Attachment 7 Communicating Test Results to Providers and Patients MVAHCS.pdf

MIAMI VA HEALTHCARE SYSTEM

MIAMI, FLORIDA

HEALTHCARE SYSTEM POLICY MEMORANDUM

NO…………………………………………….11-41-19 June 14, 2019

COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS

I. PURPOSE:

This Miami VA Healthcare System (MVAHS) policy provides policy regarding communication of patient test results to providers and to patients.

II. POLICY:

A. The MVAHS is committed to reporting test results in a timely manner so that appropriate and effective therapeutic action may be taken. The MVAHS is committed to supporting the Joint Commission National Patient Safety Goal of improving the effectiveness of communication among caregivers.

All test results must be communicated by the diagnostic provider to the ordering provider, or designees, within a time-frame that allows for prompt attention and appropriate action to be taken.

1. All tests results requiring action must be communicated by the ordering provider, or designees, to patients no later than 7 calendar days from the date on which the results are available. .

2. 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. .

3. Depending on the clinical contest, certain tests results may require review and communication in shorter timeframes.

4. A lack of knowledge about test results can be a source of considerable anxiety to patients and families. Timely communication of results demonstrates respect and concern for patients’ well-being.

III. DEFINITIONS:

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. For this policy, a designee is a clinical team member authorized by the ordering provider in a manner consistent with MVAHS policies who acts on behalf of the ordering provider to receive information from 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 and VHA Directive 1088.

C. Diagnostic Provider. A diagnostic provider is a provider who performs or supervises the performance and interpretation of diagnostic tests either through privileges or by acting under a scope of practice.

D. Ordering Provider - An ordering provider is a provider authorized to enter and sign orders for diagnostic tests.

E. Patient Notification. Patient notification is communicating test results to patients or, if appropriate, to their personal representatives, including additional context and follow-up action as needed. Patient notification could occur through any 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 a 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 minor). Personal representative is further defined in VHA Handbook 1605.1 “Privacy and

Release of Information.”

G. Supervising Practitioner. Supervising practitioner refers to a licensed, independent practitioner, who has been credentialed and privileged at the

MVAHS in accordance with applicable requirements. Refer to HSPM 141-

06, Resident Supervision.

H. Synchronous Communication. Synchronous communication is when parties involved in a communication are all present at the same time, such as in person, telephone conversations, 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 define as follows:

1. Abnormal Test Results. 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:

2. 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. (Example: critically elevated Potassium).

3. Urgent Non-Life Threatening. 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). An example of this is a Chest x-ray with newly discovered nodule, which is categorized as “Critical Not Life

Threatening” with an Equivalent Radiology code such as 1001-Significant abnormality – attention needed or 1003 –Possible malignancy.

4. 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. (Example: High Cholesterol).

5. Normal Test Results. While the significance or 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. (Example: Patient on

Warfarin whose international normalized radio (INR) is sub-therapeutic but in the “normal” range; low-density lipoprotein (LDL) =120mg/dl with coronary disease). Radiologic tests can also be considered normal when radiologists use something equivalent “Radiology Code: 1000-No Alert

Required-No significant finding or provider is already aware.”

IV. RESPONSIBILITIES :

A. The MVAHS Director is responsible for ensuring the overall compliance of this policy and procedures, as outlined. That the MVAHS collects and assesses data on the timeliness of reporting critical tests and critical values or results; determines whether there is a need for improvement; that the organization takes appropriate action to improve and measure the effectiveness of those actions; and ensures that communication of results to practitioners and patients is periodically monitored to document adherence to

VHA and local policies.

B. The Chief of Staff (COS) is responsible for:

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

2. Ensuring that each clinical service has a written standard operating procedure consistent with this policy and VHA Director 1088 that identifies all providers and staff who can communicate test results to patients. These policies and procedures need to 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 tests and certain types of patients, synchronous methods are preferred.

3. Resolving with service chiefs any gaps detected in test result follow-up processes.

4. Will develop a performance improvement process to ensure appropriate or timely follow-up of test results if any issues are identified through the monthly EPRP review.

C. Service Chiefs are responsible for:

1. Establishing procedures consistent with this HSPM and VHA Directive

1088 within their service for the receipt of test results from diagnostic providers to the ordering provider, or designee. These procedures need to include plans for the delegation of authority and specify which team members can receive test results from diagnostic providers and/or notify patients of test results as appropriate within their scope of practice or position description. These procedures need to also include processes so that each provider will have coverage at all times in the provider’s absence by a designee within their scope of practice or position description. If no one of the previously identified personnel are available, test results will be reported to the ordering provider’s service chief. Note: The Emergency

Department (ED) will not be the primary service responsible for receiving afterhours test results that are not life threatening unless ordered by and

ED providers.

2. Reviewing procedures and practices for test result communication to both providers and to patients from each section or department they supervise as applicable.

3. Monitoring effectiveness of the patient notification process and addressing performance improvement issues as needed.

D. Diagnostic Provider. Each diagnostic provider is responsible for:

1. Identifying and communicating all critical life threatening test results and urgent non-life threatening abnormal test results to the ordering provider or their designee.

2. Documenting in the medical record the time and means of communication of critical life threatening results and the name of the ordering provider or designee informed of these results.

3. Ensuring that test results reports are available in the patient’s electronic medical record as soon as the reports are verified. Other diagnostic practitioners will immediately transmit critical values or results by direct communication to the ordering practitioner or surrogate practitioner.

