D.8 - Attachment 8 - COMMUNICATING TEST RESULTS.pdf

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Department of Veterans Affairs VHA DIRECTIVE 1088 Veterans Health Administration Transmittal Sheet Washington, DC 20420 July 11, 2023

COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS

1. SUMMARY OF MAJOR CHANGES: This directive:

a. Maintains that, with listed exceptions, test results requiring action must be communicated to patients within 7 calendar days from the date on which the results are available to the Department of Veterans Affairs (VA) medical facility ordering provider or designee and 14 days for those that do not require any action. Depending on the clinical context, the VA medical facility ordering provider or designee may need to review and communicate test results in shorter timeframes (see timeframe standards in paragraph 3 and definitions for abnormal and normal results in paragraph 9).

b. Adds responsibilities in paragraph 2 for the Under Secretary for Health; Assistant

Under Secretary for Health for Clinical Services; Assistant Under Secretary for Health for Operations; Executive Director, Office of Primary Care.

c. Adds paragraph 3 describing timeframe standards for communicating test results, paragraph 4 describing special circumstances and paragraph 5 describing content to include in VA medical facility policies and service-level workflows.

d. Provides clarification on documentation requirements for test results communication, to include recommending, but not requiring, documentation in the electronic health record (EHR) for patient communication of test results not requiring action. See paragraph 3.

e. In cases where test results require action, at the discretion of the VA medical facility ordering provider or designee, a certified letter may be sent to the patient when attempts to communicate with the patient have not been successful. See paragraph 3 for updated guidance.

f. Requires written service-level workflows that describe the role of various team members in the test results communication process. See paragraphs 2 and 5.

g. Adds a timeframe for the development of the VA medical facility policy and service-level workflows. See paragraph 6 of the Transmittal Sheet.

2. RELATED ISSUES: VHA Directive 1105.03, Mammography Program Procedures and Standards, dated May 21, 2018, and VHA Directive 1330.01(7) Health Care Services for Women Veterans, dated February 15, 2017.

3. POLICY OWNER: The Veterans Health Administration (VHA) Office of Primary Care (11PC), is responsible for the content of this directive. Questions regarding ordering tests and reporting test results to ordering providers may be directed to VHA Diagnostic

July 11, 2023 VHA DIRECTIVE 1088

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Services (11DIAG) at VHA11DIAGActionGroup@va.gov. Questions regarding communication of test results to patients may be directed to the VHA Office of Primary Care (11PC) at VHA11PCPrimaryCareAction@va.gov.

4. RESCISSIONS: VHA Directive 1088(1), Communicating Test Results to Providers and Patients, dated October 7, 2015, is rescinded.

5. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of July 2028. This VHA directive will continue to serve as national

VHA policy until it is recertified or rescinded.

6. IMPLEMENTATION SCHEDULE: This directive is effective upon publication, with the exception that VA medical facilities have 6-12 months from the date of publication to develop the VA medical facility policy and service-level workflows required by the directive.

BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Erica M. Scavella, M.D., FACP, FACHE

Assistant Under Secretary for Health for Clinical Services/CMO

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on July 12, 2023.

