Tracking Referrals and Test Results
Anne M. Menke, RN, PhD, OMIC Risk Manager
Digest, Fall 2009
The OMIC claim discussed in this issue’s lead article involved a patient who was never informed of the need for tests. Other claims result from patients who do not follow instructions to see consultants or undergo diagnostic testing. Both scenarios can lead to patient harm and increased liability risk.
Q Whose responsibility is it to order and review tests and disclose the results to the patient?
A This question needs to be explicitly addressed and answered for each patient when more than one physician is involved. If you want to have the results of tests in hand when you first examine the patient, consider developing a form to send to the referring physician. Ask the physician to state the reason and urgency of the appointment being requested and to provide the contact and medical information you need to evaluate the patient. Indicate the tests that should be completed before you will see the patient. Clearly state who will order the tests and verify that the patient has completed them: “Please send the patient for the following tests and contact my office when you have received the test results.” In some situations, you may not know which tests need to be done until you examine the patient. Tests you choose after examination would normally be tracked by your office.
Q Do you have a system you can ecommend to track referrals and tests?
A Yes. When you determine that a patient needs a consultation with a specialist or a diagnostic test, disclose it to the patient, explain the reason for the order, and document your discussion and order. Ask the patient to schedule a follow-up visit or telephone consultation with you before leaving the office so you can review the results and revise the care plan. Next, instruct your staff to enter the information into a tracking system (see sample below). The system can be a follow-up tracking form, logbook, card file, or spreadsheet on the computer. When the report arrives, instruct staff to attach it to the patient’s file and place on your desk for your review. Date and sign the report, indicate any follow-up needed, and place in the medical record. Disclose the results to the patient and document the discussion. Communicate and document the new treatment plan. update the tracking form.
Q What steps do I need to take to ensure that I get the report?
A There are two ways to ensure that patients obtain the requested tests/consultations and you receive a report. First, assign to a reliable staff member the responsibility of reviewing the tracking system on a regular basis. Second, ask staff as part of preparing records for the next day’s patients to review each file to see if any report or result is expected. If the report is not received in the usual time, ask staff to call for results. If you learn that the patient did not present for the test or consultation, ask staff to contact the patient to learn why. Be sure to question patients in a non-judgmental manner: “We called to get the results of your MRI and were told that you had cancelled it. Was there some kind of problem? Could you tell me why you didn’t have this done?”
Q What if patients refuse the recommended care?
A Clarify why the patient is not complying with treatment recommendations. Possible reasons for not scheduling tests or procedures may include financial difficulties, HMO authorization problems, transportation difficulties, child care problems, confusion about the disease or the need for treatment, or fear of the significance of the results of the test, procedure, or consultation. Next, educate the patient about the disease process, treatment recommendations, and consequences of non-compliance. Target the education to the reasons for non-compliance. When possible, identify social service resources that may help. For example, some pharmaceutical companies provide free or reduced-cost medications. Be familiar with the enrollment criteria and process for state and federal assistance, and of transportation services for patients. If treatment is not authorized by the patient’s HMO, act as a patient advocate and appeal the decision. Verify that the patient understands the points being made by asking the patient to explain them back to you in his or her own words. Give written materials whenever possible, and use visual teaching aids, such as videos, charts, diagrams, and models of the eye. If your efforts to educate and clarify the need for treatment are not effective, you may need to terminate the relationship (see “Noncompliance” and “Termination of the Physician-Patient Relationship” at www.omic.com.
Authorization For Use or Disclosure of Health Care Information
Patient name: ___________________________________________________________________________
Date of birth:______________________________ SSN: ______________________________
I. My Authorization
You, [insert physician or practice name], may use or disclose the following health care information:
All my health information maintained by you
My health information relating to the following treatment or condition: _________________________________
My health information for the date(s):____________________________________________________________
Other:_____________________________________________________________________________________
You may disclose this health information to:
Name (or title) and organization__________________________________________________________________
Address: _________________________________City ________________________State _________Zip_______
Reason(s) for this authorization (check all that apply):
| at my request | check here only when [insert physician or practice name] will get something of value for providing health information for marketing purposes |
| other (specify)______________________________________________________________________________________________________________________________________ |
This authorization ends: on (date) __________________
when the following event occurs _____________________________________
II. My Rights
I understand I do not have to sign this authorization in order to receive treatment. However, I may be required to sign this authorization form:
- To take part in a research study; or
- To receive health care when the purpose is to create health information for a third party.