E. Ordering Provider or Designee. Each ordering provider, or designee, is responsible for:

1. Initiating appropriate clinical action and follow-up for any orders that they have placed.

2. 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 test are ordered by residents or other health professions trainees, the supervising practitioner is the designee and has the responsibility for ensuring that the required communication and documentation occurs.

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

4. 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 communicating 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 of 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.

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 or 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 impairment.

b. Documentation. Patient notifications and subsequent clinical actions must be documented in CPRS b 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 diagnosis of terminal cancer or Human

Immunodeficiency Virus (HIV) in a sensitive, empathic manner may require 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.

d. 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 acknowledgement or acceptance by the outpatient provider.

e. 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.

f. Taking additional measures in the following situations:

g. If the patient lacks decision making capacity, communicate results to the personal representative of the patient as defined in this policy.

h. If, despite, best efforts, it is not possible to communicate test results to the patient (e.g., 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.

5. The Chief, Medical Administration Service, is responsible for ensuring and updating the accuracy of the patients’ demographic data through the Pre-registration Package and the attending physician’s name for the purpose of notification to the provider and patient.

V. PROCEDURES:

A. The provider will see a patient and place an order.

B. The test or procedure is completed and results are obtained. The provider may choose to receive results from several options in CPRS i.e. through

Notifications, scrolling through past clinics, or if a critical value through verbal communication from the diagnostic practitioner (lab etc.).

C. If the result is normal, the provider will complete one of several available note templates, forward the Notification of the test result to a designated nurse if available, or communicate to the patient in such fashion as identified by the particular service chief. If forwarded to a nurse, the nurse will then complete one of the available note templates for notification.

D. If the result is Abnormal but stable, the provider will also complete a note template to notify the patient that they have stable results, review the plan of action with the patient, or communicate to the patient in such fashion as identified by the particular service chief.

E. If the result is a new abnormal result the provider conducts a phone encounter to review the results with the patient and discuss the plan of action. The phone encounter will be documented by the provider with the test result reporting template for phone encounters.

F. If the result is critical the provider conducts immediate phone encounter with the patient to notify and discuss plan of action per HSPM No. 11-03-

“Communication of Critical Test Results/Panic Values.”

G. If the provider cannot reach the patient by telephone a progress note template titled “Test Reconciliation” will be completed by the provider which in turn will generate a signed letter by said provider and be automatically queued for mailing to the patient.

H. 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.

I. Tests or results of procedures ordered while the patient is an inpatient, but results reported after discharge are treated as an outpatient test. These tests are communicated by ordering inpatient provider or their surrogate, and forwarded to the outpatient primary care provider.

J. If the patient lacks decision making capacity, results will be communicated to the personal representative of the patient.

K. Communication with patients can occur in person, by telephone

MyHealtheVet or in writing.

L. The results are communicated by licensed or certified health care staff. It is no longer required that the ordering practitioner be the only one to personally communicate every result. This task can be delegated or shared with other licensed health care staff when clinically appropriate.

M. When tests are ordered by residents, the supervising practitioner has the responsibility for ensuring that the required communication and documentation occurs.

N. Communication of test result templates that are completed in the templates will populate health factors in CPRS indicating said communication. Tests which do not have health factors associated with them will be used to generate reports to assist service chiefs and help monitor compliance with this communication initiative.

VI. OTHER:

See Attachment A – Lab Notification Process

VII. REFERENCES:

VHA Directive 1088, Communicating Test Results to Providers and Patients dated

October 7, 2015

HSPM No. 11-03-, Communication of Critical Test Results/Panic Values.

VIII. FOLLOW-UP RESPONSIBILITY:

Chief of Staff (11)

IX. RESCISSION:

Healthcare System Policy Memorandum No. 11-41-16, “Ordering and Reporting

Test Results,” dated May 18, 2016.

X. This policy is due for review/revision on June 14, 2022.

David VanMeter, FACHE Date

Interim Medical Center Director

Attachment: 1

Distribution: A(Electronic)

The following concurred with this Healthcare System Policy Memorandum:

Anesthesiology Service

Audiology and Speech Pathology

Biomedical Engineering Service

Chief of Staff

Customer Service

Dental Service

Dermatology Service

Education Service

Emergency Management

Engineering Service

Environmental Management Service

Fiscal Service

Geriatrics/Extended Care

Human Resources Service

Imaging Service

Information Resources Management Service

Logistics Service

Medical Administration Service

Medical Service

Mental Health and Behavioral Sciences Service

Neurology Service

Nursing Service

Nutrition and Food Services

Pathology and Laboratory Medicine

Physical Medicine and Rehabilitation Service

Police Service

Prosthetic Treatment Center

Psychiatry Service

Psychology Service

Quality Management and Performance Improvement Service

Recreation Therapy Service

Research Service

Social Work Service

Spinal Cord Injury Service

Surgical Service

Voluntary Service

ATTACHMENT A: LAB NOTIFICATION PROCESS

CRITICAL

Result

Per HCPM (11-

03-XX)

All Other Results

Suggested

Guideline

View Alert/

Phone Call from

Lab

Verbal notification

Phone Call

ASAP

Does provider feel test need to be reported now?

Call Patient

Appointment within 14 days of results?

Phone Call

Mail Letter

Patient comes to appointment?

Test Series

Complete?

Wait for other results

Successful

Reconciliation of test results?

Notification

Completed

NO YES

YES

NO

YES

NO

YES

NO

NO

YES

Face to Face

Reporting

Test Resulted