Referral and Test Tracking:Finding Peace in the Process

Christian Hermansen, MDMedical Director, Downtown Family MedicineAsst Deputy Director, Lancaster General FM ResidencyAssistant Director, LGHP PCMH Implementation

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

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

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

The ReasoningNCQA PCMH 2011 Requirements

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

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

NCQA Nitty Gritty – Element 5

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

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

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

Do I NEED EMR To Do This Stuff?

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

Test TrackingDeveloping a System

• Determine what test(s) are needed• Be aware of what test(s) have already been done• Generate the order for the correct test(s)• Document in record that test(s) have been ordered

• Understand why the test is being ordered• Understand the importance of having the test done• Have the capacity (mental, physical, financial) to have the test done• Be motivated to actually go to the lab!

• Receive the test order (on paper or electronically)• Correctly identify and perform the test that has been ordered• Generate an accurate report of the test results• Communicate the results to the ordering physician

• Be made aware of the test results (preferably automatically and passively)• Be notified if the test has not been done as planned!• Recognize the significance of the test results• Communicate abnormal and normal test results to the patient in a timely manner• Document that this communication has occurred!

Test TrackingHow it’s supposed to work!

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”

Test Tracking Options

Paper Chart• Order sheet in chart

• Staff transcribes to test sheet (and keeps copy)

• Tests come back in the mail

• Staff file in chart and place on provider desk for action

• Open orders linger with staff?

EMR• Order typed in chart

• Lab slip generated

• Tests return to your inbasket

• Ordering clinician takes action on result

• Open orders linger in an inbasket?

Notify Patients of Normal Results

Patient at DM goal

Copy of That Letter

Follow-up with patients on abnormal results

Action plan notes

Sample Letter to Patient

Flagging Overdue Lab Results

Providers in the practice

Sample Letter to Patient

Reminder re: Overdue Labs

Flagged Abnormals

Yellow bar indicated abnormal

value

Sent electronically to ordering physician’s

InBasket

Our Policy

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!

Our Policy

Suggestions and Recommendations

• 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!

for Test Tracking

ReferralsDeveloping a System

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

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

Referral Tracking

• Determine the need for consultation/referral• Select the appropriate specialty and specialist• Provide the referral specialist with necessary information (Sx, Dx, PMHx, previous testing, etc.)• Generate whatever referral documents are necessary• Assist the patient in making an appointment

• Understand why the referral is being ordered• Understand the importance of having the referral done• Have the capacity (mental, physical, financial) to go to the referral specialist• Be motivated to actually go to the appointment!

• Be aware of the question(s) to be answered• Have the necessary background information available• Generate a document (chart note, letter) that clearly communicates the impressions and recommendations to the consulting physician• Transmit that document in a timely manner

• Be made aware of the consultant’s impressions and recommendations(preferably automatically and passively)• Be notified if the consult did not take place!• Incorporate the results of the referral into the patient’s plan (discuss with patient if needed)•Document that this communication has occurred!

How it’s supposed to work!

Referral Options

Paper Chart• Order sheet in chart

• Staff or coordinator calls office for appt

• Letter sent to specialist and appropriate records sent (with release from patient)

• Specialist sees patient and renders report back to PCP

• Open appts linger with staff?

EMR• Order typed in chart

• Referral slip generated and staff or coordinator make appt

• 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

• Open appts linger with staff?

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”

Clinical Details – Letter to Consultant

Letter to consultant created by ordering physician and typically includes past medical history, medications, family history,

social history, etc

Origination – at Referral Screen – and some clinical and admin detail

Clinical detail

Admin detail with insurance info

Tracking Status

Tracking

Consultant report is returned to the practice

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

DFM Referral Tracking Report

If not on an EMR, you

could do this

by hand in

a log book….uggh

Our Policy

Question…If the primary care practice is a PCMH, then where do the specialists fall into the PCMH?

http://www.acponline.org/advocacy/where_we_stand/policy/

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

PCMH-Neighbor DefinitionPractices 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

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

http://www.cms.org/uploads/Primary-Care-Specialist-Compact-Level-1-5.pdf

Medical Neighborhood

Agreement

Screenshot of Specialist Communication

Suggestions and Recommendations

• 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!

for Referral Tracking

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

Questions or Comments?