D.6 VANEOHS MCP - 011-098 Ordering and Communicating Test Results.pdf

ORDERING AND COMMUNICATING TEST RESULTS

MCP 011-098

VA NORTHEAST OHIO Rescinded Document:

HEALTHCARE SYSTEM

10701 East Boulevard MCP 011-073 Cleveland, Ohio 44106

Signatory Authority: Effective Date:

Jill Dietrich Mellon, JD, MBA, FACHE July 8, 2024 Executive Director

Responsible Owner: Recertification Date:

Chief of Staff July 8, 2029

1. POLICY

This medical center policy (MCP), 011-098 Ordering and Communicating Test Results, establishes local policy on this subject.

2. JUSTIFICATION

VHA Directive 1088, Communicating Test Results to Providers and Patients (dated July 11, 2023) requires a local policy.

3. RESPONSIBILITIES

a. Diagnostic Practitioners. Diagnostic Practitioners are responsible for:

(1) Therapeutic and Diagnostic Imaging Service providers will identify and directly communicate to the ordering provider or designee the following in accordance with paragraph 4f (1):

(a) Any finding that has the potential to be life threatening or could cause serious harm, and that requires an urgent intervention or change in patient management.

(b) Any finding that might result in prolongation of patient pain or discomfort.

(c) Any finding that would result in the cancellation of on-going or imminent treatment.

(d) Serious conditions or situations, such as (but not limited to): new unsuspected malignancy; new pneumonia; unsuspected osteomyelitis or other infection;

high probability V-Q scan; unsafe position of medical device; large reversible defect on myocardial perfusion scan; acute fracture; concern for impending pathological fracture;

pneumothorax; or active hemorrhage.

July 8, 2024, MCP 011-098

(2) Pathology and Laboratory Service providers identify and directly communicate to the ordering provider or designee all critical laboratory test results in accordance with paragraph 4f (1).

(3) All diagnostic providers will:

(a) 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.

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

b. Clinical Service Chiefs. Clinical Service Chiefs are responsible for:

(1) Establishing written workflows consistent with VHA Directive 1088 (see paragraph 5 b (1) through (5) within their service for:

(a) 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.

(b) Includes a process for assigning a designee when health care providers are no longer available, based on the service structure.

(c) Includes a process for assigning surrogates for health care providers when they are not available on a temporary basis based on service operations.

(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 the effectiveness of the patient notification process and addressing performance improvement issues as needed. Monitoring must be documented in appropriate service level meeting or integrated clinical community meeting minutes. As part of this process periodically review the View Alerts Checklist on the Communicating Test Results SharePoint and take action as needed. Review must be on an annual basis at a minimum.

(4) Monitoring the timely completion of EHR notifications. Monitoring must be documented in appropriate service level meeting or integrated clinical community meeting minutes.

(5) Ensuring appropriate staff members are involved in the processes related to patient notification of all types of test results. Their participation must be within their scope of practice, functional statement, or position description.

(6) Ensuring all providers have surrogates assigned when appropriate.

c. Ordering Practitioners. Ordering practitioners are responsible for:

https://dvagov.sharepoint.com/sites/VHAOPCOps/Policy/CTR/CTR%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FVHAOPCOps%2FPolicy%2FCTR%2FCTR%20Documents%2FView%20alerts%20checklist%2Epdf&parent=%2Fsites%2FVHAOPCOps%2FPolicy%2FCTR%2FCTR%20Documents

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

(2) Assigning a qualified surrogate practitioner to receive critical 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. Ensure that their or their designee’s contact information is available and up to date.

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

(4) Documenting patient notifications and subsequent clinical actions in response to critical, urgent, and clinically significant test results that require therapeutic intervention or action in the patient’s electronic medical record. 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.

d. Clinical Contact Center. Clinical Contact Center staff will note requests for test results from Veterans the EHR and tag PACT team to address.

