Closing the Loop on Abnormal Lab Results in Primary Care

Normal lab results take up a lot of inbox time. Abnormal results are where the real risk sits. A result that never reaches the patient, or a follow-up test that never gets ordered, is one of the most common ways a diagnosis gets delayed in outpatient care.

Most primary care teams already have a process for abnormal results. The harder question is whether that process holds up on a busy Monday, during a vacation, or when the patient sees the result before anyone else does.

How often results fall through

The research has been consistent for more than 15 years.

• In a study of 23 primary care practices, researchers found a failure to inform patients of a clinically significant result, or to document that they had, in 7.1% of cases. Rates ranged from 0% at some practices to 26% at others.
• In a VA study of electronic alerts for abnormal labs, 6.8% lacked timely follow-up at 30 days, even with the alert system working as designed.
• A systematic review of 19 studies found that failure to follow up on lab results ranged from 6.8% to 62%, depending on the setting and the test.

The wide range is the point. The gap between practices that close the loop and practices that don’t is mostly about process, not about how much clinicians care.

Why it happens

Volume. Primary care physicians spend about 85 minutes of every weekday on inbox work, according to a study in the Annals of Family Medicine. Abnormal results arrive mixed in with normal labs, documents, refill requests and messages.

Coverage gaps. A result that comes back while the ordering provider is out can sit in a queue no one is watching.

Patients see results first. Since the 21st Century Cures Act information blocking rules took effect in 2021, most results go to the patient portal right away. ONC has said that blanket delays on routine results don’t qualify for its preventing harm exception. Patients mostly like this. In a survey of more than 8,000 portal users, 95.7% preferred to get results immediately. But among people whose results were abnormal, 16.5% said seeing them early made them more worried, compared with 5.0% of people whose results were normal.

Follow-up is a second step. Reading an abnormal result is one task. Making sure the repeat test or referral actually happens is another, and it is the one most likely to slip.

What closing the loop means

A closed loop has five steps, and each one needs an owner:

1. Acknowledge. Someone with the authority to act sees the result.
2. Interpret. The result is compared with the patient’s history and prior values.
3. Decide. The next step is chosen: no action, a repeat test, a medication change, a referral or a visit.
4. Communicate. The patient hears what the result means and what happens next, in plain language.
5. Track. The next step is followed to completion, and someone notices if it doesn’t happen.

Practical steps for your team

Based on guidance from the ECRI Partnership for Health IT Patient Safety and AHRQ:

• Name inbox coverage for every absence. Every provider’s queue should have a named backup, every day.
• Set response times by urgency. Decide how fast abnormal and critical results have to be acted on, and write it down.
• Use team protocols. Nurses and medical assistants can handle defined parts of the work, like scheduling a repeat test, under clear protocols.
• Send a plain-language message. If patients see results early, a short message that explains the result and the next step heads off worry and phone calls.
• Track open loops. Keep a list of results that need a follow-up action, and check it weekly.
• Audit a sample each month. Pull ten abnormal results and check that each loop closed.

Where Droxi Unbox helps

Droxi Unbox gives providers more time for the results that need them. Lab notes summarizes each result against the patient’s chart and history and drafts the patient message in plain language, for the provider to review. Auto-close for routine normal results is a provider’s choice, set per provider, and many keep it off. If you’d like to see it on your own workflow, we’re happy to show you. For the normal side of the inbox, see our normal lab results letter template.

Frequently asked questions

How often are abnormal test results missed in primary care?

Studies find failure rates of roughly 7% for informing patients of significant results, with wide variation between practices, from 0% to 26% in one study. A systematic review found failure to follow up on lab results ranged from 6.8% to 62%.

Do patients see lab results before the provider?

Often, yes. Under the Cures Act information blocking rules, most results are released to the patient portal right away. ONC has said blanket delays on routine results don’t qualify for the preventing harm exception.

Does the Joint Commission’s critical results goal apply to clinics?

The National Patient Safety Goal on reporting critical results applied to hospital, critical access hospital and laboratory programs, not ambulatory care. Clinics should still have their own written policy.

How fast should a practice act on an abnormal lab result?

There is no single federal standard for routine abnormal results. Set your own response times by level of urgency, write them down and audit against them.

Can Droxi auto-close abnormal results?

No. Auto-close applies to routine normal results, and only when a provider turns it on. Abnormal results are summarized for the provider, who decides what happens next.