Referral and Test Tracking: Developing a System

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SOUTH CENTRAL October 30, 2013

Discuss the quality improvement and medico-legal aspects of referral and test tracking. Address barriers and consider low and high tech options for referrals and test tracking.
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Christian Hermansen, MD
Downtown Family Medicine
Lancaster, PA

Published in: Technology, Business
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  • The Medical Neighbor Model proposes a framework that fosters patient centered care integration and communication so that our patients are neither falling through the cracks nor getting duplicated services
  • The policy paper defines the concept of Neighbor practices as practices that :
  • Referral and Test Tracking: Developing a System

    1. 1. Referral and Test Tracking: Finding Peace in the Process Christian Hermansen, MD Medical Director, Downtown Family Medicine Asst Deputy Director, Lancaster General FM Residency Assistant Director, LGHP PCMH Implementation
    2. 2. A Typical Visit • Mrs. Jones is a 55 yo female that has an appointment at your office. • She sprained her ankle and is a little gimpy • She has diabetes and front staff recommends to her to get her labs to morning of the appointment as she has not had labs in 15 months • Because of your huddle tools and HM reminders, you notice she has not had a mammogram in 3 years and needs a referral to see the eye doctor which you order for her that day
    3. 3. However • Mrs. Jones forgets to go to her mammogram appointment • She also was late getting to the eye doctor so they wouldn’t see her
    4. 4. Objectives for Our Time Together • How can we help in closing the loop in test tracking and referrals? • Review benefits to quality improvement • Consider medico-legal aspects of referrals and test tracking • Consider low and high tech options • Take your questions at the end
    5. 5. The Reasoning NCQA PCMH 2011 Requirements
    6. 6. PCMH Element 5: Track and Coordinate Care • 5A = Test Tracking and Followup • Tracks labs and imaging for overdue results • Flags abnormals • Notifies patients/families • Incorporates results into medical record • 10 Factors total with first 2 must pass • Need 8 for full points
    7. 7. PCMH Element 5: Track and Coordinate Care • 5B: Referral Tracking and Followup • Communicating to specialist clinical reason for referral • Tracking status of referrals • Obtaining (and following-up to obtain) specialist's report • Establishing co-management agreements with specialist • Asking patients about self-referrals • Demonstrating capacity for electronic exchange of information • Providing electronic summary of care • 5-7 needed for full points
    8. 8. NCQA Nitty Gritty – Element 5
    9. 9. The Spirit of the Metrics • Quality Improvement • Ensure the care that is needed gets to who needs it • Example: If A1c is high, what can we do as a team to address? • Bad example: If A1c is high, patient is just non-compliant and doctor moves on • Additionally, we are increasing incentivized (P4P) for closing gaps in care from a quality standpoint • May be able to use this P4P to help pay staff to address
    10. 10. The Spirit of the Metrics • Medico-legal Aspects • Ensure patient is aware of risk involved in test or the results • If A1c is high, is patient aware of increased cardiovascular or complication risk? • If A1c not done, is patient aware of potential cardiovascular or complication risk? • If abnormal results, how is patient made aware? • How do I ensure good patient care and avoid lawsuits? • Having a system documents the engaged conversation
    11. 11. Bottom Line • You can’t just ignore results • You can’t just tell patients the information at next visit • You can’t just punt to a specialist without a reason why • You can’t just not get a report from the specialist
    12. 12. Do I NEED EMR To Do This Stuff?
    13. 13. Not Necessarily • A system needs to be in place whether it be in paper chart or electronic system • Clinicians and staff need to know what is expected of them • EMR may help: • Prevent things from getting lost • Provide time and date stamp • EMR may also decrease verbal communication
    14. 14. Test Tracking Developing a System