I may revoke this authorization at any time, in writing, sent to [insert physician or practice name] at the address provided below. If I do, it will not affect any actions already taken by [insert physician or practice name] based upon this authorization; uses and disclosures already made cannot be taken back. I may not be able to revoke this authorization if its purpose was to obtain insurance.
- [insert physician or practice address]
Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
___________________________________________ __________________ ____________________
Patient or legally authorized individual signature Date Time
Patient is unable to sign because of:_______________________________________________
Age of minor or reason for patient’s inability to sign
___________________________________________ ______________________________________________
Printed name if signed on behalf of the patient Relationship & Authority (parent, legal guardian, personal representative, etc.)
III. Additional Consent for Certain Conditions
This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this information can be released.
___ I consent to have the above information released.
___ I do not consent to have the above information released.
___________________________________________ __________________ ____________________
Patient or legally authorized individual signature Date Time
IV. Additional Consent for HIV/AIDS
This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Separate consent must be given to have this information released.
___ I consent to have the above information released.
___ I do not consent to have the above information released.
___________________________________________ __________________ ____________________
Patient or legally authorized individual signature Date Time
Interpreters for Deaf Patients
Anne M. Menke, RN, PhD, OMIC Risk Manager
For our risk management recommendations on interpreters for deaf patients, please click here. For advice on limited English proficiency patients, click here.
Digest, Winter 2006
Physicians are well aware of the central role clear communication plays in the physician-patient relationship. Patients who are deaf present special challenges to effective interactions. Ophthalmologists often have questions about how to obtain and reimburse interpreters and whether family members can fulfill this role.
Q My deaf patient insists that I provide a translator. Am I required to do so?
A Although the law has been interpreted “by some as creating a requirement that the physician provide and pay for the cost of hearing interpreters for their patients who are hearing disabled,” the American Medical Association has noted that there is “no hard and fast requirement for the provision of such services” and that the Americans with Disabilities Act (ADA) “does not mandate the use of interpreters in every instance.” The Supreme Court ruled in an education suit, for example, that American Sign Language (ASL) interpreters are not required when lip reading or other accommodations are sufficient. In the medical arena, physicians often rely upon note pads to communicate with deaf patients. At times, such as before major surgery, or when initiating a treatment plan for a complex condition, an interpreter may be necessary.
Q Does the ADA even apply to my practice?
A Yes. Intended to stop discrimination on the basis of disability, the ADA requires those who own, lease, or operate a place of public accommodation, such as a physician’s office, to make reasonable accommodations to meet the needs of patients with disabilities, unless “an undue burden or a fundamental alteration would result.” Actions, standards, and policies that either intentionally discriminate or have the effect of discrimination against persons with disabilities are prohibited. Moreover, failure to take steps that may be necessary to ensure access, such as providing auxiliary aids and services, could be seen as discriminatory.
Q What steps must my group take to meet the needs of patients with disabilities?
A First, conduct and document an analysis of your overall obligations. Decide what particular aid or service will be provided, based in part upon an analysis of the length and/or complexity of the medical service, treatment, or procedure. A patient’s request for a sign language interpreter should be a significant factor in the decision. Determine whether providing such a service would result in an undue burden on the overall practice. Second, assess the patient’s needs before providing a particular auxiliary aid or service. Ask the referring physician how he or she usually communicates with the patient. Consult with the patient about his or her needs when the appointment is scheduled and document the discussion. If a patient requests an interpreter, ask staff to acknowledge the request and gather more information about the patient’s concerns/expectations for the visit so the physician can determine the best way to meet them. Document the decision and the assistance provided. For many routine office visits, a notepad may be sufficient to ensure good communication. Office visits before major surgery or for a new, complex treatment plan may require an interpreter. If the physician and patient disagree, reconsider the decision. Finally, maintain a list of qualified sign language and oral interpreters.
Q Can I charge the patient for the cost of the interpreter?
A No, the cost of aids cannot be passed onto the patient. However, the patient’s employer, health plan, Medicare, or a local hospital may be able to help provide or pay for an ASL interpreter.
