HIM Happenings: Delayed Test Results Impact Continuity of Care
By Keith Olenik, MA, RHIA, CHP
For The Record
Vol. 31 No. 10 P. 26
Did you know delayed test results negatively impact patient safety? Are you aware that 30% to 40% of tests pending at discharge (TPADs) return potentially actionable results that often remain unbeknownst to physicians?
From continuity of care gaps to avoidable medical errors and readmissions, inadequate physician follow-up of TPADs can lead to patient harm. Delayed test results pose a particular challenge during clinical care transitions from the hospital to outpatient follow-up settings.
Patient shifts inherently cause a significant number of clinical management changes and information exchange inefficiencies. Diagnostic findings from the hospital are critical to patient care during the transition—but are often nowhere to be found. Furthermore, physicians may be unaware of these potentially actionable results that are pending due to high volumes of testing, delays in order completion, and limited systematic tracking of diagnostic tests still in progress after acute care hospital discharge.
Closing the communication gaps on TPADs has the potential to reduce medical errors during care transitions, mitigate readmission risk, and improve clinical outcomes. However, this requires prompt examination of test results and clear channels for communicating the information to patients and providers within and beyond the hospital setting.
Health care professionals have a shared obligation to use every means possible to prevent delayed test results from falling through the cracks. It’s everyone’s responsibility—including HIM.
National Recognition of the Issue
A survey of residents at a large urban teaching hospital revealed that nearly one-half of the respondents had witnessed a patient’s condition worsen at least several times in the past year due to inadequate follow-up on clinical results. The study identified barriers to timely review and action, including the lack of reminder systems, difficulty accessing results, competing care demands, and miscommunication about follow-up responsibilities.
Residents aren’t the only ones concerned about TPADs. This issue is also recognized at the national level.
The Office of the National Coordinator for Health Information Technology, or ONC, developed the Safety Assurance Factors for EHR Resilience (SAFER) Guides that enable health care organizations to address EHR safety in various areas, including test results reporting and follow-up. The guides provide a checklist of recommended practices that organizations can use to evaluate their status compared with the best evidence developed from literature review, expert opinion, and field testing at a wide range of health care organizations. The SAFER Guides are designed in part to help deal with safety concerns created by the constantly changing health care landscape.
The Joint Commission addresses TPADs in its National Patient Safety Goal NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis. It notes that critical result policies are an important way to enhance communication among caregivers and decrease the risk of patient harm.
The goal includes the following:
• Rationale: Critical results of tests and diagnostic procedures that fall significantly outside the normal range and may indicate a life-threatening situation.
• Objective: Provide the responsible licensed caregiver results within an established time frame so the patient can be treated promptly.
How Can HIM Help Improve Test Result Communication?
HIM professionals play a pivotal role in assisting their organizations to ensure that providers and patients are aware of test results post discharge. One example is the impact on coding. The capture of accurate information that reflects the care provided to the patient is a crucial goal of the coding process. Failure to include all pertinent information, and therefore the related diagnosis code, occurs when a subsequent diagnosis from delayed results is not included.
Consider this scenario: A patient who was discharged with a pneumonia diagnosis also had a biopsy performed on a lung mass during their stay. After discharge, the pathology report comes back with a lung cancer diagnosis. In that case, what should the HIM department or coder do to ensure this new information is accurately captured in the medical record? Is it appropriate to send a query to the physician and ask for an addendum of the discharge summary and a list of final diagnoses?
According to AHIMA’s “Standards of Ethical Coding,” coders may not misrepresent the patient’s clinical picture through incorrect coding or by omitting diagnosis or procedure codes. It can be considered a breach of professional ethics if a pathology report documents a definitive diagnosis that is not included in the patient’s record.
These types of cases are common. Coders have a professional responsibility to take action.
A second reference to consider is the ICD-10-CM Official Guidelines for Coding and Reporting, approved by the four organizations that compose the Cooperating Parties for ICD-10-CM: AHIMA, the American Hospital Association, the Centers for Medicare & Medicaid Services (CMS), and the National Center for Health Statistics. In reference to the example regarding a cancer diagnosis, Section I, C. Chapter-Specific Coding Guidelines, Chapter 2: Neoplasms provides clear direction on the documentation required to support the assignment of codes.
Infectious disease provides another clear example of how proper coding and communication of delayed results impacts lives. Timely notification of positive test results for infectious diseases must be made to ensure prompt response by public health services. From flu to Ebola, minutes matter.
HIM departments must have policies and procedures regarding how medical record documentation can be modified to provide the coder with information to support the results found in the record. The appropriate process to include additional information in the medical record or to obtain clarification of information begins by asking the physician responsible for the documentation.
Six Ways for HIM to Take Action on TPADs
Organizations should use the AHIMA and Association of Clinical Documentation Integrity Specialists reference materials that outline the process to effectively manage the query process in the Practice Brief Guidelines for Achieving a Compliant Query Practice. AHIMA has also published a Practice Brief on Clinical Validation that should be referenced to ensure documentation and coding are complete, reliable, and consistent.
Regardless of the rationale for sending a provider query, CMS encourages providers to ensure all entries are congruent with other parts of the health record. When an entry is made that contradicts documentation found elsewhere in the record, clarification should be obtained from the attending physician. CMS requires that any information that affects billed services and is acquired after the health record is complete must be added to the existing documentation in accordance with accepted standards for amending health record documentation.
HIM, coding, and clinical documentation improvement have an opportunity to address patient safety concerns while ensuring the medical record accurately reflects the care and treatment provided. Here are six best-practice recommendations:
• Create a critical results policy that includes notification timeline requirements.
• Define provider responsibility for reviewing, documenting, and communicating results.
• Provide education on the appropriate documentation procedures to update or amend the medical record.
• Evaluate technological capabilities to assist in all aspects of the process.
• Determine expectations for patient communication and access to information.
• Specify the HIM, coding, and clinical documentation improvement roles in the process.
Patient Experience Reigns Supreme
Partnerships between patients and clinicians designed to improve patient engagement promote improved care transitions and positive outcomes. This is relevant to test results in that patients can access their EHRs and facilitate communication with health professionals through secure electronic patient portals. Patients are the primary beneficiary in the prompt and proper sharing of delayed test results—as they should be.
Consumer education, support tools, and patient engagement processes are needed to ensure effective implementation of strategies such as the direct notification of results to patients. Consumers want to be involved in their care. They need communication gaps to be closed and better care transitions supported through the development of policies, practices, and tools that offer the greatest potential for improving their health care experience.
— Keith Olenik, MA, RHIA, CHP, is vice president of revenue cycle services at Pivot Point Consulting.
AHA’S STANCE ON DELAYED TEST RESULTS
The American Hospital Association’s Coding Clinic has answered a number of questions regarding delayed test results. Those responses can be referenced when writing an organizational policy to ensure code assignment reflects all documentation.
In the outpatient arena specifically, the Coding Clinic from the first quarter of 2000 provides numerous examples that state it is appropriate to code a more definitive diagnosis that was documented as part of the laboratory, radiology, and pathology results. A subsequent Coding Clinic from the third quarter of 2008 states that a coder cannot code based on the results of a pathology report and the only way to use this additional information is through an interpretation of these results by the attending physician.