D7 - Attachment - Communicating Test Results to Providers and Patients.pdf

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COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS

MCP F-11-82

G.V. Sonny Montgomery VA Medical Center Jackson, Mississippi 39216

Signatory Authority:

G.V. Sonny Montgomery VA Medical Center Director

Responsible Owner:

Chief of Staff (11)

Rescinded Document:

Communicating Test Results to

Providers and Patients dated May 5, 2022.

Effective Date: 10/14/2022

Recertification Date: 10/14/2027

1. POLICY

It is this medical center’s policy test results must be communicated to the ordering practitioner, or surrogate practitioner, within a timeframe allowing prompt attention and appropriate clinical action to be taken. Critical result/value (abnormal test result) is measured from identification of critical result to time of report – the report is to be communicated as soon as clinically indicated; however, in no case is the time from result to report to exceed one (1) hour (for example, it is reasonable to assume a potentially life-threatening value is reported immediately). Following notification, the ordering practitioner, surrogate, or licensed health care staff will communicate such test results to patients or personal representatives, so that they may participate in health care decisions. Licensed health care staff may be delegated to communicate only normal or stable test results

2. JUSTIFICATION

To establish policy and procedures for the communication of test results to providers and patients, and alerting clinical staff of significant abnormal laboratory, radiology, nuclear medicine, or other diagnostic findings so appropriate action is taken. Authority:

38 United States Code (U.S.C.) 7301(b)

3. RESPONSIBILITES

a. a. G.V. (Sonny) Montgomery VA Medical Center Director. The GVSMVAMC Director is responsible for ensuring overall compliance with this MCP.

(1) Ensuring that a Diagnostic Results Management and Reporting Process/Policy is in place that is consistent with VISN and national guidance.

(a) Defines the test results that are considered critical life threatening, 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.

(b) Ensures that the organization collects data on the timeliness of reporting critical tests and critical values or results.

(c) Ensures the facility assesses the data collected and determines whether there is a need for improvement, and that the organization takes appropriate action to improve and measure the effectiveness of those actions.

(d) Ensures that communication of results to practitioners and patients is periodically monitored to document adherence to Veterans Health Administration (VHA) and local policies.

b. b. G.V. (Sonny) Montgomery VA Medical Center Chief of Staff. The GVSMVAMC Chief of Staff is responsible for:

(1) Reviewing monitors of test result communication.

(2) Resolving process deficiencies with service chiefs.

(3) Ensuring the facility clinical service chiefs establish a chain of responsibility within their department for receipt of test results and communication of results to patients.

c. G.V. (Sonny) Montgomery VA Medical Center Clinical Service Chief. The GVSMVAMC Clinical Service Chief is responsible for

(1) Ensuring that the diagnostic practitioner identifies and communicates expediently all critical, emergent, or abnormal test values or results to the ordering practitioner, the practitioner’s surrogate, or the supervisor as appropriate.

(2) Ensuring that verified test result reports are available in the patient’s electronic medical record in a timely manner.

(3) Ensuring that the ordering practitioner or designee communicates all test results to the patient or patient’s representative with appropriate medical record documentation.

d. G.V. (Sonny) Montgomery VA Medical Center Ordering Practitioners. The GVSMVAMC Ordering Practitioner is responsible for

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

(2) Initiating appropriate clinical action and following up on the results of any orders which they have placed.

(3) Assigning a qualified surrogate practitioner to receive critical, emergent, 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.

(4) Documenting treatment actions in response to critical, emergent, or abnormal test results in the patient’s electronic medical record.

(5) Communicating outpatient test results to patients in accordance with the following standards:

(a) 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 timeframes.

Note: Separate VHA policies may set standards regarding communication of results for specific tests. When separate VHA policies exist that set standards for communication of specific test results, the shorter standard (of the separate policy or the 14-day standard of this policy) takes precedence.

(b) Tests ordered while the patient is an inpatient, but results reported after discharge is treated as outpatient tests. These tests are communicated by the ordering inpatient provider or their surrogate according to the standards in this policy.

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

(d) Communication with patients can occur in person, by telephone or in writing.