mailto:VHA11DIAGActionGroup@va.gov mailto:VHA11PCPrimaryCareAction@va.gov i

CONTENTS

COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS

1. POLICY

2. RESPONSIBILITIES

3. TIMEFRAME STANDARDS FOR COMMUNICATING TEST RESULTS

4. SPECIAL CIRCUMSTANCES

5. LOCAL PROCEDURE REQUIREMENTS

6. TRAINING

7. RECORDS MANAGEMENT

8. BACKGROUND

9. DEFINITIONS

10. REFERENCES

COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS

1. POLICY

It is Veterans Health Administration (VHA) policy that all test results must be communicated by the Department of Veterans Affairs (VA) medical facility diagnostic services provider to the VA medical facility ordering provider or designee within a timeframe that allows for prompt attention and appropriate action to be taken (see paragraph 2.i.). All test results requiring action must be communicated by the VA medical facility ordering provider or designee to patients within 7 calendar days from the date on which the results are available to the VA medical facility ordering provider or designee. For test results that require no action, results must be communicated by the VA medical facility ordering provider or designee to patients within 14 calendar days from the date on which the results are available to the VA medical facility ordering provider or designee. Depending on the clinical context, certain test results may need review and communication in shorter timeframes (see paragraph 9 f. for definitions of abnormal and normal test results). In addition, all VA medical facilities must have appropriate systems and processes for communication and follow-up with patients regarding test results, within the timeframes stated in this directive, to ensure safe and effective health care for patients. NOTE: This directive applies to all VA medical facility services, departments and clinics in which tests are ordered. In addition, when test results requiring action are communicated to patients via a standard or certified letter it is acceptable for the letter to be sent within the 7 calendar day timeframe indicated above. When test results not requiring action are communicated to patients via a standard or certified letter it is acceptable for the letter to be sent within the 14 calendar day timeframe indicated above. AUTHORITY: 38 U.S.C. § 7301(b).

2. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Assistant Under Secretary for Health for Clinical Services/Chief Medical

Officer. The Assistant Under Secretary for Health for Clinical Services/Chief Medical Officer is responsible for supporting the Office of Primary Care with the development and dissemination of this directive.

c. Assistant Under Secretary for Health for Operations. The Assistant Under

Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive and its effectiveness.

d. Executive Director, Office of Primary Care. The Executive Director, Office of Primary Care is responsible for collaborating with the Office of Quality and Patient

Safety to establish External Peer Review Program (EPRP) communication of test results (CTR) measures for the VISN Director, VA medical facility Director, VA medical facility Chief of Staff (CoS), VA medical facility Associate Director for Patient Care Services (ADPCS) and VA medical facility service level leadership to use in providing oversight of VISN and VA medical facility compliance with this directive. NOTE: See oversight responsibilities under VISN Director, VA medical facility Director, VA medical facility CoS, VA medical facility ADPCS and VA medical facility service level leadership.

Also see the EPRP information in question 10 in the Frequently Asked Questions

(FAQs) at:

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

This is an internal VA website and is not available to the public .

e. Veterans Integrated Services Network Director. The VISN Director is responsible for:

(1) Communicating the contents of this directive to all VA medical facilities within the

VISN.

(2) Ensuring that all VA medical facilities within the VISN have the resources to implement this directive.

(3) Ensuring that all VA medical facilities and programs (e.g., Clinical Resource Hubs) within the VISN comply with this directive and informing leadership when barriers to compliance are identified. At a minimum, the VISN Director must ensure that quarterly EPRP CTR measures are reviewed and identified deficiencies are addressed by each VA medical facility Director.

f. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring development and implementation of a written policy regarding communication of test results to VA medical facility ordering providers and patients. See paragraph 5.a. for local policy requirements. Templates and additional resources regarding policy development can be found in question 1 of the FAQs at:

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

NOTE: This is an internal VA website and is not available to the public .

(2) Providing oversight for the VA medical facility compliance with this directive. At a minimum, the VA medical facility Director must ensure quarterly EPRP CTR measures are reviewed and identified deficiencies are addressed.

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

g. VA Medical Facility Chief of Staff and Associate Director for Patient Care Services. The VA medical facility CoS and VA medical facility ADPCS are responsible for:

(1) Reviewing data related to the compliance with this directive (e.g., EPRP CTR measures, VA medical facility test results communication performance monitoring data) and ensuring corrective action is taken when non-compliance is identified.

(2) Ensuring that each service develops or adapts from other services written workflows consistent with this directive that identify all providers and staff who can communicate test results to patients. See paragraph 5.b. for additional service-level workflow requirements.

