The CPSS has recently dealt with two cases where malignant pathology results have been inadequately managed by physicians. Given the potential serious ramifications of delayed management, we though it may be helpful to remind physicians of their obligations when managing pathology results.
CPSS position: The physician who submitted the specimen is responsible for follow up
The College wishes to remind physicians that the physician who submitted the specimen to the pathology department is responsible for the follow up and appropriate management of the result, in keeping with the College’s standards of practice, the Code of Ethics and the Code of Conduct.
The College’s Policy “Standards for Primary Care” is clear that the CPSS expects that “physicians will … provide the medical follow-up required by a patient’s condition after undertaking an examination, investigation or treatment of a patient unless the physician has ensured that another physician, another professional or another authorized person has agreed to do so.”
The issue of after-hours management of test results is addressed in the CPSS Policy “Medical Practice Coverage” as follows:
Physicians must ensure that any practice location in which they work has appropriate systems in place to receive and review investigations results after-hours, to permit them to take appropriate action in response to critical diagnostic test results reported by a laboratory or imaging facility for urgent attention, and to follow-up with the patient with appropriate urgency.
The primary responsibility for review and follow-up is with the ordering physician, but after-hours or in the absence of the ordering physician, investigation results should be reviewed by a licensed physician or eligible alternate healthcare provider pursuant to a coverage arrangement as referenced [...].
It is also important that referring physicians and consultants review the CPSS guideline: Referral-Consultation Process which covers the responsibility of the consulting physician in regards to tests as follows:
After seeing the patient, the consulting physician should:
a) within 14 days of the attendance, provide the referring practitioner (and primary care provider if not the referring practitioner) a legible written report that includes:
…
management plan, including goals and options for treatment and management:
- the appropriate investigations/diagnostics, with clear articulation of responsibility for ordering and following up the results;
…
Guidance found in CPSO policy “Managing Tests”
Useful guidance can also be obtained from the policy of the College of Physicians and Surgeons of Ontario “Managing Tests”. That policy includes detailed criteria and expectations for physicians and specifies whether tasks are mandatory (“must”) or can be determined by the physician’s reasonable discretion (“advised”).
Ideally each clinic or practice should have a robust protocol for the management of test results, (it is important to note that the individual physicians are responsible for the way their own tests results are managed) with the following components as detailed in the CPSO policy:
1. Test result management system:
a. In order to ensure appropriate follow-up on test results can occur, physicians must
have an effective test results management system that enables them to:
- record all tests they order;
- record all test results received;
- record that all test results received by physicians have been reviewed;
- identify patients who have a high risk of receiving a clinically significant result, and critical and/or clinically significant test results; and
- record that a patient has been informed of any clinically significant test results and the details of the follow-up taken by the physician.
b. Physicians who are not responsible for choosing the test results management
system must be satisfied that the system in place has the capabilities listed above.
2. Tracking tests:
a. For patients who have a high risk of receiving a clinically significant test result,
physicians must track their test results when they are not received when
expected.
b. For patients who are not at high risk of receiving a clinically significant test result,
physicians must use their professional judgment to determine whether to track a
test result. In making this determination, physicians must consider the following
factors:
• the nature of the test that was ordered,
• the patient’s current health status,
• if the patient appears anxious or has expressed anxiety about the test,
and
• the significance of the potential result.
c. Physicians must either personally track test results or assign this task to another
duly qualified practitioner with a clear and documented agreement.
3. Follow up:
a. Ordering physicians must ensure that follow-up on test results received occurs in
accordance with provisions as detailed under the communication strategy
b. In certain health-care environments, the ordering physician may not be the same
physician who receives the test result (e.g., in an emergency department or a
walk-in clinic). In these situations, ordering physicians must either delegate, assign
or otherwise ensure that there is another person that is responsible for
coordinating the follow-up or that there is a system in place to do so.