    15. 15. Test Tracking How it’s supposed to work! • Be made aware of the test results (preferably automatically and passively) Be notified the the are being ordered ••Receive the ifwhyorderhas is needed done as planned! • Determine what test(s)(on not been electronically) Understand test test test paper or Recognize what test(s) have already been done ••Correctly identifyimportance of the test that test done ordered • Be aware of thesignificance of the test the has been Understandthe and perform having results Communicateorder for the of the test results to have the test done ••Generate an accurate reportphysical, test results to the patient in a • Generate capacity (mental,correct test(s) Have the the abnormal and normal financial) timely manner to actually test(s) ordering ••Communicate record that go thethe lab! physician • Document in the results to to have been ordered Be motivated • Document that this communication has occurred!
    16. 16. Where and why does the testing chain break down? • Correct order not generated by physician (including diagnosis code) • Timing of testing and other instructions (e.g. fasting) not communicated to patient • Patient not convinced that test is necessary • Patient unable to get to lab (transportation, child care, finances) • Patient unable to afford test (insurance -> Medicare ABN!) • Incorrect test entered in lab system -> wrong test done! • Test results “lost in the system” • Test results not brought to physician’s attention • Abnormal or critical results not recognized and acted on in a timely manner • Results not communicated to patient in a timely manner • Result not linked to order in EMR to “close the loop”
    17. 17. Test Tracking Options Paper Chart • Order sheet in chart EMR • Order typed in chart • Staff transcribes to test sheet (and keeps copy) • Lab slip generated • Tests come back in the mail • Staff file in chart and place on provider desk for action • Open orders linger with staff? • Tests return to your inbasket • Ordering clinician takes action on result • Open orders linger in an inbasket?
    18. 18. Notify Patients of Normal Results Patient at DM goal
    19. 19. Copy of That Letter
    20. 20. Follow-up with patients on abnormal results Action plan notes
    21. 21. Sample Letter to Patient
    22. 22. Flagging Overdue Lab Results Providers in the practice
    23. 23. Sample Letter to Patient Reminder re: Overdue Labs
    24. 24. Flagged Abnormals Yellow bar indicated abnormal value Sent electronically to ordering physician’s InBasket
    25. 25. Our Policy
    26. 26. It would be very easy to order test today and have computer expect patient to get it today. If not done today, may increase overdue results bin Consider using standing orders!
    27. 27. Our Policy
    28. 28. Suggestions and Recommendations for Test Tracking • Have written policies in place that address the critical steps in the process; educate providers and staff and periodically review compliance • Educate the patient! • Develop mechanisms (paper or EMR) to detect “missing” labs and bring them to provider’s attention • Have mechanism in place to flag abnormals! • Notify patients of results in a timely manner (phone, e-mail, letter, web site) • “Close the loop” and document it!
    29. 29. Referrals Developing a System
    30. 30. Office Consultations The “three R’s” • Request from a referring provider (written or verbal, and must be documented) • Render opinion and order treatment or tests • Report back in writing to referring provider Please document name of requesting physician
    31. 31. PCMH Element 5: Track and Coordinate Care • 5B: Referral Tracking and Followup • Communicating to specialist clinical reason for referral • Tracking status of referrals • Obtaining (and following-up to obtain) specialist's report • Establishing co-management agreements with specialist • Asking patients about self-referrals • Demonstrating capacity for electronic exchange of information • Providing electronic summary of care
    32. 32. How it’s supposed to work! Referral Tracking •Be aware the need for consultant’s ordered Be made aware of referral to be answered ••Determine of the the the consultation/referral Understand why question(s) is being impressions and recommendations(preferably having the referral done Have the appropriate specialty and specialist ••Select the necessary background information available Understand the importance ofautomatically and passively) •Generate a if the consult did with letter) that to go to the Be the capacity (mental, physical, financial) ••Provide the referral specialist note,necessary information referral the Havenotified document (chart not take place! clearly communicates impressions and resultstesting,referral into the patient’s plan (discuss • Incorporate previous of the etc.) specialist (Sx, Dx, PMHx,therecommendations to the consulting physician with patient if document Transmit whatever referral to the appointment! ••Generate thatto actually go a timely mannernecessary Be motivated needed) in documents are •Document that this communication has occurred! • Assist the patient in making an appointment
