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. 2001 Sep 1;323(7311):516.
Accessing emergency test results on ward computers
Results indicating that lifesaving treatment is needed should probably be telephoned
Editor—Kilpatrick and Holding report an audit of the introduction of computer terminals to two wards so that emergency test results could be accessed.1 They have opened the debate on the presumption that computerised results are superior to telephoned results for emergency tests. Their study highlights several important issues.
In each of the two busy clinical areas audited only one terminal could be used to access results. This may have led to limited access to results at certain times. The audit was carried out one month after the computer terminals were activated. Whether staff had a period of learning and familiarisation before using the system is unclear. Also, teething problems would have to be overcome before such a new system was implemented. It would be interesting to see the results of an audit carried out today.
The attitude of junior doctors in practice must be considered. With the high workloads and numerous patients, they are often anxious to get through the admissions that need to be seen rather than to formulate a differential diagnosis, arrange tests, and, most importantly, review the results requested. Frequently, inappropriate blood tests are requested for patients seen in accident and emergency departments, or those requested are not noted down or the results examined, so that effort is duplicated.
Possibly the reporting system used in this audit could be improved. Abnormal results could be highlighted by a colour, not an asterisk. The system used is not particularly user friendly for novices or inexperienced staff: this could be improved with more modern software facilities.
In many centres results are not routinely telephoned; in some hospitals paper is obsolete for reporting results. We would suggest that results indicating that lifesaving treatment should be initiated rapidly should always be telephoned—otherwise a system failure will result.
References
1.Kilpatrick ES, Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ. 2001;322:1101–1103. doi: 10.1136/bmj.322.7294.1101. . (5 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Sep 1;323(7311):516.
Electronic transmission is generally the way forward
Editor—I was disappointed at the negative tone of Kilpatrick and Holding's paper on using computer terminals on wards to access emergency test results.1-1 As a chemical pathologist and someone who often has to contact the laboratory for results, I have no doubt that electronic transmission of all authorised results to computer terminals in wards, clinics, and general practitioners' surgeries would be a great advance. This assumes that this method of transferring results is part of a strategy that recognises the laboratory's responsibility to interact with clinicians when abnormal results are obtained.
Anybody who contacts a busy NHS laboratory for results regularly will agree that this is frustrating and time consuming. Equally, laboratory staff are upset, and their efficiency is compromised, when their work is repeatedly interrupted by phone calls for results—often results that have already been telephoned, faxed, or delivered in report form. Computer terminals on wards can be used to access all results, both routine and emergency, and those pertaining to the current and previous patient episodes. The electronic transmission of results greatly improves efficiency and reduces frustration.
I was surprised to read in Kilpatrick and Holding's paper that some laboratories had dispensed with the telephoning of results in the knowledge that they can be accessed on the wards by clinicians at their convenience. Surely the communication of abnormal laboratory results is too important to be left to chance. The results of this audit were, in my opinion, entirely predictable. It is not all surprising that the busy staff in an accident and emergency department and an acute medical admissions unit did not look at a considerable proportion of laboratory results.
The authors mention that there might be legal and financial consequences for the clinician responsible and the hospital trust if it transpired that harm to a patient occurred because abnormal results had not been viewed. I believe that the onus lies with the senior laboratory staff to ensure that all abnormal results outside agreed limits are telephoned immediately, preferably to the doctor looking after the patient. With this safeguard in place, I would be much more upbeat than the authors and conclude that electronic communication of laboratory results is far superior to traditional communication methods.
References
1-1.Kilpatrick ES, Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ. 2001;322:1101–1103. doi: 10.1136/bmj.322.7294.1101. . (5 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Sep 1;323(7311):516.
Introduction of electronic communication alone would not improve clinical care
Editor—The audit by Kilpatrick and Holding highlighted two important issues of interest to the NHS2-1: the need for the evaluation of new technology and to understand and redesign systems.2-2 The central law of improvement says that every system is perfectly designed to achieve the results it achieves.2-3 When laboratory staff telephone results to a clinician it prompts a review of the patient. The new system removed this prompt, and in this audit over a third of emergency results were never seen before they were printed.
It is interesting that the laboratory staff were not satisfied that they had transferred the clinical responsibility for an abnormal result to another person so that he or she could act on it. This could have medicolegal implications. The difference of synchronous (telephone) and asynchronous (messaging) communication is a fundamental issue. How existing systems have evolved over time, the behaviour of clinicians, and system features such as the doctor's shift arrangements are other design issues.
When communication systems need to be improved there must be, as Berwick pointed out, a change of a system, not a change within a system.2-3 Direct booking systems for general practitioners are now being presented as solutions for current NHS referral problems.2-4 These initiatives are essential. Their full implications are apparent only when the whole system is in place. It is time to look at how these systems are developed before it is too late.
Technology is sufficiently advanced to make real changes to the lives of patients. Without a holistic approach to the development of information systems, however, it is unlikely to achieve this.
References
2-1.Kilpatrick ES, Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ. 2001;322:1101–1103. doi: 10.1136/bmj.322.7294.1101. . (5 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2-2.Friedman CP, Wyatt JC. Evaluation methods in medical informatics. New York: Springer-Verlag; 1997. [Google Scholar]
2-3.Berwick MD. A primer on leading the improvement of systems. BMJ. 1996;312:619–622. doi: 10.1136/bmj.312.7031.619. [DOI] [PMC free article] [PubMed] [Google Scholar]
