Practice Tips

Failure to diagnose is one of the most frequent allegations in malpractice claims. A direct relationship exists between this allegation and the lack of a comprehensive, reliable test/consult tracking system. Juries believe that if a test or consultation was important enough for a physician to order, then it is important enough to ensure the results are received.

Close the Loop

The goal of implementing a results management process is to “close the loop” on outstanding reports. The Joint Commission issued in 2019 a Quick Safety on Closed-Loop communication for test results and focused on communication and how essential it is to reduce diagnostic errors. Office staff involved in the process should understand that this system's purpose is to identify and act on test results and consult reports not returned to the practice. Following up on outstanding results increases patient safety and reduces malpractice liability risks.

Results Management Policy

Practices should develop a comprehensive written results management policy that outlines the steps and expectations of their results management process.

Steps in Results Management Process: Whether the results management process is paper-based or a component of the electronic health record (EHR), it must consist of the following steps:

• Ordering: Diagnostic tests can be ordered either manually or electronically through the EHR. Whichever process is used, the practice must establish a system to log in the order so it can be tracked to completion.
• Testing: Patients generally have the option to have diagnostic tests performed at the facility of their choosing. Health insurance coverage or cost can also dictate where patients have tests performed. This can create issues with tracking test results if the testing facility systems do not interface with the practice’s EHR.
• Test/Result Tracking Process: Diagnostic tests ordered by providers must be tracked. This process can be a paper process or an electronic process through the EHR. The tests ordered have been logged and after a pre-determined period of time, for example, two weeks, if a report has not been received the first step is to contact the patient to determine if the test was completed.
  • If the test was not completed, advise the patient to complete the test within a specified time frame. If a situation has changed and/or the patient does not intend to complete the test, notify the provider for further instructions.
  • When the test is completed, contact the appropriate facility and notify them that the results were not received. Request a copy of the results and continue to track until the results have been received.
  • Document patient contact and discussion in the medical record. Document facility contact and physician notification.
  • Testing facilities must call the practice with critical values. Only clinical staff should accept critical values via the phone. The staff member should “read back” the critical value and document the read-back in the patient’s medical record.
• Reporting: If the practice uses an electronic system, reports will be automatically routed to the provider who ordered the test. Paper reports must be physically given to the provider for his/her review. Prior to filing paper reports, they must be reviewed, initialed, and dated by the provider reviewing them.
  • Establish a process to redirect results when the physician responsible is on vacation or unavailable.
  • Establish an expected time frame for review of results. If time frames are not met, identify who in the practice will take steps to assure results are reviewed.
  • Providers will specify additional orders and any changes in the patient’s treatment plan.
• Patient Notification:
  • Inform patients of all normal and abnormal test results. Teach the patient the adage: “No news is NOT good news.” Tell the patient to expect notification within a specified time frame of test completion and if not notified to call the office to obtain results.
  • Establish a policy that requires only providers or clinicians to notify the patient of critical results such that questions posed by the patient can be addressed and follow-up treatment explained.
  • Note discussion and patient understanding in the patient’s medical record.
  • Do not depend on follow-up appointments to convey results as patients may miss or cancel appointments.
  • Do not leave results on voicemail or by text.
• Patient Follow-Up: The provider will recommend changes in the patient’s treatment plan based on the results of diagnostic tests. Review of test results, changes to the treatment plan, and follow-up of recommendations should be documented in the patient’s medical record.
• Unsolicited Test Results and Consult Reports: Unsolicited reports may come in from various sources. Physicians may receive courtesy copies of test results/consultations from another provider on a current patient; misdirected reports intended for another provider; patient information including abnormal test results for referred patients. Unsolicited reports carry a high risk for patient harm as too frequently, abnormal results “fall through the cracks.” To reduce the risk associated with unsolicited reports:
  • Review all unsolicited test results and consultation reports.
  • Contact the sender to confirm patient intervention if results are abnormal. If not confirmed, decide who will contact the patient and direct follow-up care.
  • If misdirected, contact the appropriate physician regarding abnormal results and forward misdirected reports.