1. AMA Legal Issues: Americans with Disabilities Act and Hearing Interpreters, accessed 11/21/2005.
2. American with Disabilities Act (ADA), 42 U.S.C.§ 12101, et seq. ADA Title III Tecnical Assistance Manual, http://www.usdoj.gov/crt/ada/taman3.html, accessed 1/10/2006.
My Doctor Never Told Me That Could Happen
By Anne M. Menke, RN, PhD
OMIC Risk Manager
Digest, Summer 2007
Why do patients sue? This question, pondered by most physicians at some point in their careers, prompted a famous study that was published in JAMA in 1992. GB Hickson and his co-authors queried obstetrical patients who filed lawsuits after their infant had experienced permanent injuries or death. The study showed that patients initiated malpractice claims, in descending order of frequency, when they were advised to sue by a knowledgeable acquaintance (often a physician), needed money, believed there was a cover-up, felt their child would have no future, wanted more information, or wanted revenge or to protect others. 1 This article will explore physician-patient communication with particular focus on how to use the informed consent process to keep the lines of communication open before and after surgical procedures.
The insurance industry has long known that the majority of claims involve a relatively small number of physicians. The Hickson study authors wondered why. Do these high risk physicians attract higher risk patients? Do they practice bad medicine? Or do they relate differently with patients? In order to explore the relationship between physicians’ malpractice experience and their patients’ satisfaction, the authors devised a new study and asked a different group of mothers about their satisfaction with pregnancy and delivery care (see table 1). 2
The results confirmed the authors’ hypothesis that lawsuit frequency correlates with the volume of patient complaints about interpersonal aspects of care. Physicians with no claims history were perceived as “concerned, accessible, and willing to communicate,” whereas those with multiple claims were viewed as “hurried, uninterested, and unwilling to listen and answer questions.” In a companion article that examined quality of clinical care, SS Entmann et al found no correlation between prior malpractice history and either objective or subjective measures of quality of care. 3 This supports the Hickson findings that factors other than bad medicine are to blame for lawsuit frequency.
the central role that provider- patient rapport plays in malpractice claims was also supported by a 1994 finding by hB Beckman et al that a breakdown in patient-physician communications could be associated with over 70% of professional liabil- ity litigation.4 Patients would rather not sue their physicians. Vincent et al note that they want their doctor to do three things after a poor out- come: explain what happened, say he or she is sorry that the patient experienced the poor outcome, and assure the patient that steps will be taken to prevent the same thing from happening to other patients.5
Risk management experts have suggested that much of this communication dysfunction could be avoided by engaging the patient and family in a constructive, ongoing informed consent dialogue designed to invite them to participate in their care, clarify misconceptions, and minimize unrealistic patient expectations. Rather than being a purely legal function that must be fulfilled prior to invasive procedures, consent becomes an opportunity to establish a “therapeutic alliance” between the ophthalmologist and the patient wherein each acknowledges the clinical uncertainties that exist to some degree with each medical or surgical intervention.6 As the next section shows, forging such an alliance takes careful consideration and thoughtful communication.
What Do Patients Want?
Weighing the risks and benefits of a proposed surgery is central to the informed consent process and begins with understanding what the patient wants from surgery. CK Pager’s expectations and outcomes in Cataract surgery (EOCS) study analyzed preoperative expectations about outcomes and studied what led to patient satisfaction.7 After an informed consent discussion, patients completed the Visual function index, known as the VF-14, and indicated what they felt their score would be after surgery. Expectations ran “unreasonably high” in the patients in this 2004 study. They anticipated achieving a mean VF-14 score of 96.1 (an 11 point gain), and fully 60% assumed they would achieve a perfect score of 100 postoperatively. One might expect satisfaction to correlate with improvement in VF or the actual outcome. instead, patients weren’t satisfied unless they got what they expected, and those with an ocular comorbidity were most likely to be dissatisfied. When patients had expectations of reading small print, doing fine handiwork, reading a newspaper, or driving at night, they were decidedly unhappy if they had difficulty performing these tasks postoperatively. Indeed, few patients realistically achieved their goal, leading Pager to conclude that 70-year-old patients expect cataract surgery to enable them to see like 20-year-olds. Given the current advertising about the benefits of “multifocal” and “premium” IOLs, it is worth noting that these unrealistic patients all had monofocal implants, and had not been subjected to advertising promising them full recovery of their youthful vision. The only suggestion the study offered was to use the informed consent process to contribute to more accurate patient expectations.
