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"Dr. Pelzman, can you explain what all those scary little red arrows pointing up mean?"

It feels like nearly every day, and sometimes several times a day, we get portal messages like this from patients, requesting that we explain what all the abnormalities flagged on their lab test results mean.

"My basophils are marked as abnormal, they seem on the low side, what can I do to increase them?"

"My labs show that my CO₂ is 32, and the upper limit of normal is 31. Is there something wrong with my breathing? Google said this might be a problem."

"My urine was flagged as abnormal for having mucus, am I going to be okay?" (Why are we even measuring mucus in urine?)

The Downside of Immediate Access

We cannot blame our patients for not knowing what these things mean, and understanding which results are clinically important for them.

In 2021, partly in response to the pandemic, and partly as a sensible overhaul to how our healthcare system works (or doesn't), Congress passed the 21st Century Cures Act. Part of that law allowed patients immediate access to most parts of their electronic medical record, including provider notes and test results. As every provider now knows, this means that the results of tests you order on your patient get released to them immediately once they are finalized from the lab, radiology, or pathology. Is this the right thing for us to do, and if it is going to be there anyway, can we figure out a way to make this a kinder and gentler process for everyone involved?

Much emphasis has been placed on the anxiety that patients have around healthcare, waiting for their test results to come back, waiting for the doctor to call them back. This information they are waiting for is often monumental, and of course matters hugely to all of our patients.

'No News Is No News'

In the old days there was the phrase "No news is good news," which probably caused more problems over the years than it helped. The standard line at the end of an office visit used to be, "If you don't hear from me, just assume everything's okay; if there's something we need to act on, I'll let you know."

How often have I sat in the office with a patient, asked them what the result of their mammogram was this past year, and they said, "Well, I never heard from the doctor who ordered it, so I guess everything was okay"? The new standard of care is "No news is no news," and this affirms that closing the loop is critical to patient empowerment, their knowledge and ability to manage their healthcare, their autonomy, and their right to participate in decision-making.

But for those of us in day-to-day practice, the stress of them getting the result the instant it's back -- most often before we've even had a chance to take a look at it -- has led to overwhelming stress and anxiety for everybody. Often when I arrive at the office in the morning, my in-basket is packed not only with the results of tests from the day before, but with multiple portal messages from patients expressing various degrees of concern and alarm over test results and what they mean and what they should do about them.

This certainly does serve a purpose, of making sure we close that loop, which is one of the toughest things to do in an outpatient practice. Providers are overwhelmed with in-basket messages, notices about scanned images entered in the Media Manager that need our attention, copied charts with information on our patients seen by others, clinical orders that need to be cosigned, notes that need to be cosigned, electronic consults to review, and prescription refill requests that need to be authorized that patients are waiting on.

And then there's that always daunting and looming Results in-basket folder, jammed with stuff you ordered yesterday, a few days earlier, or sometimes months ago that are finally getting done. The immediacy with which patients receive these results often catches us off guard -- there is that awful feeling when you get a message from a patient that they've learned that they have cancer before you've had a chance to even read the pathology report.

These are some of the things that keep us up at night, working in our pajamas, or filling our weekends when we should be paying attention to our families.

Improving the Workflow

Many folks have developed really efficient workflows for themselves to try and keep on top of these in-basket results, using the amazing tools within the electronic medical record to do results management, communicating to patients, to let them know the plan, to reassure people that things are okay or that we have some steps to take to further their health moving forward. Many providers see to it that their in-basket results are cleaned out by the end of the day, an amazing feat that many others say they struggle to attain. Others lie farther along the spectrum, getting to these results at the end of the week, or cleaning out their in-basket at the end of the month, or quickly scanning through stuff when you get a moment to make sure nothing bad is there and then figuring they'll catch up with things later.

We've been working on some projects to analyze these different strategies, to explore what makes certain providers really good at this, and others admittedly not so good. And we're working to build new tools, including some really cool new bits of technology, that may help with an immediate response to patients to let them know that we're going to take a look at these results and get back to them.

We want systems smart enough to know the normal from the clinically insignificantly abnormal, and distinguish the dangerous and life-threatening. The system should highlight results that are truly critical -- a significant change, a new diagnosis, or something that needs a new medicine, a referral, follow-up testing, or maybe even a scheduled phone call to discuss. That could help providers keep on top of this endless stream of stuff coming at them.

We want to make sure that nothing falls through the cracks, that we never discover weeks or months later that something's been festering in an in-basket folder and no one's been paying attention to it. We should all engage our patients and make sure they get the follow-up they need, that they are empowered and helping take care of themselves and see to it that we are keeping up with this endless tide.

I don't really have much advice on how to increase your basophils, and I think your breathing is just fine, but as we continue down this road, we want to make sure we've built a system that does the right thing for every patient, and for every provider, at exactly the right time.

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