    33. 33. Referral Options Paper Chart EMR • Order sheet in chart • Order typed in chart • Staff or coordinator calls office for appt • Referral slip generated and staff or coordinator make appt • Letter sent to specialist and appropriate records sent (with release from patient) • Letter sent to specialist electronically or by mail and appropriate records sent (with release from patient) • Specialist sees patient and renders report back to PCP • Specialist sees patient and renders report back to PCP • Open appts linger with staff? • Open appts linger with staff?
    34. 34. Where and why does the referral chain break down? • Sufficient order not generated by physician (including pertinent info) • Breakdown in appointment process • Patient not convinced that referral is necessary • Patient unable to get to consultant (transportation, child care, finances) • Referral not covered by patient’s insurance • Consultant not in possession of all pertinent information • Consultant report not generated and sent in a timely manner • Consultant report not brought to physician’s attention • Unclear responsibility for implementing consultants recommendations • Results not communicated to patient in a timely manner • Completed referral not linked to order in EMR to “close the loop”
    35. 35. Clinical Details – Letter to Consultant Letter to consultant created by ordering physician and typically includes past medical history, medications, family history, social history, etc
    36. 36. Origination – at Referral Screen – and some clinical and admin detail Admin detail with insurance info Clinical detail
    37. 37. Tracking Status
    38. 38. Tracking Consultant report is returned to the practice
    39. 39. Daily Tracking • Referral Coordinator daily reviews referral status in our electronic medical record to update status of existing referrals • Screenshot of what this reports looks like in next slide
    40. 40. DFM Referral Tracking Report If not on an EMR, you could do this by hand in a log book…. uggh
    41. 41. Our Policy
    42. 42. Question… If the primary care practice is a PCMH, then where do the specialists fall into the PCMH?
    43. 43. http://www.acponline.org/advocacy/where_we_stand/policy/
    44. 44. PCMH-Neighbor Model/Policy Paper • Supports the importance of Medical Neighbors • An infra-structure or framework to support Care Coordination and Communication • Improve Care Transfers and Transitions to enhance Safety and Stewardship • Restore Professional Interactions needed for Patient Centered Care • Definition of PCMH-Neighbor • Describes the Types of Interactions between PCMH practices & Specialty Practices • Principles Care Coordination Agreements
    45. 45. PCMH-Neighbor Definition Practices that: • Communicate, coordinate and integrate bidirectionally with PCMH as well as with patient • Ensure appropriate & timely consultations and referrals • Ensure effective flow of information • Address responsibility in co-management situations • Support patient centered care • Support the PCMH practice as the “hub” of care and provider of whole person primary care to the patient
    46. 46. Co-Management • Shared Care for the disease • PCP responsible for Elements of Care • Principal care for the disease. • Specialist responsible for Elements of Care for that disorder or set of disorders • Principal care of the patient • for a consuming illness for a limited period of time • specialist serves as first contact but patient maintains PCP as Home
    47. 47. Medical Neighborhood Agreement http://www.cms.org/uploads/Primary-CareSpecialist-Compact-Level-1-5.pdf
    48. 48. Screenshot of Specialist Communication
    49. 49. Suggestions and Recommendations for Referral Tracking • Work to have written agreements with “usual” consultants that define expectations and responsibilities • Educate the patient! • Help patient cut through the appointment red tape • Develop mechanisms (paper or EMR) to detect “missing” referrals and bring them to provider’s attention • Document physician review of consultations • “Close the loop” and document it!
    50. 50. Conclusion • Test tracking and referral coordination are an important part of a PCMH • Also allows for patient engagement, enhanced quality of care and system based improvement • Develop a system and policy to address the issues • Connect with your friendly neighborhood specialists
    51. 51. Questions or Comments?

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