D.6 ORDERING AND RESPORTING TEST RESULTS.pdf

D.6 ORDERING AND RESPORTING TEST RESULTS

36C25922R0102

DEPARTMENT OF VETERANS AFFAIRS

Oklahoma City VA Health Care System

March 25, 2016 Center Memorandum 11-138 11/MH:rm

ORDERING AND REPORTING TEST RESULTS

1. Summary: Center Memorandum 11-138, Ordering and Reporting Test Results dated March 7, 2012, is rescinded and reissued.

2. Purpose: To establish the policy and procedures regarding communication of patient test results to practitioners and to patients.

3. Policy: To outline policies and procedures for communicating test results to the ordering practitioner, or designee, 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.

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

a. Asynchronous Communication: Asynchronous communication is when parties involved in communication are not present at the same time, such as electronic notifications in Computerized Patient Record System (CPRS), secure messaging, AudioCARE, FAX, or letter.

b. Designee: A designee is a clinical team member authorized by the ordering provider to act on behalf of the ordering provider to receive information form the diagnostic provider (in the absence of the ordering provider) and/or notifies patients of test results in a timely manner and discusses such results with the patients, in accordance with this policy.

c. Diagnostic Practitioner: A diagnostic practitioner is a practitioner who performs or supervises the performance and interpretation of diagnostic tests by privileges or acting under a scope of practice.

d. 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.

e. Patient Notification: Patient notification is communication test results to patients, or, if appropriate, to their personal representatives, including additional contact and follow-up action as needed. Patient notification could occur through any

Center Memorandum 11-138, March 25, 2016

Synchronous or asynchronous method. For certain types of tests and certain types of patients, synchronous methods are preferred.

f. 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.”

g. Preceptor (Attending): 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.

h. Synchronous Communication: Synchronous communication is when parties involved in a communication area all present at the same time, such as in person, telephone conversation, or Clinical Video telehealth (CVT).

i. Test Result: Test results include the results of laboratory and pathology testing, diagnostic imaging, and diagnostic procedures. Test results are categorized as abnormal or normal as determined by a clinical provider and are further defined as follows:

(1) Abnormal Test Result: Abnormal test results are results that fall outside a specified normal reference range, are unexpected, or could indicate the presence of disease. An abnormal test may or may not require action and therapeutic intervention, depending on the clinical context. There are three types of abnormal test results that require action or therapeutic intervention:

(a) Critical Life Threatening: Any diagnostic finding which must be acted upon by the ordering provider or their designee immediately or within a short window of time and could result in severe morbidity or mortality if left untreated.

(b) Urgent Non LifeThreatening: Any diagnostic finding which must be acted upon by the ordering provider or their designee within a relatively urgent timeframe (as clinically indicated to ensure timely, appropriate and effective therapeutic action).

(c) Clinically Significant: A diagnostic finding that requires action by the ordering provider, or their designee, but not necessarily in an immediate or urgent time-frame.

(2) Normal Test Result: While the significance of a “normal” test result needs to be determined clinically, in the context of this Directive it is defined as a diagnostic finding that falls within the normal reference range for the test and may or may not require immediate action or change in treatment depending on clinical circumstances.

5. Procedures:

a. Chief of Staff is responsible for:

(1) Reviewing monitors of test result communication and ensuring that any identified performance improvement issues are addressed.

(2) Ensuring that each service has written policies and procedures that identify all providers and staff who can communicate test results to patients. These policies and procedures should also specify what type of test results providers and staff can communicate, and how the results are communicated (e.g., synchronous versus asynchronous). For certain types of test and certain types of patients, synchronous methods are preferred.

(3) Resolving with service chiefs any gaps detected in test results follow-up processes.

(4) Ensuring that the diagnostic practitioner or designee:

(a) Identifies and communicates expediently all critical life threatening test results and urgent non-life threating abnormal test results to the ordering practitioner, the practitioner’s surrogate, or the supervisor, as appropriate.

(b) Ensures that verified test results reports are available in the patient’s electronic medical record as soon as the reports are verified.

(c) Documents in the medical record the time and means of communication of critical life threatening results and the name of the ordering provider contacted. This documentation is not required for an abnormal test that is not critical or emergent.

b. Service Chiefs are responsible for ensuring:

(1) That procedures are developed that include plans for the delegation of authority and specify which team member can receive test results from diagnostic providers and/or notify patients or test results as appropriate within their scope or practice or position description. These procedures should also describe processes so that each provider will have coverage at all times in the provider’ absence by a designee within their scope of practice or position description. If none of the previously identified personnel are available, test results should be reported to the ordering provider’s service chief or equivalent supervisor.

(2) That critical test and critical results and values are defined

(3) That the acceptable length of time between the ordering of tests or collection of specimens and the availability of results or critical values is defined. In all cases when the ordering practitioner and surrogate practitioner are unavailable, a process must be in place for the communication of critical test results to another practitioner who can follow-up as appropriate. NOTE: it is understood that many abnormal results do not require an immediate response by the practitioner that receives the information.

(4) That the acceptable length of time between the availability of critical tests, values, or results and receipt by the responsible provider is defined.

(5) The organization collects data on the timeliness of reporting critical tests and critical values or results.

(6) The facility assesses the data collected and determines whether there is a need for improvement, and that the organization takes appropriate action to improve and measure the effectiveness of those actions.

