At New York City's Hospital for Special Surgery, the process for reporting critical lab results was a prime candidate for modernization.

THE PROBLEM

A typical workflow involved a message from a lab tech to a provider requesting a return call, a subsequent phone conversation where the tech asked the provider to check the EHR for a critical result, and an EHR login from the provider to inspect the result. The potential for delays or extended rounds of phone tag was simply too high.

When a critical lab result is returned, it frequently means that action or intervention from a provider must take place as quickly as possible to prevent patient harm. In this instance a manual outreach process puts a bit of an onerous burden on the shoulders of lab techs. They have to try to contact a provider continually, and it might take multiple attempts to reach one.

"Manual documentation of communication efforts presented its own set of challenges, making it harder to track turnaround times for compliance purposes," said Robyn Townsend, assistant director of clinical applications at the Hospital for Special Surgery.

"HSS was always in line with documentation requirements, but the manual nature of this process made it more of a burden than it should've been."

PROPOSAL

PerfectServe, a secure clinical communication and collaboration platform, was already widely deployed at HSS before this particular integration was launched, with 3,500 users utilizing the application to enable real-time, interdisciplinary communication among members of the extended care team. 

PerfectServe is available on mobile devices and desktops, and it also has been embedded directly within the Epic EHR environment for greater ease of use.

"There's a tremendous amount of complexity built into this integration, but for the end user it's still quite simple to use."

Robyn Townsend, Hospital for Special Surgery

"With a laboratory information system in place and a clinical communication platform deployed and heavily used across the enterprise, HSS already had the pieces in place to modernize this process. But it wasn't until the two were tightly integrated that we were able to dramatically cut down the time required to close the loop on critical lab results," Townsend explained. "HSS worked closely with the PerfectServe team over a number of months to scope, design and implement this project.

"The new system takes what used to be a manual workflow and automates it almost completely, using the platform's intelligent routing capability to deliver lab results to the right person at the right time," she continued. "As soon as a critical lab result is identified in the LIS, an interface automatically sends the flagged value to PerfectServe, which assembles and delivers the alert."

The communications platform evaluates numerous variables – time of day, on-call schedules, patient service line, level of urgency and others – to deliver the result to an appropriate provider.

"Many hospitals have to manage sizable and still growing technology stacks, so finding ways to enhance interoperability between important systems means you're getting more value for your investments while simultaneously improving hospital operations," Townsend said. 

"The communications platform's proposal was appealing in part because HSS could add new functionality without deploying new software or adding a new vendor to the mix."

MEETING THE CHALLENGE

The primary users of this integration are laboratory personnel and providers. HSS elected to send critical alerts to a blend of physicians and mid-level practitioners (PAs), but they could, for example, also choose to deliver alerts to a patient's nurse if that's the preferred operational workflow.

"This demonstrates one of the main benefits of tapping PerfectServe for this project: the amount of available customization," Townsend said. "Before implementation, the project team was able to envision and account for almost any scenario, resulting in a nuanced but seamless system that is easy for end users to engage with and understand.

"There's a tremendous amount of complexity built into this integration, but for the end user it's still quite simple to use," she continued. "Once the alert is sent, the platform tracks when the recipient receives, reads and selects 'Accept' or 'Decline' on the message. Accepting closes the loop, and declining sends a message back to the lab for follow-up. The lab is immediately notified if a result is declined."

Importantly, this workflow also needed built-in fail-safes to make sure results never fall through the cracks. If the provider who receives the results doesn't respond within five minutes, the message is automatically escalated to the next provider in line. If for some reason no provider accepts responsibility, lab techs and pathologists are automatically engaged to serve as final safeguards.

"Two real-time, auto-refreshing tracking monitors also were installed in the lab at HSS to display the status of all critical lab results," Townsend noted. "This means lab personnel can take a few seconds to glance up and check the progress of any critical lab result and take action if something seems off."

RESULTS

HSS's new automated critical result reporting process has yielded impressive success metrics while reducing workload for staff, eliminating inconsistencies related to reaction times, and accelerating speed to care for vulnerable patients, Townsend reported. It's also served as a blueprint for other projects during the COVID-19 era, she added.

"Since the integration went live in July 2019, roughly 2,700 chemistry results and 850 hematology results have been delivered," she said. "Last year, HSS dug a bit deeper into about 1,100 of these results and noted an average 42% improvement in acknowledgement times."

One especially noteworthy stat is turnaround times – the time from when the result is verified in Epic to when the provider acknowledges it in the communications platform – which have been measured to be as fast as seven seconds. That's about the same amount of time it takes a lab tech just to dial a provider's number.

"Like many other hospitals in New York City, HSS also was heavily impacted by the COVID-19 pandemic," Townsend noted. "As the specialty facility began opening back up for surgeries, the PerfectServe integration created for delivering critical lab results paid dividends in an unexpected way.

"As HSS started accepting patients for surgeries again, they needed a way to get their COVID test results to providers in an efficient way," she continued. "They realized that the blueprint for this kind of process had already been created with the critical labs project, so they had all positive and negative COVID test results delivered via the clinical communication platform."

ADVICE FOR OTHERS

Aside from finding a willing technology partner, there were three elements that contributed most to the success of this integration, Townsend said.

"First and foremost, HSS had to guarantee that alerts were being delivered to the right care team member," she explained. 

"For example, depending on routing logic, a critical potassium alert will always go to the PA and/or the physician, while critical microbiology results are shared with the infection control team as FYIs. You need a communication platform that allows custom alert paths for different clinical findings so care team members only receive notifications relevant to their roles."

Ensuring that physicians and care team members could easily accept or decline results was another key element, she said. The new process saw greater adoption because all recipients could easily respond to alerts by tapping a button to acknowledge, accept or decline the message. This was all happening on a platform they already knew how to use, she added.

"Built-in escalation protocols that transmit critical results to the next-level provider if a response is not received within a certain time frame also have been critical for the project's overall success," she concluded. 

"If a physician or care team member is unavailable or inaccessible, all messages should automatically be escalated to someone who can take action to guarantee a timely response. In many cases, there's very little room for errors or delays."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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