Number 546 (Reaffirmed 2016. Replaces No. 461, August 2010)
Committee on Patient Safety and Quality Improvement
This document reflects emerging concepts on patient safety and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: An accurate and effective tracking or reminder system is useful for the modern practice of obstetrics and gynecology. Practices should not rely solely on the patient to complete all ordered studies and to follow up on health care provider recommendations. Health care providers should encourage their patients to complete studies believed essential for patient care within an acceptable time frame. Each office should establish a simple, reliable tracking and reminder system to facilitate communication, improve patient safety and quality of care, and minimize missed or delayed diagnoses.
The accurate and timely flow of information between patients and health care providers is important for safe and effective care. Patient visits often require some form of follow-up that involves further screening, referrals, communication of test results, or consultations. Health care providers’ offices should have procedures in place to track these events effectively and to enhance the quality of care and patient safety. An effective and reliable reminder system need not be complex or expensive but is a necessity for obstetric and gynecologic care in all practice settings. Failure to follow up may cause delayed or missed diagnoses or treatment, which may result in an adverse patient outcome and potential liability for the health care provider. Failure to follow up on laboratory results has been identified as one of the leading causes of lawsuits in the outpatient setting 1 2. Courts have held that the health care professional is responsible for contacting patients about laboratory, imaging, and consultation results; however, patients have the responsibility to follow through on their health care providers’ recommendations. An adequate tracking system can help reduce risks and provide safe, high-quality patient care. Tracking and reminder systems can help practices and patients increase their rates of preventive screening tests. Health care providers should recognize the potential to improve patient safety by adopting tracking and reminder systems. Additionally, practices increasingly are being measured on rates of preventive services delivered to their patients, such as cervical cancer, breast cancer, and colon cancer screening. As more health care providers adopt an electronic health record (EHR) system, choosing a system that can enhance the tracking and reminder process is an important consideration.
The process of tracking patients begins at the initial visit with the health care provider explaining to the patient the need for any test, referral, or follow-up. This discussion is then documented in the chart. Clear information and instructions can help the patient participate in her care and understand why a test or appointment is important. Additional information, including printed information supplied by the office or produced from the EHR, may provide written confirmation of instruction and recommended testing. When an EHR is available, the patient also may access this information through a patient portal. Patient adherence to physician recommendations may improve when a patient is provided with follow-up information. The next step is to promptly log these open items into a tracking or reminder system and review them frequently and regularly according to the office’s established procedures.
An appropriate tracking system can be manual or electronic. A successful system may be in the form of a logbook, card files, file folders, or computer system, or any system accessible for ongoing updating and monitoring. Computerized systems can be helpful, but they also may be expensive and time-consuming. As more practices incorporate EHRs, the use of computer-driven tracking and reminder systems will become more common. In many EHR systems, health care providers can receive notifications when preventive screening tests are due or overdue, and many systems also will search for the results of previously ordered tests. In practices without an EHR system, a simple paper-based “tickler system” can be developed. No matter which system is used, data entry should be prompt and correct.
Once information is entered into the EHR system, it should be retrieved and reviewed regularly with accompanying documentation of any actions taken or discussions held with the patient. Information on each patient should be reviewed throughout the entire process from data input through resolution. To decrease the risk of system failure, the number of steps in the process should be minimized.
Each office should establish priorities for tracking important information, test results, and follow-up ordered by the health care provider. As the tracking system is tested and improved, additional elements can be added. Listed as follows are examples of information, test results, and follow-up that should be tracked in obstetric and gynecologic practices:
Pap test results and follow-up, or need for colposcopy
Mammography results and recommended follow-up
Pertinent laboratory tests and radiologic studies
Pathology reports from procedures performed
Results of genetic testing, with emphasis on time- sensitive results, such as multiple marker tests
Details of on-call emergencies
Consultations and referrals to other health care providers, noting whether the patient has visited with the health care provider and whether the health care provider’s report has been filed in the chart
Referrals of patients from other health care providers, with notification to the referring health care provider after the patient has been seen
Follow-up appointments should be scheduled if necessary. Patients should be reminded about the importance of keeping any postoperative visits and other follow-up appointments. If a patient does not appear for a scheduled appointment, that fact should be recorded in her medical record. Although patients cannot be forced to keep their appointments, an attempt should be made to contact them when an appointment is missed and to assist them in rescheduling.