What Do Patients Hear?
What do patients hear and understand about risk during an informed consent discussion? More pointedly, if patients expect perfect vision, how can ophthalmologists prepare them to accept not only realistic outcomes but possible complications? Unfortunately, just as prospective patients overestimate the benefits of cataract surgery, they underestimate the risks.8 In a study by CG Kiss et al, patients were provided with a standardized informed consent document that fully explained the risks, benefits, and alternatives. When questioned after the consent discussion, patients nonetheless believed that cataract surgery was relatively easy. Fully 76% felt there was no risk of a complication; when pressed, 60% maintained that even in their own surgery, there was no risk of a severe complication. Even when they finally admitted that the risk of a severe vision-threatening complication was real, 77% did not take risk into account when making the decision to proceed with surgery. Indeed, 78% said that the discussion had no impact on their decision, while the rest reported that it only confirmed the choice they had already made.
What frustrates ophthalmologists and healthcare risk managers is that these same patients may well claim in court that the discussion never took place or that they never would have consented to the surgery if informed of the risks. The authors of the study acknowledge that some patients do lie, but feel this explanation does not account for flawed recall of the informed consent discussion. They concluded instead that when patients come to ophthalmologists with a visual problem, they have already made a decision to have surgery in order to solve the problem and improve their vision. When confronted with what they perceive as negative objections (i.e., an accounting of associated risks), patients experience stress. Since they need to feel comfortable with their decision and minimize the stress, patients hear (and remember) what enhances a positive attitude and devalue (and forget) objections. In other words, patients “believe in and hope for the best.” To counteract this cognitive dissonance and help patients take in more accurate information about the risks of treatment, patients should be given information about the procedure earlier than the day before surgery.7
Why Don’t Patients Hear?
JE Pauling, an expert from a non-medical field who has studied how to communicate risks to the public, feels the problems lie not so much in how patients process information as in the way it is communicated to them.9 In other professions such as aviation and nuclear energy, there is great concern about the consequences of misunderstanding. To decrease its likelihood, only a few well-trained individuals are authorized to speak to the public. They always begin their message by addressing the potential emotional impact of the message before going on to provide information in the form of visual aids.
In the medical field, almost all clinicians are called upon to communicate risk. They receive little to no training, minimize their own and the patient’s emotions, and offer data with few visual aids. Poor process and training are only part of the problem, Pauling argues. Physicians want to build trust with their patients and know that it depends in part upon showing the patient that one is a good doctor. They assume that their patients know they care (“i went into medicine to help people”) and focus their efforts on demonstrating their competence, calling upon science and probability to calculate comparative risks. they are quite comfortable both with accepting a certain level of risk as inherent in treatment and with the uncertain, ever-changing nature of knowledge. Patients, on the other hand, assume that physicians are competent (“she went to medical school”) and watch anxiously for signs that their physician cares about them. Disregarding the data, they are only interested in hearing if the proposed procedure is or isn’t safe for them and knowing the personal consequences of treatment. Moreover, patients consider any discussion of uncertainty as evidence not of competence but rather of the physician’s lack of knowledge (“he doesn’t know the answer”).
Pauling illustrates his points and begins to give some practical advice with the following example. Imagine you are an obstetrician and are trying to help a 39-year-old woman understand her risk of having a fetus with Down’s syndrome. You know that it is 1.2% or 1 in 83. You provide these figures and reassure the woman that her risk is “quite low.” As table 2 shows, however, a patient’s perception of quite low is different, as anything higher than 1% is actually considered a high risk. Only when the likelihood falls in the 1 in 1000 to 1 in 10,000 range is it considered by patients to be a low risk.
In addition to using the same risk calculus, there are other steps physicians can take. First, use a common denominator to place the particular patient’s risk in a continuum (e.g., for a 35-year-old woman, the risk of having a child with Down’s syndrome is <3/1,000, and for a 40- year-old woman, it is <9/1,000). Second, to improve the likelihood of being understood, the physician can translate this information into a visual aid by using a graph available online at www.riskcomm.com. A 35-year-old woman would see a chart with stick figures for 1000 people. Three of those would be darkened to represent the number of women who will have a Down’s infant. The woman would also note that the vast majority—997/1000 women in her age group—are likely to have a child without Down’s syndrome. Providing both a positive and negative perspective and context enhances the message. Finally, relate the risk to one the patient knows and understands (e.g., people have a 1 in 10,000 risk of being struck by lightning or of dying from an accident in their own home).