(3) Working with VA medical facility service-level leadership to resolve any gaps detected in test result follow-up processes.

h. VA Medical Facility Service-Level Leadership. NOTE: Service-level leadership can include but is not limited to VA medical facility service chiefs, Chief Nurses, Associate CoS or Administrative Executives in all services, sections, clinics or departments in which tests are ordered (e.g., primary care, specialty care, surgery). VA medical facility service-level leadership are responsible for:

(1) Developing written workflows consistent with this directive for each unit of service

(e.g., section, clinic or department within each service) within their responsibility including contractors. These workflows must address the receipt of test results from VA medical facility diagnostic services providers to the VA medical facility ordering provider, or designee, and the communication of test results to patients by the VA medical facility ordering provider, or designee. Regardless of organizational alignment, VA health care providers practicing in the service, section, clinic or department must follow the service-level workflows. See paragraph 5.b. for additional service-level workflow requirements.

(2) Ensuring all staff in any unit of service within their responsibility are aware of and follow workflows. This includes ensuring that all contracted staff under their supervision comply with this directive.

(3) Reviewing data related to compliance with this directive (e.g., EPRP CTR measures, VA medical facility test results communication performance monitoring data) and ensuring corrective action is taken when non-compliance is identified.

i. VA Medical Facility Diagnostic Services Provider. NOTE: A diagnostic services provider is a provider who performs or supervises the performance or interpretation of diagnostic tests (e.g., laboratory, radiology tests, asynchronous telehealth interpretation) either through privileges, scope of practice or other approved documentation. The VA medical facility diagnostic services provider is responsible for:

(1) Identifying and communicating all new emergent and imminently life-threatening test results and new urgent not immediately life-threatening abnormal test results to the

VA medical facility ordering provider or designee or through an approved communication cascade (as determined by each VA medical facility’s policies or procedures). NOTE: In the inpatient or Emergency Department (ED) setting, it may be appropriate for the VA medical facility diagnostic services provider to communicate these findings to an alternate provider who has assumed responsibility for care of the patient.

(2) Documenting in the electronic health record (EHR) the time and method of communication of new emergent and imminently life-threatening test results and the name of the VA medical facility ordering provider or designee or alternate provider informed of these results.

(3) Ensuring that test result reports are available in the patient’s EHR as soon as the reports are verified.

j. VA Medical Facility Ordering Provider or Designee. NOTE: An ordering provider is a provider authorized through privileges or scope of practice to enter and sign orders for testing after obtaining any necessary informed consent in accordance with VHA Handbook 1004.01(5), Informed Consent for Clinical Treatments and Procedures, dated August 14, 2009. Ordering providers include all health care providers and designees in all services, sections, clinics or departments in which tests are ordered (e.g., primary care, specialty care, surgery). An appropriate designee is a clinical team member authorized by the VA medical facility ordering provider or by a formally documented, VA medical facility-approved communication cascade who (1) acts on behalf of the VA medical facility ordering provider to receive information from the VA medical facility diagnostic services provider or (2) notifies patients of test results and discusses them in accordance with this directive. VA medical facility ordering providers maintain responsibility for all test results they order unless there are pre-existing, mutually agreeable and clear arrangements made with a designee. The VA medical facility ordering provider or designee is responsible for:

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

(2) Assigning a qualified designee to receive test results when the VA medical facility ordering provider is unavailable. NOTE: The designee assumes the responsibility to initiate appropriate clinical action and follow-up and to ensure that patients are notified of test results per this directive.

(3) Communicating test results to patients and initiating appropriate clinical action and follow-up in accordance with this directive when orders are entered into the EHR by other health professionals using local protocols, clinical pathways or clinical algorithms.

See paragraph 5 of this directive for further guidance.

(4) Ensuring that their own and their designee’s contact information is available and up to date in the EHR or other readily available source (such as a SharePoint site).