Suggested Characteristics of the Reminder System
The following characteristics are important for any reminder system, whether electronic or paper based:
Policies and procedures––An office policy and procedure on tracking should be developed with input from the staff. All office members should agree to follow the same protocols. The policy should address how to contact the patient and how to document the follow-up in the patient’s chart. Time frames for when to expect test results should be defined, and a protocol should be established for handling delayed or missing reports.
Health Insurance Portability and Accountability Act (HIPAA) compliance––When contacting patients, whether by mail or electronically, health care providers and their staff must follow the Health Insurance Portability and Accountability Act regulations 3. Care also must be taken to limit the amount of information disclosed by way of voice mail or to other individuals who may answer the call without prior consent. Instead, it may be preferable to leave a name and telephone number, asking the patient to call the office.
Specificity––The reminder system should contain specific data and dates, including the dates for receipt of information and timelines for notifying the patient.
Central location––The reminder system should be centrally located in the office and should not be kept in individual patient charts. Reminders should be accessible to the entire staff.
Reliability––The tracking system should not be the responsibility of a single individual. Office staff should be cross-trained so that the system is reliable and efficient. It should be updated and monitored regularly.
Sample Tracking Form
A tracking form can pinpoint key follow-up areas. Listed as follows are the important elements to be tracked:
Test, procedure, consultation, or referral
Date of test results
Evaluation completed and patient notified
Results of all Pap tests, mammograms, consultations, and pathology reports provided on paper should be reviewed, initialed, and dated by a health care provider who has been designated to perform this function. Electronic results should be signed off electronically and time stamped. Test results should then be filed permanently in the patient’s chart, whether paper or electronic, including a notation of what follow-up tests or procedures are recommended.
Patients should be made aware of the office practice for notification of test results and should be instructed to call back for test results if they are not received in a timely fashion. However, the office should not rely solely on the patient to call back for test results but should have a more effective system. Computerized tracking and reminder systems, although not required, are available with custom alerts, telephone reminders, and telephone numbers to call for automated test results using individual identifying numbers. Some practices are now using secure patient portals where patients can receive their test results electronically, and can receive electronic reminders about when their next test should be scheduled. Allowing patients to view their test results electronically can improve patient satisfaction with the results notification process as well as the communication of their treatment plan 4. In many cases, educational material describing the purpose of the recommended tests also can be accessed by the patient. In considering the use of a computerized tracking and reminder system, factors such as staff time, cost, ease of use, and effect on end-user workflow should be evaluated. Allowing all personnel who participate in health care record tracking to provide input into the system design and implementation should encourage its use. As practices increasingly incorporate EHRs to meet Meaningful Use requirements, the use of the EHR to facilitate the tracking and reminder process is a logical progression. The use of EHRs also can facilitate tracking appointments, test results, and patient reminders. Use of tracking systems may enhance the quality of care, patient outcomes, and patient satisfaction while helping to improve patient safety 5.
Designing and implementing a tracking and reminder system also provides an opportunity to develop further a culture of safety in the office. A system that is standardized, simple, and accessible to all potential users will reduce the likelihood of error. When problems or mistakes occur, staff should be encouraged to report them. Errors are a valuable way to learn why and how systems fail, and exploring the causes of errors provides an opportunity to improve those systems. Ultimately, an informed and involved patient, a well-designed tracking system, and health care providers and staff who feel safe to discuss system failures will render safe patient care and improve outcomes.