4. OTHER PARAGRAPHS

a. The Communication of Test Results Toolkit SharePoint Site provides additional tools and information to include frequently asked questions.

b. Therapeutic and Diagnostic Imaging Service providers reference SOP 114-09 for implementation procedures to ensure compliance with VHA Directive 1088.

c. Pathology and Laboratory Service providers reference MCP 113-005 Blood and Blood Component Transfusion Policy and 113-006 Ancillary Laboratory for implementation procedures and guidance to ensure compliance with VHA Directive 1088.

d. All other providers reference their respective service guidance.

e. Monitoring of test result communication

(1) Assessment of critical value communication from diagnostic practitioners to ordering providers is reported at the Medical Executive Council (MEC).

(2) Assessment of non-critical value from diagnostic practitioners to ordering providers is monitored at and documented in appropriate service level meeting or integrated clinical community meeting minutes.

(3) Assessment of test results communication to patients is monitored appropriate service level meeting or integrated clinical community meeting.

f. Communication Standards:

https://dvagov.sharepoint.com/sites/VHAOPCOps/Policy/CTR/SitePages/Home.aspx

(1) Directly communicate critical results to an ordering provider or surrogate within two business days for first-time malignancy and one hour for all other critical laboratory results.

(2) Electronically communicate all non-critical imaging test results to the ordering practitioner or surrogate within 48 hours. Use appropriate diagnostic codes when indicated to generate view alerts to the ordering clinician for abnormal, but not critical imaging results.

(3) Electronically communicate non-critical pathology test results to the ordering practitioner, or surrogate, within 1 hour for STAT requests, 2 hours for Urgent requests and 4 hours for routine requests.

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

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

(b) The receiver of the information reads back the critical values or results.

(5) If the ordering practitioner and surrogate practitioner are not available, communication needs to be made to the supervisor/Service Chief. Diagnostic providers will communicate critical test results to the supervisor or service chief when the ordering provider and his/her designee are unavailable. See Attachment 1 for the facility reporting algorithm.

(6) Communication of test results to patients by ordering provider or designee:

(a) All test results requiring action must be communicated to patients no later than 7 calendar days from the date on which the results are available to the VA medical center ordering Provider or designee.

(b) For test results that require no action, results must be communicated to patients no later than 14 calendar days from the date on which the results are available to the VA medical center ordering Provider or designee.

(c) Critical lab values will be communicated to the patient within 24 hours.

(d) Critical imaging results will be communicated to the patient no later than 2 business days.

(e) If potentially life-changing test results are being provided to a Veteran with a High Risk for Suicide – Patient Record Flag, the ordering provider or designee must coordinate communication to the patient with the Mental Health Treatment Coordinator, mental health provider(s) or the Suicide Prevention Coordinator to devise an appropriate strategy within the time standards above.

(7) If the patient lacks decision making capacity, results will be communicated to the patient and the personal representative of the patient as defined in this policy.

(8) 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 the electronic medical record. At a minimum, a certified letter should be sent for all test results requiring action.

(9) 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.

(10) 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 the Electronic Health Record (EHR).

g. When a transfer of responsibility from an inpatient provider to an outpatient provider is required, it must be documented in the EHR. The transfer of responsibility may occur via synchronous or asynchronous communication. This also applies to test results that are ordered to be performed in the future in the outpatient setting.

h. During patient check-in, appropriate staff or electronic process should verify and update as necessary contact information for all patients in the EHR.

5. DEFINITIONS

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

b. Diagnostic Practitioner. 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.

c. Test Results. Test Results include the results of laboratory testing, diagnostic imaging, and diagnostic procedures.

d. 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. These include finding that are associated with a high likelihood of short-term poor outcome and requires either immediate therapeutic intervention or close monitoring. Emergent tests are also considered critical.

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

f. Direct Communication. Direct Communication is the transmission of test results by direct, dialogue between the diagnostic practitioner and the ordering practitioner, or surrogate practitioner, by MS Teams message, telephone or face-to-face conversation, or hand carried report.

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

h. Personal Representative. 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).

6. REFERENCES

a. VHA Directive 1088, Communicating Test Results to Providers and Patients, dated July 11, 2023, VA Policy Library - Document Viewer

b. MCP Blood Culture Collection Policy, dated April 26, 2029.