(5) Communicating test results to patients in accordance with the timeframe requirements described in paragraph 3. For more information on which test results this directive applies to see question 14 of the FAQs at:

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

NOTE: This is an internal VA website that is not available to the public.

k. VA Medical Facility Health Professions Trainee Supervising Practitioner. The VA medical facility health professions trainee supervising practitioner is responsible for ensuring health profession trainees communicate test results to patients and initiate appropriate clinical action as required by this directive under the supervision of a supervising practitioner. NOTE: If the health profession trainee is unavailable to meet the directive requirements, the supervising practitioner or the practitioner responsible for the patient’s care (as defined by VA medical facility policy) is the designee and has the responsibility for ensuring that the required communication, action and documentation occurs per this directive. The supervising practitioner is a VA health care provider (e.g., licensed independent practitioner (LIP) or advance practice provider) who has been credentialed and/or privileged at a VA medical facility in accordance with applicable requirements and who oversees and instructs health professions trainees. Supervising practitioners in physician education are often referred to as “attendings.” See VHA Directive 1400.01, Supervision of Physician, Dental, Optometry, Chiropractic, and Podiatry Residents, dated November 7, 2019, and VHA Handbook 1400.04, Supervision of Associated Health Trainees, dated March 19, 2015.

3. REQUIREMENTS FOR COMMUNICATING TEST RESULTS

a. Standard Timeframes.

(1) All test results requiring action must be communicated by the VA medical facility ordering provider or designee to patients within 7 calendar days from the date on which the results are available to the ordering provider or designee. If a letter is mailed, it must be mailed within 7 calendar days from the date on which the results are available to the ordering provider or designee.

(2) For test results that require no action, results must be communicated by the VA medical facility ordering provider or designee to patients within 14 calendar days from the date on which the results are available to the ordering provider or designee. If a letter is mailed, it must be mailed within 14 calendar days from the date on which the results are available to the ordering provider or designee.

(3) Depending on the clinical context, certain test results may need review and communication in shorter timeframes (see paragraph 9.f.).

(4) All communication must occur within a timeframe that minimizes risk to the patient. NOTE: Patients can view test results (those requiring action as well as those not requiring action) in less than 7 days by accessing online patient portals.

https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Furldefense.proofpoint.com%2Fv2%2Furl%3Fu%3Dhttps-3A__dvagov.sharepoint.com_sites_VHAOPCOps_Policy_CTR_SitePages_Home.aspx%26d%3DDwMFAg%26c%3DZQs-KZ8oxEw0p81sqgiaRA%26r%3DEyedK0iNVK6fSf4BkPlDQ0HWzB_vbgMj1Vfc-kLZZLY%26m%3DJaQnZlJNZzFvwwaWt5HeqLy9lFIJCmzsHZyTcb-Pa8vz2w1A24D9PoJxLLbbtaxz%26s%3DHSolNolOgoLPN9dH8CcWbBEko9OE8Uexv1lM8bXp3x0%26e%3D&data=05%7C01%7C%7Ca543d2ed390747f407c908daf339938b%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638089725859121029%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=ykXSD7aLbCAo4CaCGN1x%2F%2FK9a9dU2Boqjd44I76NxwM%3D&reserved=0

b. Content and Method of Communication.

(1) For Results Not Requiring Action. 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. Depending on the circumstances, appropriate methods of communication may include a telephone call, a standard or certified letter or other synchronous and asynchronous methods, such as automated test results release or secure messaging via the patient portal (e.g., MyHealtheVet), telehealth and face-to-face encounters. If a letter is mailed, it must be mailed within 14 calendar days from the date on which the results are available to the VA medical facility ordering provider or designee. Automated test result release via the patient portal is an acceptable method for communicating test results not requiring action. Communication methods must be adjusted for patients with accessibility requirements. See question 7 of the FAQs at:

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

NOTE: This is an internal VA website and is not available to the public.

