36C24419R0074-010.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 111-39 December 24, 2013

ORDERING AND REPORTING TEST RESULTS

I. PURPOSE: To establish policy, procedure and guidelines regarding communication of patient test results to practitioners and to patients.

II. BACKGROUND:

A. Erie VAMC is committed to reporting test results in a timely manner so that appropriate and effective therapeutic action may be taken.

B. Erie VAMC is committed to supporting the Joint Commission National Patient Safety Goal of improving the effectiveness of communication among caregivers.

C. Timely communication of diagnostic test results to patients is important to the provision of quality care. Communication of test results to patients:

1. Facilitates patient involvement in their care

2. Reduces poor patient outcomes and malpractice suits for VHA

3. Ensures timely review by the practitioner, enhancing follow up care

4. Reduces unnecessary repetitive diagnostic testing

5. Reduces patient and family anxiety concerning test results

D. Definitions: These definitions are provided for implementation of this MCM and do not necessarily coincide with any other common use of these terms.

1. Ordering Practitioner: An ordering practitioner is a practitioner authorized to enter and sign orders for diagnostic tests by privileges or acting under a scope of clinical practice.

2. Preceptor: A preceptor is a licensed independent practitioner who supervises the ordering of tests by residents, or by other practitioners authorized to order tests under a scope of clinical practice.

3. Diagnostic Practitioner: A diagnostic practitioner is a practitioner who

Attachment H

MCM 111-39, Ordering and Reporting Test Results performs or supervises the performance and interpretation of diagnostic tests by privileges or acting under a scope of practice.

4. Test Result: Test results include the results of laboratory testing, diagnostic imaging, and diagnostic procedures.

5. Critical Value or Result: A critical test result is defined as those values or interpretations that, if left untreated, could be life threatening or place the patient at serious risk. Critical values or results are those results from laboratory, cardiology, radiology departments and other diagnostic areas that upon analysis are determined to be “critical” regardless of the ordering priority. All Emergent Test Results and some Abnormal Test Results constitute Critical Values or Results.

6. Emergent Test Result: An emergent test result is a diagnostic finding that is associated with a high likelihood of short-term poor outcome and requires either immediate therapeutic intervention or close monitoring.

7. Abnormal Test Result: An abnormal test result is a diagnostic finding that requires attention by the ordering practitioner, but not necessarily in an immediate time frame.

8. Direct Communication: Direct communication is the transmission of test results by direct, non-electronic dialogue between the diagnostic practitioner and the ordering practitioner, or surrogate practitioner, by telephone or face-to-face conversation, or hand carried report.

9. Electronic Communication: Electronic Communication is the transmission of test results by electronic means (e.g., view alerts, e-mail, Secure Messaging, FAX, etc.).

10. Personal Representative: A personal representative is a person who under applicable law has authority to act on behalf of the individual. This may include power of attorney, legal guardianship of an individual, the executor of the estate of a deceased individual, or someone under Federal, state, local or tribal law with such authority (e.g., parent of a minor). Personal representative is further defined in VHA Handbook 1605.1 “Privacy and Release of Information.”

III. POLICY: It is Erie VAMC policy that all test results must be communicated to the ordering practitioner, or surrogate practitioner, within a timeframe allowing prompt attention and appropriate clinical action to be taken, and that the ordering practitioner further communicates such test results to patients, so that they may participate in health care decisions.

IV. RESPONSIBILITY:

A. Chief, Clinical Services is responsible for:

1. MCM 113-05 Communication Critical Results for Laboratory Tests and

MCM 201R-03 Critical Tests and Critical Results for Non-Laboratory Tests are established which describe the reporting process for values and interpretations that are immediately life threatening, as well as those that otherwise require prompt clinical attention.

2. Standard Operating Procedure in place for ordering provider/surrogate to communicate in a timely manner all test results to Veteran.

B. Medical Directors of Primary Care, Surgical Services, and Behavioral Health and Program Leader, Behavioral Health are responsible for:

1. Ensuring a process for assignment of surrogates when ordering provider is not available.

2. Reviewing monitors of test result communication by periodically tracking the patient notification letter note and the patient telephone notification notes.

3. Resolving process deficiencies.

4. Ensuring that the ordering practitioner follows procedure for assignment of a surrogate practitioner to receive critical, emergent, or abnormal test result notifications when they themselves are unavailable to review results in a timely manner to prevent avoidable delays in treatment or response.

5. Ensuring that the ordering practitioner or surrogate:

a. Places the initial order, includes the appropriate contact information.

b. Initiates appropriate clinical action and follows up the results of any orders which they have placed.

c. Documents treatment actions in response to critical, emergent, or abnormal test results in the patient’s electronic medical record.

d. Communicates test results in accordance with this MCM.

C. Results are communicated to patients no later than 14 calendar days from the date on which the results are available to the ordering practitioner or surrogate.