7. RESCISSION

MCP 011-073, Communication Test Results to Providers and Patients, Including Reporting of Critical Values of Diagnostic Results, dated March 6, 2023.

8. REVIEW

Review required at recertification, when there are changes to the governing document and any regulatory requirement for more frequent review.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before July 8, 2029. This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

https://ba.va.gov/policy/viewer/paKMOE00000008iK4AQ

Jill Dietrich Mellon, JD, MBA, FACHE Executive Director VA Northeast Ohio Healthcare System Date Approved: July 9, 2024

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Cleveland Medical Center Policies

Attachments A & B https://dvagov.sharepoint.com/sites/VHACLEMCP/Shared%20Documents/Forms/List%20sort%20by%20name.aspx

Algorithm

Attachment A

Attachment B

Tests Pending at Discharge Guide– Emergency Room

Significant?

- Yes, or no?

Is this abnormal value significant considering the patient context/clinical scenario?

Would treatment of this patient change have based on this result?

If you were the PCP, is this a value you would want to be aware of?

Why not? - If lab is considered NOT significant, why not?

- Trivial – lab is very close to normal range.

EX. Sodium of 135 (normal range: 136-148)

- Baseline – lab is close or within previous values for this patient.

EX. Creatinine 1.6 in patient with previous values 1.4 - 1.6

- Consistent with known diagnosis – lab is additional evidence of a diagnosis already made on the patient (chronic illness, or new diagnosis made in the ER or during admission)

EX #1. UA with +blood/nitrites/esterase in patient already diagnosed with UTI.

EX #2. High procalcitonin in patient admitted for bacterial pneumonia.

Already followed? – Has a provider already noticed the abnormal value since result was back? If you are unsure, the answer is no.

-N/A – lab result not significant

-Yes – lab was already noticed/documented by another provider

EX #1. Pt was admitted and inpatient provider documented abnormal value in notes (antibiotics were stopped based on negative procalcitonin)

EX #2. Pt already followed up with PCP who documented the result.

EX #3. Lab has been re-checked since and trended.

-No – no one has noticed the lab → action is needed

Action? What action are you taking to address the significant abnormal value?

-N/A – no action is indicated

-PCP note only – use “medicine result follow-up” templated note in CPRS to communicate results with PCP – also tag PACT RN, any other people you think may be interested (ie.

Specialists, ER provider, etc.)

Write or paste to top of note:

“The following test resulted after the patient left the Emergency

Department, was reviewed and determined to be potentially significant.”

-Paged PCP – result is considered more urgent or complex that PCP was paged, skyped, or called and result communicated at the time of review. In addition, CPRS note also needs to be written documenting communication using “medicine result follow-up” note.

-Paged inpatient team – Patient is still admitted to the hospital, and inpatient team has

NOT documented abnormal result / might not be aware result. Again, document this communication using “medicine results follow-up” note.

-Called patient – Patient was called and informed of abnormal result and given instructions of any recommendations based on the result. Again, document this communication using

“medicine results follow-up” note.

-Medication ordered – Abnormal result warrants a new medication or change in dose or current medication. EX. Positive UA in patient with no culture or contaminated culture, who still complains of symptoms → antibiotics ordered. Patient also needs to be called and CPRS note completed, tagging PCP.

-Consulted specialist – Abnormal result warrants consult to another service or follow up with already established specialist. EX. Endo consult for further work up of abnormal hormone levels. Patient also needs to be called and informed of consult and rationale and CPRS note completed tagging PCP.

Comments: interesting trends we are tracking

-N/A – none

-Result known in ER- ER provider documented result in note. There was an error in the time result was entered in the system or time the patient left the ER. Result was already known and should not have been on list.

-Wrong requisition – lab requisition from the ER was not collected during ER stay and was used later. This is obvious when date lab ordered is different from date lab was drawn. It is unclear how this happens, because uncollected lab orders should be d/c’ d upon discharge from the ER.

-Patient died

-Patient re-admitted

Notes: free text for any personal notes (optional)

**If there is the same result listed twice or multiple times, simply delete the duplicate row. **