Once established, secure messaging through MyHealtheVet is an acceptable method of communication. Until approved secure messaging systems have been established by VHA, no patient identifiable information is to be communicated to patients by email.

(e) Document that the communication was received and understood, for communications where it is important for the patient to quickly take some kind of action, such as a change in medication or a return to the medical center for further evaluation.

Note: Due to the sensitive nature of certain test results, such as psychological tests, the determination of how to report these results are best made on a case-by-case basis.

Review and discussion of the test results need to be provided to the patient or appropriate representatives in person, with an opportunity for questions and discussion.

Human Immunodeficiency Virus (HIV) test results should be communicated according to current VHA policy (see Handbook 1004.01).

(f) Communication of the test results to patients outside of the setting of an outpatient visit is documented in the medical record.

(g) The results are communicated by licensed or certified health care staff. It is not required that the ordering practitioner personally communicates every result, but this task may be delegated to other licensed health care staff when clinically appropriate.

(h) When tests are ordered by residents, the preceptor has the responsibility for ensuring that the required communication and documentation occurs.

(i) When, despite best efforts, it is not possible to contact the patient (e.g., the patient has moved and left no contact information), all attempts to communicate with the patient are documented in the medical record.

(6) Inpatient, emergency, or urgent care often involves 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 practitioner or the care team the patient is part of should strive to effectively communicate relevant information to the patient about the patient's medical condition. Results of specific tests may be included in this communication as appropriate.

e. G.V. (Sonny) Montgomery VA Medical Center Diagnostic Practitioners. The GVSMVAMC Diagnostic Practitioner is responsible for

(1) Identifying and communicating expediently all critical, emergent, or abnormal test values or results to the ordering practitioner, the practitioner’s surrogate, or the supervisor, as appropriate.

(2) Ensuring that verified test results reports are available in the patient’s electronic medical record in a timely manner.

(3) Documenting the time and means of such communication and the name of the practitioner contacted, in the medical record. This documentation is not required for abnormal tests that are not critical or emergent.

f. G.V. (Sonny) Montgomery VA Medical Center Administrative Officer of the Day (AOD). The GVSMVAMC Administrative Officer of the Day is responsible for is responsible for assisting the physician on duty during off-duty hours to contact Veterans treated in the emergency department or ambulatory care, which includes all primary care teams, specialty care clinics, ambulatory surgery unit, and ancillary clinics about a critical test result. If the practitioner feels the situation warrants and other means of contacting the patient failed, the county sheriff’s department will be requested to make a welfare check to the patient’s residence. The practitioner’s clinical judgment and the significance of the results, determine the method of the patient’s notification as well as the urgency for follow-up care will determine if the patient is informed to report to the G.V. (Sonny) Montgomery VA Medical Center Emergency Department area as soon as possible for medical evaluation or admission if necessary or advised to seek immediate treatment at the closest community emergency room if the situation warrants.

4. OTHER PARAGRAPHS

a. During administrative hours (Monday through Friday (0800 – 1630) the following procedures shall be followed:

(1) Critical test results must be transmitted by direct communication of the diagnostic practitioner to the ordering practitioner, other responsible physician, or the registered nurse in charge of the patient.

(2) The testing service should contact the patient’s provider who ordered the test(s).

The provider may be a physician, physician’s assistant, or advanced practice nurse.

(3) The provider is paged once by the testing service. If no answer after 10 minutes, the provider’s service chief should be contacted, if unable to contact the service chief, the Chief of Staff should be contacted.

(4) Required elements when receiving critical test results include:

(a) The person receiving the critical test result shall write down the patient’s name and Social Security Number (SSN), date test completed, date and time result called, and the complete result.

(b) The result shall be “read back” verbatim from what is written to confirm the accuracy of the result.

b. During non-administrative hours (after 1630, weekends, and holidays) the following procedures shall be followed:

(1) Inpatient: The testing service shall contact the ordering provider or hospitalist on duty. The sending and receiving individuals shall follow established “read-back” process. If no provider is available or willing to accept the test results, the Chief of Service or Chief of Staff is called.