(2) For Results Requiring Action. 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 VA medical facility ordering provider or designee must discuss potential actions or therapeutic intervention options with the patient, and initiate action. This communication can occur synchronously (e.g., in person or by telephone) or asynchronously (e.g., a standard or certified letter, a template-generated standard or certified letter or via secure messaging in the patient portal e.g., MyHealtheVet). If a letter is mailed, it must be mailed within 7 calendar days from the date on which the results are available to the VA medical facility ordering provider or designee. If it is not possible to communicate test results requiring action to the patient (e.g., the patient has not returned phone calls or secure messages), all attempts to contact the patient must be documented in the EHR. A certified letter may be sent at the discretion of the VA medical facility ordering provider or designee. Communication methods must be adjusted for patients with accessibility requirements. See question 7 of the FAQs at:

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

NOTE: This is an internal VA website and is not available to the public .

a. Documentation. Patient notifications and subsequent clinical actions must be documented in the EHR by the VA medical facility ordering provider(s) or designee(s) in response to emergent and imminently life-threatening, urgent not imminently life-threatening and clinically significant test results that require therapeutic intervention or action. The extent of documentation may vary depending on the context of the test result and resultant action plan or therapeutic intervention. Documentation in the EHR is encouraged but not required for test results not requiring action.

b. 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, a hereditary disease or Human Immunodeficiency Virus (HIV) in a sensitive, empathic manner may require a scheduled visit at a time convenient to the patient, which could extend beyond the 7-day timeframe. Due to the sensitive and complex nature of certain test results, the clinical determination of how to report these results is best made on a case-by-case basis.

4. SPECIAL CIRCUMSTANCES

a. Care Transitions. Care transitions occur when patients transition between different settings of care such as between inpatient, residential Community Living Centers (CLCs), ED, Urgent Care and outpatient settings. When results of tests ordered and performed while the patient is in settings such as inpatient, residential CLCs, ED or Urgent Care become available after discharge, such as a send-out test, the VA medical facility ordering provider or designee must communicate the test results to the patient and initiate required clinical action and documentation as required by this directive.

These responsibilities may be transferred to an outpatient provider or their designee as defined by VA medical facility agreements, such as Coordinated Care Agreements, policy or service-level workflows. NOTE: The same principles also apply to results of tests ordered by providers in these settings to be performed in the future in the outpatient setting.

b. Communicating Test Results in Inpatient or Equivalent Residential Care Settings. Inpatient or equivalent residential care settings (e.g., CLCs) could involve extensive and repetitive testing, sometimes with rapidly changing clinical conditions. For patients in these settings, it is not required or expected that each individual test result is communicated to the patient. The VA medical facility ordering provider or the patient’s care team must effectively communicate relevant information and test results to the patient about the patient's medical condition, as needed, to ensure the patient is able to engage effectively in their treatment plan.

c. Decision Making Capacity. If the patient lacks decision-making capacity, as outlined in VHA Handbook 1004.01(5), the VA medical facility ordering provider or designee is responsible for communicating test results to both the patient and the patient’s surrogate as defined in this directive.

d. Breast and Cervical Cancer Screening. Breast and cervical cancer screening test results must be communicated and documented in accordance with VHA Directive 1105.03, Mammography Program Procedures and Standards, dated May 21, 2018, and

VHA Directive 1330.01(7) Health Care Services for Women Veterans, dated February 15, 2017.

e. Traveling or Relocating Veterans. Test results for traveling or relocating Veterans must follow the requirements outlined in this directive. See VHA Handbook

1101.11(4), Coordinated Care for Traveling Veterans, dated April 22, 2015, for more information on communicating test results for traveling or relocating Veterans.

f. VA Community Care Program. VA Community Care Program providers who order tests for a Veteran are responsible for communicating those test results to the patient and addressing results that require action, including incidental findings. For such tests, Veterans receive test results according to the contracts or policies used by their VA Community Care Program providers and according to their specified methods (e.g., phone, letter, certified letter) and timing. After completion of an episode of care, VA Community Care Program providers are required to provide medical documentation

(including lab results, radiology reports and images) to the VA medical facility that referred the Veteran to the VA Community Care Program provider.

g. Clinical Contact Centers. VA medical facility policies and service-level workflows must incorporate the role of the Clinical Contact Centers in releasing test results to patients. NOTE: For more information on Clinical Contact Centers, see VHA Directive 1006.04(1), Clinical Contact Centers, dated May 16, 2022.

h. Suicide Prevention. A review of mental health referral options and suicide risk screening is advised when a Veteran receives potentially life-changing test results.

