensure that it is used to ratify the original diagnosis or treatment plan even if the patient has already been discharged. If the results do not confirm the accuracy of the diagnosis or propriety of treatment then further action may need to be taken even if that is simply informing the patient and their GP of the findings.
Communication of life threatening or critical results
It is essential that results relating to potentially life threatening problems are communicated promptly and directly to clinicians caring for patients. All organisations whether utilising electronic or paper test reporting should ensure that clear policies for communicating critical or life threatening results have been implemented.
The results may include (but not be limited to) critically high potassium levels, grossly abnormal renal function, cancer diagnoses, grossly abnormal radiographs and in some instances cardiac biomarkers. In these instances the laboratory generating the result should telephone the responsible clinician.
Shared team in-boxes
Procedures should be in place to ensure that results are actioned when they arrive in to a team and a team member does not incorrectly assume that a result will be actionedby his or her colleague. Shared team in-boxes are one such way of achieving this, but may only be appropriate in certain scenarios.
Thought should be given to how results requiring immediate action should be dealt with, who should review results during short term, long term and unexpected absence of a team member and how these procedures are communicated to those who are not regular members of the team for example locums. Consideration could be given to making a member of staff, for example the team secretary, responsible for flagging and following up unread or unactioned reports on a regular basis.
Retention of paper copies of test results
Whether to retain paper copies of results will be a local decision. If appropriate electronic systems and protocols are in place it should be unnecessary to retain paper copies as an audit trail will be retained on the electronic system; duplicating electronic and paper results can result in greater confusion.
Shared electronic records
Shared records may blur the lines of responsibility for acting upon test results. Acting upon test results is covered in the Royal College of General Practitioners 'Shared Records Professional Guidance', which covers 'responsibility for responding to clinically significant data items'. It states that 'with more than one health professional having access to a shared electronic health record, there needs to be a system which can analyse the results and send alerts to the 'responsible' health professional, who may differ from the person ordering the test (e.g. in patients recently admitted to or discharged from hospital'.
There must be processes in place to ensure that it is clear who is responsible for acting upon a result and it must not be assumed that because others can see the result in the shared record they will know to take action. Generally the clinician who ordered the test will retain the responsibility for taking action, which could be ensuring that processes are in place to instruct another clinician to take action as described above. This should include all results even those that are normal. It should also be clear to others viewing the record when a result has been signed off and by whom.
Results sent electronically by patients
Some patients already capture health information following advice from a clinician or because they wish to monitor their own healthcare. This is likely to become more commonplace with products infiltrating the market and becoming available to the public including both products to take measurements and platforms or software to record measurements e.g. Healthspace, Microsoft HealthVault or iphone apps. There is also political interest in preventative care and patients taking more control over their health.
- At present, patients may bring a printout of such measurements to their appointment but in the future it may become more commonplace for clinicians to receive a feed of patient taken measurements. Receiving measurements from patients raises a number of issues but this guidance focuses on responsibilities for taking action.
- It would be inadvisable to receive directly a feed of patient taken measurements without an agreement between a healthcare professional and patient. This should set out the responsibilities on each side for example, the timescales for follow up and ensuring patients understand that if they take an abnormal reading and feel unwell in the middle of the night they should not rely on the healthcare professional to pick up the reading but should seek medical care as appropriate. By agreeing to receive patient taken measurements you assume responsibility for taking action on the measurements when clinically necessary.
- It would be useful if electronic systems could be set up to filter measurements so alerts are generated for abnormal readings. Once receiving an alert the clinician would be responsible for considering the reading and deciding the action to be taken. This would include if you decided to access results out of hours remotely from home and viewed a result, which required urgent attention.
This would be complicated by shared records; if there are multiple clinicians accessing a shared record, who is responsible for taking action on patient entered measurements? Generally the clinician who asked the patient to submit measurements, or who had an agreement with the patient to receive readings, would be responsible for acting upon the information unless the patient turned up in another care setting, for example in Out of Hours setting, in which case it would be appropriate for another healthcare professional to use the readings to inform the patient's care.
Electronic systems can enable fast access to test results, which can bring benefits to patient care. They can also present risks if clear processes to establish responsibility for taking action on results are absent. Sometimes it will not be clear whether any action has been taken by a colleague so these processes need to be set up and understood in advance of you receiving a result.
When viewing a test result you need to be clear whether you are responsible for taking any action regardless of whether it is ordered by you, by one of your team, by another department within your organisation, by a clinician in another organisation, it is visible in a shared electronic record or it is information sent by a patient. Generally theordering clinician will retain the responsibility for reviewing the result and taking action. This may not always be the case and processes and system design need to accommodate this.
- General Medical Council: Good Medical Practice - Continuity and coordination of care - Paragraph 44 details responsibility to share relevant information with colleagues involved in the patients' care.
- General Medical Council: Leadership and management for all doctors - Communication within and between teams - Paragraph 10-13 details guidance on team working and sharing of information.