(2) Outpatient or CBOC patient: The testing service shall contact the provider in the Emergency Department. If no provider is available or unwilling to accept the critical results, the testing service calls the Chief of Service, Associate Chief of Staff for Primary Care (ACOS/PC) or Chief of Staff. The sending and receiving individuals shall follow established “read-back” process. If critical test results indicate the need for immediate follow-up, the physician on duty shall arrange appropriate notification of the outpatient.

c. Service-Specific Procedures

(1) Critical Test Results from Radiology

(a) The following are considered critical tests for immediate reporting to care provider. (All are to be entered as Code 201): Critical Abnormality: Critical abnormal findings are any new radiology/nuclear medicine finding that may be considered life threatening or that could result in severe morbidity and require urgent or emergent clinical attention and verbal communication to the ordering provider. The decision whether a particular abnormality is “critical” is a medical judgment, to be made by the interpreting physician of the imaging study.

1) Aneurysms ≥ 5 cm, and/or leaking, and/or increased 0.5 centimeters (cm) or more in size within last 6 months.

2) Pneumothorax, if unsuspected.

3) Tension Pneumothorax.

4) Leaking or ruptured abdominal aortic aneurysm.

5) ischemic small bowel on Computed Tomography (CT).

6) Acute intracranial hemorrhage.

7) Subarachnoid hemorrhage.

8) Intraparenchymal hemorrhage.

9) Unstable spinal fracture.

10) Pneumoperitoneum (non-post-op).

11) Significant displacement of tubes or catheters.

(b) At the time of awareness of an abnormal critical radiology test result, an immediate telephone report will be made to the ordering provider or hospitalist on duty.

The established “read-back” process shall be followed. The radiologist reporting the result shall document “read-back” process within the dictated report, including the contact person’s name, title, and time of contact.

(c) New Reportable Infectious Abnormality (Code 202): Any new abnormality considered suspicious of active tuberculosis or other reportable communicable infectious disease that is a significant public health risk will be assigned Code 202. Both a verbal and electronic notification will be made to the ordering provider within three (3) hours of the finding. If the provider cannot be reached, the service chief, or designee, will be contacted. In addition, the Infection Control Nurse will receive an electronic alert.

These notifications will be documented in the report or progress note.

(d) Finding Suspicious for New Malignancy (Code 203): Any abnormality that is suspicious or highly suggestive of new malignancy will be coded 203. The ordering provider will be alerted electronically for appropriate follow-up action. The Chief of Staff ensures a monitoring process is in place and assures follow-up actions are taken and documented.

(e) Abnormality (Code 204): An abnormality that is not considered to be an urgent and immediate life-threatening finding but needs attention and follow-up action as soon as possible will be coded 204. The ordering provider will be alerted electronically for appropriate follow-up action.

(f) If an initial electronic alert is not read within four (4) days, the unprocessed alert is forwarded to the provider’s backup reviewer. After 14 days, the unprocessed alert is forwarded to the provider’s service chief.

(g) Mammography results reporting: The interpreting radiologist, whether Veteran’s Administration (VA) staff or Contract staff, must document letters, reports, and/or verbal communication with the patient and ordering provider and ensure the communication is documented in the patient’s medical record. All communication must be documented in the medical record according to Mammography Quality Standards Act (MQSA) Regulations and Veterans Health Administration (VHA) Handbook 1104.1.

All Mammography results shall be communicated to the patient in terms easily understood by a layperson within 30 days of the procedure, including all normal results for diagnostic codes 1101Breast Imaging-Reporting and Data System (BI-RADS) Category “1 – negative”) and 1102 (BI-RADS Category “2 – benign findings”).

1) Code 1104 - Breast Imaging-Reporting and Data System - BI-RADS “4” Mammogram: Suspicious abnormality – Biopsy should be considered. Mammogram findings with suspicious abnormalities (BI-RADS Category “4”) will be communicated directly by the interpreting radiologist to the ordering provider within three (3) working days. If verbal communication to the ordering provider is not possible, the provider’s designee or service chief shall be notified within the three-day limit. The interpreting radiologist will document this communication in his/her report. Prompt verbal notification to the patient should be made within five (5) working days and does not obviate the need to provide written communication to the patient within 30 days. The ordering provider must accomplish this verbal and written communication to the patient. The provider that makes the communication is responsible to ensure it is documented in the patient record.