Some Veterans may be at increased risk of suicide after receiving potentially life-changing test results. If potentially life-changing test results are being provided to a Veteran with a High Risk for Suicide – Patient Record Flag (please see VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide, dated July 18, 2008), the VA medical facility 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, with the modality and timeline guided by the VA medical facility’s policy (see paragraph 5 for information to be included in the local policy). Coordinating communication must not delay notification of results to the Veteran or next steps in care. Specific suicide risk screening and assessment information is available in question 13 of the FAQs at:

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

NOTE: This is an internal VA website and is not available to the public .

i. Asynchronous Telehealth. Asynchronous telehealth is initiated by consultation and results regularly include a test result (e.g., interpretation of an image) and care recommendations. Referring providers are responsible for communicating asynchronous telehealth test results and the care plan to patients in accordance with this directive unless otherwise specified in the Telehealth Service Agreement. For more information on telehealth visit https://vaww.telehealth.va.gov/. NOTE: This is an internal VA website that is not available to the public. Asynchronous telehealth is also referred to as store-and-forward telehealth.

j. Health Profession Trainees. Health profession trainees must communicate test results to patients and initiate appropriate clinical action as required by this directive under the supervision of a supervising practitioner. NOTE: If the health profession trainee is unavailable to meet the directive requirements, the supervising practitioner or the practitioner responsible for the patient’s care (as defined by VA medical facility policy) is the designee and has the responsibility for ensuring that the required communication, action and documentation occurs per this directive. The supervising practitioner is a VA health care provider (e.g., licensed independent practitioner (LIP) or advance practice provider) who has been credentialed or privileged at a VA medical facility in accordance with applicable requirements and who oversees and instructs health professions trainees. Supervising practitioners in physician education are often referred to as “attendings.” See VHA Directive 1400.01 and VHA Handbook 1400.04.

https://vaww.telehealth.va.gov/

5. VA MEDICAL FACILITY POLICY AND SERVICE-LEVEL WORKFLOW

REQUIREMENTS

a. VA medical facility policy for the communication of test results must:

(1) Define which test results are considered emergent and imminently life-threatening, the acceptable length of time between the availability of emergent and imminently life-threatening test results and receipt by the VA medical facility ordering provider or designee, and associated notification with verbal verification.

(2) Describe how the VA medical facility accounts for the delegation of clear responsibility and accountability related to test result follow-up, especially when multiple providers are involved in the care of a patient. Furthermore, policies must outline alternative procedures through which the VA medical facility diagnostic services provider communicates emergent and imminently life-threatening test results when the VA medical facility ordering provider and their designee are unavailable. See an example process for developing a critical value reporting algorithm in question 4 of the

FAQs at:

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

NOTE: This is an internal VA website and is not available to the public .

(3) Describe the practices and procedures the VA medical facility follows to better manage the EHR-based notifications related to test results. To ensure EHR notifications are effective and do not create unnecessary information burden on VA medical facility ordering providers or designees, VA medical facilities must evaluate the numbers and types of notifications providers are receiving and use mandatory notifications judiciously. See the View Alerts Checklist for additional information on managing EHR notifications at:

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

NOTE: This is an internal VA website and is not available to the public.

(4) Require the development of service-level workflows to ensure that patient notification includes participation of other members of the VA medical facility ordering provider’s team.

(5) Describe how the VA medical facility:

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

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

(c) Determines thresholds under which VA health care providers on leave assign designees within the EHR and their paging/notification systems where appropriate.

