D.19- COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS DEC 2019.pdf

DEPARTMENT OF VETERANS AFFAIRS

VA HEALTHCARE NETWORK

UPSTATE NEW YORK @ SYRACUSE

Medical Center Professional Memorandum December 2019

MCPM 11-004

COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS

I. PURPOSE:

Establish policy regarding communication of diagnostic test results to ordering and treating practitioners and to patients. Diagnostic tests can include but are not limited to imaging studies, electrocardiograms, and laboratory test results.

The Syracuse VA is committed to the timely communication of test results, which is essential to ensuring safe and effective health care.

II. POLICY:

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

III. RESPONSIBILITIES:

A. Director: Medical Center Director is responsible for:

1) Ensuring the facility has policies and procedures in place on communication of diagnostic test results.

2) Ensure that the facility accounts for the delegation of clear responsibility and accountability related to test result follow-up.

3) Ensure the facility follows practices and procedures to better manage Computerized Patient Record System (CPRS) based notifications (known as view alerts) related to test results.

Attachment D.19 RFP 36C24224R0049

Medical Center Professional Memorandum December 2019 Chief of Staff 11-004 Page 2

4) Ensures inclusion and participation of other members of the ordering provider’s team to facilitate processes related to patient notification of all types of test results.

5) Describe how the facility:

(a) Maintains updated contact information for all patients in CPRS and all providers and their designees who have access to CPRS.

(b) Makes contact information available to all staff involved in the test result notification processes.

(c) Demonstrate how communication of results to patients is being periodically monitored to document adherence to this policy.

B. Chief of Staff is responsible for:

1) Reviewing monitors of test result communication.

2) Ensuring each clinical service (and section(s) or department(s) within each service) adheres to this policy.

3) Resolving process deficiencies with Service Chiefs by taking appropriate action to improve the effectiveness of communicating test results.

C. Service Chiefs/Section Chiefs are responsible for:

1) Establishing a chain of responsibility for receipt of emergent (critical) or abnormal test results.

2) Establishing a plan to measure, monitor, assess and if appropriate, take action to improve the communication of test results process.

D. Diagnostic Provider:

1. Identifying and communicating all critical life-threatening test results Medical Center Professional Memorandum December 2019 Chief of Staff 11-004 Page 3 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.

4. Ensuring that verification “read-back” is performed when giving an emergent (critical) test result.

5. Identifying and communicating abnormal test results, using direct or electronic communication.

E. Ordering Provider or Designee:

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

2. Reading alerts/notifications in a timely manner.

3. Ensuring that verification “read-back” is performed when receiving an emergent (critical) test result.

4. 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 supervising practitioner is the designee and has the responsibility for ensuring that the required communication and documentation occurs.

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

6. 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

Medical Center Professional Memorandum December 2019 Chief of Staff 11-004 Page 4 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. 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 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 persons on the other end of the phone. For certain types 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.

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

Medical Center Professional Memorandum December 2019 Chief of Staff 11-004 Page 5 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.

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 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. Communicating test results to patients after discharge

- When results of tests ordered and performed while the patient is an 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.

9. Taking additional measures in the following special situations:

Medical Center Professional Memorandum December 2019 Chief of Staff 11-004 Page 6

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

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.

F. Diagnostic Services ADPACS are responsible for:

Ensuring that parameters for electronic view alerts/notifications are maintained in VISTA software applications.

G. Clinical Informatics Specialists are responsible for:

Ensuring that electronic view alerts are appropriately set in CPRS.

IV. PROCEDURES:

An efficient and effective back-up process must be developed in order to have test results followed-up in a timely manner. All service chiefs and providers are encouraged to conduct a self-assessment on how patients will be notified of test results in the absence of the ordering provider.

A. E mergent (Critical) Test Results . An Emergent (critical) 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. The term Emergent (Critical) Test Results applies to all diagnostic tests including, but not limited to imaging studies, electrocardiograms, laboratory tests and other diagnostic tests and studies that require urgent response.

1) All Emergent (Critical) Test Results must be transmitted by direct communication to the ordering practitioner. If the ordering practitioner is not available, communication needs to be made to the ordering practitioner’s surrogate. Suitable surrogates include the practitioner’s supervisor or preceptor, or another practitioner who may take appropriate diagnostic or therapeutic action.

Medical Center Professional Memorandum December 2019 Chief of Staff 11-004 Page 7

2) The practitioner receiving the Emergent (Critical) Test Result will “read- back” the test result to confirm understanding of the results.

Whenever possible, the receiver of the test result will write down the complete test result or enter it into the computer, then read it back, and receive confirmation from the individual who gave the test result.

3) The ordering practitioner or surrogate must document receipt of this information and confirmation that the read-back process was completed, as well as any changes to the care plan. Documentation will be entered in CPRS either as a progress note or within the study report.