2) Code 1105 - Breast Imaging-Reporting and Data System - BI-RADS “5” Mammogram: Highly suggestive of malignancy – Appropriate action should be taken.

Mammogram findings highly suggestive of malignancy (BI-RADS Category “5”) will be communicated directly by the interpreting radiologist to the ordering provider within three (3) working days. If verbal communication to the ordering provider is not possible, the provider’s designee or service chief shall be notified within the three-day limit. The interpreting radiologist will document this communication in his/her report. Prompt verbal notification to the patient should be made within five (5) working days and does not obviate the need to provide written communication to the patient within 30 days. The ordering provider must accomplish this verbal and written communication to the patient.

The provider that makes the communication is responsible to ensure it is documented in the patient record.

3) Code 1106 - Breast Imaging-Reporting and Data System BI-RADS “6” Mammogram: Known biopsy – Proven malignancy appropriate action should be taken.

Mammogram findings proven for malignancy (BI-RADS Category “6”) will be communicated directly by the interpreting radiologist to the ordering provider within three (3) working days. If verbal communication to the ordering provider is not possible, the provider’s designee or service chief shall be notified within the three-day limit. The interpreting radiologist will document this communication in his/her report. Prompt verbal notification to the patient should be made within five (5) working days and does not obviate the need to provide written communication to the patient within 30 days. The ordering provider must accomplish this verbal and written communication to the patient.

The provider that makes the communication is responsible to ensure it is documented in the patient record. When a biopsy reveals proof of malignancy, the summary results and recommended course of action are communicated by the Radiology staff or contract staff to the ordering provider. The ordering provider assumes responsibility for notification of the patient and communication of the plan of care (e.g., follow-up diagnostic examinations and/or surgical consultation) within five (5) working days, by telephone and/or letter and documentation of the same in the medical record.

(h) Communication of Diagnostic Imaging Results: Radiology will complete data entry and submit it monthly to South Central Veterans Administration Health Care Network (SCVAHCN) Diagnostic Services Program Office.

(2) Critical Test Results from Laboratory: Critical values shall be telephoned immediately by laboratory personnel to the ordering provider, or another provider. The Pathology and Laboratory Management Service (P&LMS) staff may phone critical test results to a Pharm.D if that individual is the ordering provider. The established “read-back” process shall be followed. The lab tech that enters and verifies the critical value into Veterans Health Information Systems and Technology Architecture (VistA) is responsible for verbal/phone notifications. The lab tech is also responsible for documenting notification of the critical value in the VistA laboratory report as a comment along with date, time called, name and title of person notified, and caller’s initials. Lab tech is to notate “RCV” in computer as a comment; (RCV expands to “read back critical value”). A list of Critical Test Results may be found on the Pathology and Laboratory Management Service intranet page and P&LMS General Laboratory Procedure “Reporting Critical Laboratory Values.” The Critical Test Results list is reviewed annually, revised as appropriate and placed into effect after review by the Laboratory Utilization Committee and approved by the Medical Executive Committee (MEC).

(3) First Time Malignancy from Pathology: According to VHA Handbook 1106.01, if the evaluation of any anatomic pathology specimen concludes that there is malignancy and that there has been no prior definitive diagnosis of that malignancy (excluding skin squamous and basal cell carcinomas), the patient’s provider or surrogate practitioner must be personally notified by verbal communication as soon as possible (preferably within 1 working day of the time that diagnosis was made).

(4) Critical Test Results from Respiratory Therapy: Critical test results for arterial blood gases and other pulmonary studies shall be telephoned immediately by Respiratory Therapy (RT) personnel to the ordering provider, or another provider. The established “read-back” process shall be followed. The Respiratory Therapist who enters and verifies the critical value into VistA is responsible for verbal/phone notifications. The RT is also responsible for documenting notification of the critical value in the VistA report as a comment along with date, time called, name and title of person notified, and caller’s initials. RT, as Lab tech, is to notate “RCV” in computer as a comment”). The following arterial blood gas results require immediate clinical action, and therefore must be reported immediately:

Low High pH 7.250 7.550 pC02 25.0 60.0

P02 54.0 161.0

(5) Critical Test Results from Electrocardiograms (EKG’s): All EKG’s have a copy made and copies are delivered directly to the ordering provider, or another provider. EKG technicians are not credentialed to interpret the EKG results. These EKG results require immediate clinical action:

(a) Acute Myocardial Infarction (Computer interpretation).

