D.34 Communicating Test Results to Providers and Patients.pdf

DEPARMENT OF VETERANS AFFAIRS Policy Memorandum 11-16-78 South Texas Veterans Health Care System San Antonio, Texas 78229-4404 November 18, 2016

COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS

1. PURPOSE: To establish policy regarding the communication of test results to providers and patients. AUTHORITY: 38 U.S.C. 7301(b).

2. BACKGROUND

a. Veterans Health Administration (VHA) is committed to the timely communication of test results, which is essential to ensuring safe and effective health care.

b. Timely communication of test results to patients is essential for high quality patient-centered care. Lack of timely follow-up of abnormal test results has been identified as a contributor to poor outcomes and can be a source of considerable anxiety to patients and families. Patient involvement in test result follow-up is fundamental to improve safety in this area and is consistent with personalized proactive patient-driven care. Patients have a right to access personal health information and expect to be notified of test results in a timely manner.

Enhancing timeliness of follow-up of test results is consistent with VHA’s goals of providing Veterans with quality health care.

3. POLICY: It is South Texas Veterans Health Care System (STVHCS) policy that 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 non-critical 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 related to abnormal and normal results). All clinical services are expected to put into place appropriate systems and processes to ensure timeliness of appropriate communication and follow-up of test results.

4. DEFINITONS

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 Department of Veterans Affairs (VA) medical facility 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 Directive.

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.

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POLICY MEMORANDUM 11-16-78

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 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).

g. Supervising Practitioner. Supervising practitioner refers to a licensed, independent practitioner, who has been credentialed and privileged at a VA medical facility in accordance with applicable requirements. NOTE: ‘Supervising practitioners’ are often referred to as ‘attendings.’ See VHA Handbooks 1400.01, Resident Supervision, and 1400.04, Supervision of Associated Health Trainees.

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 defined 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:

(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. (Example: critically elevated potassium). See STVHCS PM 113-12-08 Reporting Laboratory Test Results or PM 114-14-01 Reporting Critical Imaging Test Results.

(b) 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 Non-Life-Threatening” with an Equivalent Radiology code such as 1001- Significant abnormality - attention needed or 1003- Possible malignancy.

(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. (Example: high cholesterol).

(2) Normal Test Results. While the significance of a “normal” test result needs to be determined clinically, in the context of this policy 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 ratio (INR) is subtherapeutic 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; for example, “Radiology Code: 1000 - No Alert Required - No significant finding, or provider is already aware.”

5. ACTION

a. Medical Facility Director: The Director is responsible for development and implementation of a written policy regarding communication of test results to ordering providers and to patients.

b. Chief of Staff or Associate Director for Patient Care Services responsibilities

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

(2) Ensure that each applicable service has written policies and procedures consistent with this Directive that identify all providers and staff who can communicate test results to patients. See STVHCS PM 114-14-01 Reporting Critical Imaging Test Results; STVHCS PM 113-12-08 Reporting Laboratory Test Results; STVHCS PM 113-14-07 Bedside Blood Glucose Monitoring/Verification of Proficiency; and STVHCS PM 113-14-02 Ancillary Testing Policy.

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

c. Service Chiefs, Associate Nursing Service Chiefs, and Administrative Executives responsibilities

(1) Define what tests within their area of responsibility are considered life threatening and the acceptable length of time between the availability of critical life threatening results and receipt by the ordering provider, or designee, and associated notification and read-back verification processes. See STVHCS PM 114-14-01 Reporting Critical Imaging Test Results;

STVHCS PM 113-12-08 Reporting Laboratory Test Results; STVHCS PM 113-14-07 Bedside Blood Glucose Monitoring/Verification of Proficiency; and STVHCS PM 113-14-02 Ancillary Testing Policy.

(2) Establish procedures (as applicable) consistent with this policy for the receipt of test results from diagnostic providers to the ordering provider, or designee, and the communication of test results to patients by the ordering provider, or designee. These procedures should 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 should also describe 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 none of the previously identified personnel are available, test results should be reported to the ordering provider’s service chief or an equivalent supervisor. The emergency department (ED) should not be the primary service responsible for receiving afterhours test results that are not life threatening unless ordered by ED providers.

(3) Review procedures and practices for test result communication to both providers and to patients from each section or department they supervise as applicable.

(4) Monitor the effectiveness of the patient notification process and address performance improvement issues as needed.

d. Diagnostic Provider Responsibility

(1) Identify and communicate all critical life threatening test results and urgent non-life threatening abnormal test results to the ordering provider or their designee.

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

e. Ordering Provider or Designee Responsibility

(1) When placing the initial order, the ordering practitioner includes the appropriate contact information for receipt of reported results and indicates when ordering a laboratory or diagnostic test, the desired date and acceptable turnaround time of the diagnostic test to be completed.

(2) Initiate appropriate clinical action and follow-up for any orders placed.

(3) Assign 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.

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

6. PROCEDURES:

a. Interdisciplinary participation in notification of test results. The physician or Nurse Practitioner/Physician Assistant PACT Team Lead will determine the extent of the team participation according to the clinical specialty area and the functioning of the team members.

The team could include Nurse Practitioners, Physician Assistants, Registered Nurses, Licensed Vocational Nurses, Licensed Practical Nurses, Clinical Pharmacists, Medical Support Assistants and other staff as appropriate within their scope of practice, functional statement, or position description. Inclusion of other team members should follow robust principles of teamwork including clarity of task delegation, clarity of roles of team members, clarity of key responsibilities on test result related action, and contingency planning.

b. Communicate 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 timeframe that minimizes risk to the patient.

c. 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. 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.

d. 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.

e. 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.

f. Tests ordered but not performed and no longer needed should be discontinued by the ordering provider.

g. 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 same principles also apply to results of tests that are ordered to be performed in the future in the outpatient setting.

h. 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.

i. Critical, life-threatening test results should be accomplished in 30 minutes or less.

See STVHCS PM 113-12-08 Reporting Laboratory Test Results or STVHCS PM 114-14-01 Reporting Critical Imaging Test Results for procedures and listing of critical tests.

j. Special situations:

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

(2) Providers will consult with Social Work Service for patients that are unable to be reached. In some instances it is appropriate to use local community resources to try to locate the patient or next of kin (police, constable etc.).

(3) 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.

7. REFERENCES

a. VHA Directive1088, dated October 7, 2015.

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

c. VHA Handbook 1400.01, Resident Supervision.

d. VHA Handbook 1400.04, Supervision of Associated Health Trainees.

e. VHA Handbook 1605.1, Privacy and Release of Information.

8. RESPONSIBILITY: Chief of Staff (11)

9. RECISSION: STVHCS Policy Memorandum 11-14-78, dated March 20, 2014.

10. RECERTIFICATION: November 2021

(Signature on File)

ROBERT M. WALTON

Director

DISTRIBUTION: A & B