Issues with Electronic Health Record Results Management: While technology has made many aspects of healthcare more streamlined and robust, some systems are problem prone and can lead to failures in the results management process. Some issues identified with electronic tracking of test results include:

• Lack of complete interface for order entry.
• Lack of consistent process to electronically receive test results.
• Lack of posting functions for all test results to the provider’s desktop and the patient’s EHR.
• Lack of ability to generate patient communications.
• Lack of a comprehensive electronic results management process.
• Lack of an interface with the practice’s appointment scheduler.
• Reliance on manual processes such as scheduling to compensate for shortcomings of the technology.¹

Practices should identify problems in their EHR and work within their practice and with the software vendor to address these issues.

Patient Portal: When a patient portal is used, document in the patient’s medical record that test results and recommended follow-up are communicated to the patient via the patient portal. Follow the practice’s written policies for patient portal notification and any restrictions on a notification via the portal. Establish a notification process to verify that the patient has accessed the information sent to them via the portal.

Something to also think about as you develop a process is how the organization will utilize a patient portal. According to a March 20, 2023, study in JAMA Network Open, most patients preferred receiving test results immediately upon release through an online patient portal even if their healthcare provider had not yet reviewed the results. This article is in the resources section below.

Effective Patient Referral Process: "Referrals to other physicians for consultation or second opinions are an important part of a medical practice. The failure to send the patient for consultation, the failure of a patient to go to a consultation, or the failure to act on the consultant's recommendations are the basis of many legal actions against physicians."²

Issues arise when clear expectations are not defined between the referring and consulting physician. When a primary care provider hands off care to a specialist, they should provide complete information to the specialist, including the reason for the referral, and the patient’s complete medical history, which includes any medication or diagnostic tests previously performed. The referring physician should clearly define the expectations of the consultation to both the patient and consulting physician. For example:

• Referral is for consultation only. The consultant's assessment and recommendations will be forwarded to the referring physician for evaluation and consideration.
• Referral is a transfer of care for a specified condition. The consultant is to assess the patient and implement the recommended treatment.

As with test result tracking, the referral process should be a closed-loop process. Office staff should have a system to:

• Log all referrals.
• Track receipt of consultant’s report.
• Route consult reports to the ordering provider, who will review and acknowledge receipt of the report manually, either with date and initials or with an electronic signature.
• Contact patients if they do not complete the referral.
• Notify the provider if the patient does not complete the referral; follow the provider’s instructions for follow-up with the patient.
• Document all steps taken in the patient’s medical record.

When a referred patient fails to schedule or keep their initial consultative appointment, the specialist’s office should notify the referring physician informing them that the patient never scheduled or did not keep the initial appointment.

Quality Improvement: Monitoring outcomes of office practice processes validate that processes are functionally effective and identify points of process vulnerabilities and failures.

The following is a list of indicators that can identify breakdowns in the results management system:

• Time frame between ordered tests and receipt of results.
• Time frame between receipt of results and review by the provider.
• Time frame between practice receipt of abnormal results and patient notification.
• Patient compliance with having test(s) performed.
• Patient compliance with appointments.
• Patient compliance with referrals.
• Patients not notified of results.
• Follow-up plan in place and completed by the patient.³

Staff Education: Staff involved in the results management process should receive training, not only on the process but also on the importance of the system in the office practice. Staff should understand that the lack of a strong results management process can lead to missed or delayed diagnosis, sometimes resulting in malpractice claims.

Resources

Steitz BD, Turer RW, Lin C, et al. Perspectives of Patients About Immediate Access to Test Results Through an Online Patient Portal. JAMA Netw Open. 2023;6(3):e 233572. doi:10.1001/jamanetworkopen.2023.3572

^{1, 3.} The Beacon, June 2018, Results Management: Are Your Patients Safe?
^2. Thomas, M. O., Quinn, C. J., & Donohue, G. M. (2009). Practicing medicine in protecting physicians from malpractice litigation. Sudbury, Mass.: Jones and Bartlett Publishers.

ASHRM: Physician Office Risk Management Playbook 2016