(b) Severe Tachycardia (Any Tachycardia with HR > 130).

(c) Frequent multifocal Premature Ventricular Contractions (PVC’s) or runs of 3 or more PVC’s.

(d) Sustained Ventricular Tachycardia.

(e) Bradycardia with HR < 40

(f) High degree Atrioventricular Block (AV) block.

(g) New onset Atrial Fibrillation/Flutter.

(h) Significantly Symptomatic – Chest Pain, Diaphoretic, Dyspneic.

d. Quality and Performance Monitoring Procedures. Regular monitoring of compliance shall be performed by designated staff from each of the diagnostic services to analyze their process for reporting and timeliness of the critical test results.

4. DEFINITIONS

a. 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. All Emergent Test Results and some Abnormal Test Results constitute Critical Values or Results. Critical Values and/or life-threatening test results have been established for laboratory, radiology, respiratory therapy, electrocardiograms (EKG), and other diagnostic testing services.

b. Read-back Process: A process of verifying critical test results or verbal/telephone orders. The staff member, who receives the result, either verbally or by telephone, must Read-Back the result(s) to the caller in order to verify that the result(s) reported were accurately heard. The receiver of the critical result should write down the result or enter it into the computer, then read it back and receive confirmation from the individual who gave the result that it is correct.

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

d. Preceptor: A preceptor is a Licensed Independent Practitioner (LIP) who supervises the ordering of tests by residents, or by other practitioners authorized to order tests under a scope of clinical practice.

e. Diagnostic Practitioner: A 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.

f. Test Result: Test results are any laboratory testing, cardiovascular studies and tests, diagnostic imaging, and diagnostic procedures including critical value or result, emergent test result, abnormal tests results, stable results (abnormal but expected), and normal test results.

g. Emergent 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.

h. 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.

i. Stable Test Result: Stable tests results are abnormal but expected. These test results are neither critical nor unexpected for that particular patient.

j. Normal Test Result: Test results within the normal limits.

k. Direct Communication: Direct communication is the transmission of test results by direct, non-electronic dialogue between the diagnostic practitioner and the ordering practitioner, or surrogate practitioner, by telephone or face-to-face conversation, mailed report, or hand carried report, or hand carried report.

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

m. 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). Personal representative is further defined in Veterans Health Administration (VHA) Handbook 1605.1 “Privacy and Release of Information.”

6. REFERENCES

a. VHA Directive 1088(1), Communicating Test Results to Providers and Patients, amended January 24, 2022.

b. Mammography Quality Standards Act (21 C.F.R. 900. 12(c), et seq)

c. VHA Directive 1330.01(6), Health Care Services for Women Veterans amended September 9, 2022.

d. VHA Directive 1605.01, Privacy and Release of Information dated August 31, 2016.

e. 2022 Joint Commission National Patient Safety Goals. National Patient Safety Goals | The Joint Commission

f. South Central VA Health Care Network Policy Memorandum No. 16-CSPO-18, “Guideline for Communication of Diagnostic Imaging Results” dated October 17, 2014.

7. RESCISSION

a. MCM F-11-82, dated May 2, 2022

8. REVIEW

This MCP must be reviewed at minimum at recertification and including when there are changes to the governing documents listed above. This review is documented on the GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda: (see NOTE: This is an internal VA Web site that is not available to the public.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before August 14, 2027. 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

/s/

Kai D. Mentzer G.V. (Sonny) Montgomery VA Medical Center Director Date Approved: 10/14/2022

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

DISTRIBUTION: Emailed to the All Employee G.V. (Sonny) Medical Center Email Distribution List on 10/18/2022. MCPs are available at: GVSMVAMC Facility https://dvagov.sharepoint.com/sites/VACOVHACOS/10B4/PIRP/10B4/SitePages/Home.aspx https://www.jointcommission.org/standards/national-patient-safety-goals/ https://www.jointcommission.org/standards/national-patient-safety-goals/

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