4. Have a communication strategy to inform patients of the results whereby:
a. When in receipt of a clinically significant test result, physicians must always
communicate the test result to their patient and must do so in a timely manner.
b. For test results that are not clinically significant, physicians must use their
professional judgment to determine whether to communicate a test result, and if
doing so, when to communicate the test result.
c. Physicians must use their professional judgment to determine how to best
communicate a test result; for example, over the phone or, at the next
appointment. In making this determination, physicians must consider a variety of
factors, including:
a. the nature of the test,
b. the significance of the test result,
c. the complexity and implications of the test result,
d. the nature of the physician-patient relationship,
e. patient preferences/needs, and
f. whether the patient appears anxious or has expressed anxiety about the
test.
d. Physicians must use their professional judgment to determine the circumstances
where it makes sense for other health-care providers and/or non-medical staff to
communicate test results. The factors physicians must consider include:
a. the nature of the test,
b. whether the patient appears anxious or has expressed anxiety about the
test,
c. the significance or implications of the test result, and
d. whether communicating the test result would mean communicating a
diagnosis.
e. When relying on others to communicate test results, physicians must have a
mechanism in place that enables them to respond to any follow-up questions
that the patient may have.
f. Physicians must ensure that the communication of test results adheres to their
legal and professional obligations to maintain patient confidentiality and privacy.
g. Physicians must ensure that all attempts made to either communicate the test
result to the patient and/or to book a follow-up appointment to discuss a test
result are documented in the medical record.
The CPSO policy goes further by adding the following expectations:
Clinically Appropriate Action Following Receipt of Test Results:
- When physicians receive a critical and/or clinically significant test result for a test that they have ordered, they must take clinically appropriate action. The timeliness of these actions will depend on the significance of the test results
Receiving Test Results in Error:
- Physicians who receive a critical or clinically significant test result in error (e.g., same or similar name or contact information) must inform the laboratory or diagnostic facility of the error.
Communication and Collaboration with other Health-Care Providers:
- Physicians in receipt of a test result must use their professional judgment to determine if it is necessary to share a patient’s test result with other relevant health-care providers whose ongoing care of the patient would benefit from that knowledge and, if sharing the test result, the timeliness with which to share it. The timeliness of the communication will depend on the degree to which the information may impact patient safety, including exposure to adverse clinical outcomes.
- Physicians whose role is to interpret and report test results (e.g., a radiologist, pathologist, laboratory medicine physician) must contact the health-care provider who ordered the test when there is an unusual, unexpected, or urgent finding to ensure that this information is communicated quickly and that it does not go astray.
Patient Engagement:
- When ordering a test, physicians must inform patients of the significance of the test, the importance of getting the test done (in a timely manner, as appropriate), and the importance of complying with requisition form instructions.
There are a number or articles and opinion pieces regarding the “No new is good news” strategy being employed in some practices. The CPSO states in its policy that:
- Physicians must only use a ‘no news is good news’ strategy for managing test results if they are confident that the test result management system in place is sufficiently robust to prevent test results from being missed and that no news really means good news.
- Physicians must use their professional judgment to determine when a ‘no news is good news’ strategy is appropriate in each instance and must consider the following factors in making this determination:
a. the nature of the test that was ordered,
b. the patient’s current health status,
c. if the patient appears anxious or has expressed anxiety about the test, and
d. the significance or implications of the potential result.
- Physicians must inform patients as to whether they are using a ‘no news is good news’ strategy and must tell patients that they have the option to personally contact the physician’s office or make an appointment to come into the office to hear their results.
Other suggestions for improved management of test results
A suggestion can be made to involve the patient in the management of test results by following the recommendations as listed above, or ensuring that the patient has access to and knows how to retrieve their own results on the eHealth Saskatchewan MySaskHealthRecord portal. This should not be used as the only way to manage tests results but may add another layer of safety.
While clinics or practices should have a robust and effective result management system and all staff should be fully trained in the procedure, it should be recognized that no system is ever 100% reliable. If an adverse event or near-miss situation does occur, the clinic protocol should be reviewed, and lessons learned should be shared with all physicians and staff to prevent a repeat occurrence.
The CMPA article "Closing the loop on effective follow-up in clinical practice" summarizes managing tests as follows:
- Physicians should have an effective system in place for managing follow-up on the results of investigative tests.
- Physicians ordering diagnostic tests have a duty to communicate the results to the patient and to make reasonable efforts to ensure appropriate follow-up is arranged.
- Physicians who receive an abnormal report, even incidentally, may have an obligation to appropriately respond to it or to redirect it, even if the patient is no longer, or never was, in their care.
- Physicians should document their review of tests results and what follow-up action they initiated.
- When away on vacation or absent for a long period of time, physicians should establish a process for follow-up.
References:
- CMPA: Closing the loop on effective follow-up in clinical practice
- CMPA: Test result follow up
- CPSO: Managing Tests
- AAFP: Four Principles for Better Test-Result Tracking
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