4) Emergent (Critical) Test Results need to be communicated to the patient within 7 calendar days. If the patient is unable to comprehend and participate in health care decisions, the authorized next-of-kin, or legal guardian, must be kept informed.

5) Procedure for notification of Emergent (Critical) Laboratory Test Results can be found in MCPM 11-25 Critical Laboratory results Reporting and MCPM 11-151 Critical test Policy for Imaging.

B. Abnormal Test Results. An Abnormal Test Result is a diagnostic finding that requires attention by the ordering practitioner, but not necessarily in an immediate time frame. Abnormal test results may be transmitted to the ordering practitioner, or surrogate, by direct or electronic communication.

The ordering practitioner, or surrogate, needs to document any change in care plan. Abnormal results need to be communicated to the patient within 7 calendar days.

C. Test Results that are Neither Emergent Nor Abnormal. Test results that are neither emergent nor abnormal must be communicated to the ordering practitioner, or surrogate to patients no later than 14 calendar days from the date on which the results are available. The ordering practitioner, or surrogate, is required to periodically review routine test results with patients under their care.

V. REFERENCES:

VA Handbook 5005/53, Medical Support Assistant (MSA) GS-0679 Qualification Standard.

Medical Center Professional Memorandum December 2019 Chief of Staff 11-004 Page 8

VHA Handbook 1400.01, Resident Supervision.

VHA Handbook 1400.04, Supervision of Associated Health Trainees.

VHA Handbook 1605.1, Privacy and Release of Information.

Baldwin DM, Quintela J, Duclos C, Staton EW, Pace WD. Patient preferences for notification of normal laboratory test results: a report from the ASIPS Collaborative. BMC Family Practice March 2005; 6(1):11.

VI. RESCISSION:

MCPM 11-04, Communicating Test Results to Providers and Patients, June

VII. REVIEW DATE:

December 2021

VIII. RESPONSIBILITY:

Chief of Staff

ORIGINAL SIGNED ON 12/16/2019

S ASIF ALI, MD

Chief of Staff

Attachment 1 - 3

Attachment 1

Definitions. These definitions are provided for implementation of this policy.

1. Ordering Practitioner. An ordering Practitioner is a practitioner authorized to enter and sign orders for diagnostic tests 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 physician who performs or supervises the performance and interpretation of diagnostic tests.

4. Emergent (Critical) 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.

5. 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.

6. Direct Communication. Direct Communication is the transmission of test results by direct, not-electronic dialogue between the diagnostic practitioner and the ordering practitioner, or surrogate, by telephone or face-to-face conversation, or hand carried report.

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

Attachment 2

RADIOLOGY

Anatomical Area Critical Result

CNS Cerebral hemorrhage/hematoma Brain tumor (mass effect) Acute stroke Cerebral edema Depressed skull fracture Cervical spine fracture Spinal cord compression/lesion with potential for s.c. compression

Chest Tension pneumothorax Aortic dissection Pulmonary embolism Ruptured aneurysm or impending rupture Mediastinal emphysema Foreign body in airway

Abdomen/Pelvis Free air in abdomen (if no recent surgeries) Ischemic bowel Appendicitis Portal venous air Volvulus Traumatic visceral injury Retroperitoneal hemorrhage Bowel obstruction/abscess Thrombosed endovascular graph Endovascular graph with large thrombis/potential for iminent occlusion Testicular torsion Ovarian torsion

General Significant Line/or Tube misplacement (e.g., feeding tube in airway, PICC Line in atrium)

Major new fractures of weight bearing bones

Note: Critical results for radiology will be called to the ordering practitioner within 15 minutes of discovery and completion of diagnosis.

Attachment 3

Test Results that are not Emergent or Abnormal must be communicated by the ordering practitioner, or surrogate to patients no later than 14 calendar days from the date on which the results are available. The ordering practitioner, or surrogate, is required to periodically review routine test results with patients under their care.

Process:

Provider writes CPRS progress note with results including needed explanation/action and alerts team member(s) with appropriate scope (RN/LPN/MSA) to call patient or send a letter.

Provider calls patient or writes Syracuse Test Result Template and letter is printed in clinic and mailed to patient by MSA.

Note this will need to be altered for Syracuse If test is ordered prior to a scheduled appointment, results are discussed at the clinic visit.

Provider sends a secure message (confidential messaging functionality of

MyHealtheVet). to patient with note printed to CPRS.

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

Abnormal results need to be communicated to the patient within 7 calendar days.

The ordering practitioner, or surrogate, needs to document any change in care plan.

Provider will telephone patient and document contact in CPRS. If unable to reach patient, a message will be left for the Veteran to contact the clinic. If no response is received within 2 days, a letter will be mailed to Veteran and documented in medical record.

Exception: 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 discussions.