(d) Creates a process that assigns a designee for the EHR notifications when health care providers are no longer available (e.g., when they take unexpected or prolonged leave or exit the station on a permanent basis).

(e) Monitors the effectiveness of the patient notification process while addressing performance improvement issues as needed.

(f) Ensures that an appropriate 24 hour, 7 days a week results communication cascade is developed and is readily accessible in the event the VA medical facility ordering provider or designee is unavailable.

(g) Demonstrates how communication of results to patients is being monitored to document compliance with this VHA directive.

(h) Defines how (modality and timeline) the VA medical facility ordering provider or designee coordinates communication of life-changing test results to patents with a High Risk for Suicide – Patient Record Flag. See paragraph 4.h. for additional information.

b. VA medical facility service-level workflows must describe the receipt of test results from VA medical facility diagnostic services providers to the VA medical facility ordering provider or designee and the communication of test results to patients by the VA medical facility ordering provider or designee. In addition, service-level workflows must include:

(1) The inclusion and participation of other members of the patient’s health care team to facilitate processes related to patient notification of all types of test results. This team could include, but is not limited to, Physicians, Nurse Practitioners, Physician

Assistants, Registered Nurses (RNs), Licensed Vocational Nurses, Licensed Practical Nurses, Medical Support Assistants, Clinical Pharmacist Practitioners, unlicensed assistive personnel and Clinical Contact Center staff. Inclusion of other team members must follow robust principles of teamwork, including clarifying task delegation, roles of team members, key responsibilities on test result related action and contingency planning. Service-level workflows should clearly define roles and allow team members to function at the top of their license, scope, functional statement or position description.

NOTE: For information on a team-based approach to managing test results, see question 3 of the FAQs at:

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

This is an internal VA website and is not available to the public .

(2) The type of test results each team member can communicate and how the results are communicated (e.g., synchronous versus asynchronous). For certain types of tests and certain types of patients, synchronous communication methods are preferred (see paragraph 9.f.).

(3) A reliable system to ensure that any tests ordered under a protocol, clinical pathway or clinical algorithm by an RN or another non-LIP include a mechanism for notifying the VA medical facility ordering provider in whose name the order was placed.

(4) Plans for the delegation of authority and specification of which team members can receive test results from VA medical facility diagnostic services providers and which team members can notify patients of test results as appropriate within their scope of practice, functional statement or position description.

(5) Processes to ensure there is always coverage to receive test results during a provider’s absence by a designee within their privileges, scope of practice, position description or other approved documentation, including during off-tour hours. If none of the previously identified personnel are available, test results must be reported according to an established communication cascade or to the VA medical facility ordering provider’s VA medical facility service chief or designated supervisor or lead. The ED must not serve as the default location for off-tour reporting of new emergent and imminently life-threatening test results without mechanisms to allow notification to the VA medical facility ordering provider or designee. If unable to reach the VA medical facility ordering provider or designee, clear processes must guide timely action on new emergent and imminently life-threatening test results and escalation of notification according to local policy, which may or may not include use of ED. Refer to the critical value reporting algorithm in question 4 of the FAQs at:

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

NOTE: This is an internal VA website and is not available to the public .

6. TRAINING

There are no formal training requirements associated with this directive.

7. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive must be managed as required by the National Archives and Records Administration (NARA) approved records schedules found in VHA Records Control Schedule 10-1. Questions regarding any aspect of records management should be addressed to the appropriate Records Officer.

8. BACKGROUND

VHA is committed to the timely communication of test results, which is essential to ensuring safe and effective health care. Enhancing timeliness of communication of test results is consistent with VHA’s goals of providing Veterans with quality health care.

Delayed 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 and is consistent with personalized proactive patient-driven care. Patients have a right to be notified of test results within a timeframe that minimizes risk and allows them to be informed and engaged in their health care.