(7) That communication of results to practitioners and patients is periodically monitored to document adherence to VHA and local polices.

c. Ordering practitioners, or designees, are responsible for:

(1) Placing the initial order, including the appropriate contact information and the surrogate practitioner, when applicable.

(2) Initiating appropriate clinical action and follow up for the results of any orders which they have placed.

(3) Assigning a qualified designee to receive test results when the ordering provider is unavailable. The designee assumes the responsibility to initiate appropriate clinical action and follow-up and to ensure that patients are notified of test results in a timely manner. When tests are ordered by residents or other health professions trainees, the preceptor is the designee and has the responsibility for ensuring that the required communication and documentation occurs.

(4) Ensuring that their or their designee’s contact information is available and up-to-date.

(5) Communicating outpatient test results to patients in accordance with the following time frame standards: all test results requiring action must be communicated by the ordering provider, or designee, to patients no later than 7 calendar days from the date on which the results are available. For test results that require no action, results must be communicated by the ordering provider, or designee, to patients no later than 14 calendar days from the date on which the results are available. Depending on the clinical context, certain test results may require review and communication in shorter time-frames (see definitions paragraph for abnormal and normal results). Patients enrolled in MyHealtheVet Premium Accounts are able to view certain test results in earlier time-frames (usually within 3 days of the date on which the results are available). All communication should occur within a time-frame that minimizes risk to the patient.

Additional Communication recommendations are listed below:

(a) Content and Method of Communication. The content of communication might vary from case to case but must be sufficiently detailed to allow the patient to be informed and engaged in their health care. When test results indicate that an action or therapeutic intervention is needed, the ordering provider is expected to discuss potential actions or therapeutic intervention options with the patient and initiate action. This discussion can occur synchronously (examples: in person or by telephone) or asynchronously (examples: in writing, through template-generated letters, or via secure messaging in MyHealtheVet). For communication by telephone, reasonable steps should be taken in order to verify the identity of the person on the other end of the phone. For certain types of tests and certain types of patients, synchronous methods might be preferred. Automated test results released through MyHealtheVet or other methods, such as template-generated letters, are acceptable methods of communicating results not requiring action or therapeutic intervention. (These communication methods are still emerging and thus processes and good clinical practices in this area will evolve.) Patient identifiable information must never be communicated via an unsecured method. Communication methods may need to be adjusted for Veterans with certain types of functional impairments. (e. g FAQs on the Communication of Test Results Toolkit SharePoint Site. NOTE: This is an internal VA Web site and is not available to the public.)

(b) Documentation. Patient notifications and subsequent clinical actions must be documented in CPRS by the ordering provider(s) or designee(s) in response to critical, urgent, and clinically significant test results that require therapeutic intervention or action. If results are discussed within a patient visit, this should be documented within the visit progress note. The extent of documentation may vary depending on the context of the test result and resultant action plan or therapeutic intervention.

(c) Exceptions. In exceptional circumstances, it may be necessary to delay communication of test results beyond the timeframes identified above. For example, communicating a diagnosis of terminal cancer or Human Immunodeficiency Virus (HIV) in a sensitive, empathic manner may require a face-to-face visit at a time convenient to the patient, which could extend beyond the 7 day time frame. Due to the sensitive nature of certain test results, the determination of how to report these results are best made on a case-by-case basis. Review and discussion of test results need to be provided to the patient, or patient’s personal representative, with an opportunity for questions and discussion

(6) Communicating test results to patients after discharge. When results of tests ordered and performed while the patient is inpatient become available after discharge, they are communicated to the patient by the ordering inpatient provider, or their designee, unless responsibility is transferred to an outpatient provider, or their designee, and the transfer is documented in CPRS. The transfer of responsibility to the outpatient provider may occur via synchronous or asynchronous communication. The requirements for transfer of responsibility, such as acknowledgment or acceptance by the outpatient provider should be determined by the local facility. The same principles also apply to results of tests that are ordered to be performed in the future in the outpatient setting.

(7) Communicating test results in acute care settings. Settings of acute care such as inpatient, emergency, or urgent care often involve extensive, repetitive testing with rapidly changing clinical conditions. Therefore, for patients in the inpatient, emergency, or urgent care setting, it is not required or expected that each individual test result is communicated to the patient. The ordering provider or the patient’s care team should strive to effectively communicate relevant information to the patient about the patient's medical condition, as needed, to ensure the patient is able to engage effectively in the treatment plan. Results of specific tests may be included in this communication, as appropriate.

(8) Taking additional measures in the following special situations:

(a) If the patient lacks decision making capacity, communicate results to the personal representative of the patient as defined in this Directive (see definitions section).

(b) If, despite best efforts, it is not possible to communicate test results to the patient (e.g., the patient has moved and left no contact information), all attempts to contact the patient are documented in CPRS. At a minimum, a certified letter should be sent for all test results requiring action.

6. References:

a. Joint Commission National Patient Safety Goals. Available at:

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

b. VHA Directive 1088; Communicating Test Results to Providers and Patients.

7. Follow-up Responsibility: Chief of Staff (11)

8. Renewal Date: March 25, 2020 http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

/s/ Gerald K. Darnell, Psy.D.

Interim Medical Center Director