Significant abnormalities may require review and communication in shorter timeframes and 14-days represents the outer acceptable limit. For abnormalities that require immediate attention, the 14-day limit is irrelevant, as the communication should occur in the timeframe that minimizes risk to the patient.

NOTE: Separate VHA policies may set standards regarding communication of results for specific tests. When separate VHA policies exist that set standards for communication of specific test results, the shorter standard (of the separate policy or the 14-day standard of this policy) takes precedence.

D. Tests ordered while the patient is an inpatient, but results reported after discharge, are treated as outpatient tests. These tests are communicated by the ordering inpatient provider or their surrogate according to the standards in this MCM.

E. If the patient lacks decision making capacity, results will be communicated to the personal representative of the patient as defined in this policy. (See under Background Section II. D. 10. ).

F. Communication with patients can occur in person, by telephone, in writing, or with secure messaging through MyHealtheVet.

NOTE: Due to the sensitive nature of certain test results, such as psychological tests, the determination of how to report these results are best made on a case-by-case basis. Review and discussion of the test results need to be provided to the patient or appropriate representatives in person, with an opportunity for questions and discussion. HIV test results should be communicated according to current VHA policy (see Handbook 1004.1).

G. The results are communicated by appropriate health care staff. It is not required that the ordering practitioner personally communicates every result, but this task may be delegated to other health care staff when clinically appropriate.

H. When tests are ordered by residents, the preceptor has the responsibility for ensuring that the required communication and documentation occurs.

I. When, despite best efforts, it is not possible to contact the patient (e.g., the patient has moved and left no contact information), all attempts to communicate with the patient are documented in the medical record.

NOTE: Inpatient andurgent care often involves extensive, repetitive testing with rapidly changing clinical conditions. Therefore, for patients in the inpatient (acute care, Community Living Center, and short term rehabilitation,) or urgent care setting, it is not required or expected that each individual test result is communicated to the patient. The ordering practitioner or the care team the patient is part of should strive to effectively communicate relevant information to the patient about the patient's medical condition. Results of specific tests may be included in this communication as appropriate.

V. PROCEDURES: For communication process of test results, see under Responsibility Section, IV. 2. B thru I. For reporting procedure for communicating tests results by diagnostic practitioners to ordering practitioners, see Attachment.

VI. REFERENCES:

A. The Joint Commission National Patient Safety Goals. Available at:

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

B. VHA Directive 2009-019, Ordering and Reporting Test Results

VII. FOLLOW UP RESPONSIBILITY: None

VIII. REPORTING REQUIREMENTS: None

IX. RESCISSION: MCM 111-39, Ordering and Reporting Test Results, dated January 25, 2010.

(Original Signed 12/24/13)

MICHAEL D. ADELMAN, MD

Medical Center Director

Attachment: Process for Communicating Test Results by Diagnostic Practitioners to Ordering Practitioners

ATTACHMENT

PROCESS FOR COMMUNICATING TEST RESULTS BY DIAGNOSTIC

PRACTITIONERS TO ORDERING PRACTITIONERS

1. CRITICAL VALUES OR RESULTS

a. Critical values or results must be transmitted immediately by direct communication from the diagnostic practitioner, or surrogate, to the ordering practitioner or surrogate practitioner, and this communication must be documented in the Veterans Health Information Systems and Technology Architecture (VistA).

b. For telephonic reporting of critical values or results, the complete test result must be verified by having the person receiving the information record “read back” the complete test values or results. It is expected that:

(1) The receiver of the information writes down the complete critical values or results or enters it into the medical record system.

(2) The receiver of the information reads backs the critical values or results.

(3) The receiver of the information receives confirmation from the individual who gave the critical values or results.

2. EMERGENT TEST RESULTS

a. Emergent Test Results must be transmitted by direct communication from the diagnostic practitioner, or surrogate, to the ordering practitioner, or surrogate, and this communication must be documented in VistA.

b. If the ordering practitioner is not available, communication needs to be made to the surrogate practitioner, as established by facility policy. The ordering practitioner, or surrogate, must document receipt of this information, as well as any changes to the care plan. In all cases, when the ordering practitioner and surrogate practitioner are unavailable, a process must be in place for the communication of emergent test results to another practitioner who can take action, such as the Administrative Officer of the Day or the lead physician of the facility’s “rapid response team.”

3. ABNORMAL TEST RESULTS. Abnormal test results may be transmitted from the diagnostic practitioner, or surrogate, to the ordering practitioner, or surrogate, by direct or electronic communication. The ordering practitioner, or surrogate, needs to document any change in care plan.

4. TEST RESULTS THAT ARE NEITHER EMERGENT NOR ABNORMAL. Test results that are neither emergent nor abnormal may be communicated to the ordering practitioner, or surrogate.