9. DEFINITIONS

a. Asynchronous Communication. Asynchronous communication is a type of communication that occurs when parties involved in communication are not present at the same time, such as through electronic notifications in the EHR, secure messaging, automated messaging, fax or letter.

b. Electronic Health Record. EHR is the digital collection of patient health information resulting from clinical patient care, medical testing and other care-related activities. Authorized VA health care providers may access EHR to facilitate and document medical care. EHR comprises existing and forthcoming VA software including Computerized Patient Record System (CPRS), Veterans Information Systems and Technology Architecture (VistA) and Oracle/Cerner platforms. NOTE: The purpose of this definition is to adopt a short, general term (EHR) to use in VHA national policy in place of software-specific terms while VA transitions platforms.

c. Patient Notification. Patient notification is the process of communicating test results to patients and, if appropriate, a surrogate, including additional context and follow-up action as needed. Patient notification occurs through synchronous or asynchronous methods. For certain types of test results and certain types of patients, synchronous methods are preferred.

d. Surrogate. A patient surrogate is an individual authorized to make health care decisions on behalf of a patient who lacks decision-making capacity. The term includes a health care agent, legal guardian, next-of-kin or close friend. See 38 C.F.R. § 17.32.

e. Synchronous Communication. Synchronous communication is communication that occurs when parties involved are all present at the same time, such as in person, telephone or Clinical Video Telehealth conversations.

f. Test Results. Test results are the outcomes of patient testing and include the results of laboratory and pathology testing, diagnostic imaging and other diagnostic procedures. Test results are categorized as abnormal or normal as determined by a health care provider and are further defined as follows:

(1) Abnormal Test Results. Abnormal test results are test 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) Emergent and Imminently Life-Threatening. An emergent and imminently life-threatening abnormal test result is any new test result which must be acted upon by the

VA medical facility ordering provider or their designee immediately or within a short window of time and could result in severe morbidity or mortality if left unaddressed.

Example: An imaging test suggestive of acute ruptured abdominal aortic aneurysm.

(b) Urgent Not Imminently Life-Threatening. An urgent not imminently life-threatening abnormal test result is any new test result which must be acted upon by the VA medical facility ordering provider or designee within a relatively urgent timeframe as clinically indicated to ensure timely, appropriate and effective therapeutic action (e.g., A test suggestive of a diagnosis of a new or unexpected malignancy).

(c) Clinically Significant. A clinically significant abnormal test result is any new test result finding that requires action by the VA medical facility ordering provider or designee, but not necessarily in an immediate or urgent time frame. Example: A lab test that shows high cholesterol.

(2) Normal Test Results. Normal test results are test results that fall within the reference range for that test. The significance of a normal test result must be determined clinically. For example, some test results may fall within the reference range for that test but still require action. Alternatively, as discussed above, some test results may be designated as abnormal and may not require any action.

10. REFERENCES

a. 38 U.S.C. § 7301(b).

b. 38 C.F.R. § 17.32.

c. VHA Directive 1006.04(1), Clinical Contact Centers, dated May 16, 2022.

d. VHA Directive 1105.03, Mammography Program Procedures and Standards, dated May 21, 2018.

e. VHA Directive 1330.01(7), Health Care Services for Women Veterans, dated February 15, 2017.

f. VHA Directive 1400.01, Supervision of Physician, Dental, Optometry, Chiropractic, and Podiatry Residents, dated November 7, 2019.

g. VHA Handbook 1101.11(4), Coordinated Care for Traveling Veterans, dated April 22, 2015.

h. VHA Handbook 1400.04, Supervision of Associated Health Trainees, dated March

19, 2015.

i. VHA Handbook 1004.01(5), Informed Consent for Clinical Treatments and Procedures, dated August 14, 2009.

j. Communicating Test Results FAQs and resources.

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

NOTE: This is an internal VA website and is not available to the public .

k. VHA Telehealth Services. https://vaww.telehealth.va.gov/. NOTE: This is an internal VA website that is not available to the public.

https://vaww.telehealth.va.gov/