Please go to the Risk Management Recommendations section of www.omic.com for an extended version of this article, including detailed suggestions for the consent process and footnote references.
Payment Issues: Avoid Delays in Treatment
Hans Bruhn, MHS, OMIC Senior Risk Management Specialist
Digest, Winter 2011
By the time a patient is referred and examined by an ophthalmic specialist, he probably has already been seen by a primary care physician and a general ophthalmologist. Most health insurers require patients to go through a referral process before they can be seen by a specialist. This can be problematic if the patient’s eye condition requires rapid diagnosis and treatment by the specialist. Critical care can also be delayed when patients do not have health insurance and cannot pay out of pocket for these services. When delays in critical care result in less than desired or poor outcomes, some patients will file a claim against the specialist and all referring health care providers, alleging failure to provide timely treatment.
Q Can I withhold care because of a patient’s inability to pay (including co-pays)?
A This is always a tricky situation. Ophthalmologists may be required to collect co-pays or deductibles by third party insurers. If emergent care is needed, we recommend separating payment issues from decisions about care. Proceed with providing as much care as possible and sort out the financial issues after the patient is stable. This will avoid delays in treatment and reduce the risk of a claim. Notify the insurance company of the urgent care situation and the patient’s inability to pay the co- payment. The insurance company may allow you to waive the co-payment; however, waiving fees without first checking with the insurer can jeopardize your provider contract. You should make a reasonable effort to work out a payment plan with the patient; document your efforts and the results.
You may have less control over the situation in a surgical facility or hospital setting that requires payment up front as a condition of admission. But before you send the patient elsewhere, act as the patient’s advocate. Explain to the facility the urgent nature of the required treatment and ask if it will work out a payment plan with the patient. If not, promptly refer the patient to another facility that may be willing to do so. If all attempts fail, it may be necessary to refer the patient to the local emergency room, where federal law mandates that treatment be provided. Throughout this process, keep the patient informed about your efforts on his behalf. This will help reduce the likelihood that you will be perceived by the patient as withholding care. Document carefully.
Q During follow-up, I noted that a patient I first saw in the ER needed surgery. Since I am not part of her HMO, I promptly called her primary care physician to secure a referral to a participating ophthalmologist, but the PCP was out of town. What action should I take?
A Advise the patient about the situation (PCP is not available; surgery is needed and you are not in her insurance provider network). If the patient elects to pay out of pocket, get that in writing and proceed with care. If not, help the patient find another provider to assume care. Contact her HMO directly and request a referral to another ophthalmologist. Once another provider is identified, contact that new physician and facilitate transfer of care along with patient authorization and your recommendation for surgery. Advise the patient of your actions and document accordingly.
Q A patient that I have been treating since June 2008 has developed a serious corneal ulcer (OS), possibly fungal. I prescribed Natamycin drops, but the patient has not gotten the drops and has canceled follow-up appointments because of the cost. The patient is blind in his right eye, and now his left eye is compromised with this serious condition. Am I obligated to continuing seeing him?
A Contact the patient and tell him of your concern. Explain that many patients are having trouble affording care and ask if his financial situation is keeping him from getting the care he needs. Advise him of the seriousness of his eye condition, including the consequences of not using the drops you prescribed and not coming in for exams. Given the urgency of the situation in this functionally monocular patient, encourage him to come in to see you so you can conduct an exam and provide care, including drops, if possible. If the patient is still reluctant to see you, ask if there are any relatives to assist him. Offer to set up a payment plan for incurred medical expenses. As a last resort, advise the patient to go to the nearest emergency room for care. If the patient refuses, document your discussion and send a letter reiterating your recommendations and explaining again the consequences of not getting care. If the patient does not respond to your discussions and letter, consider sending OMIC’s “noncompliance” letter, which gives the patient one last chance to come in for care before the physician-patient relationship is terminated.
Contact OMIC’s Risk Management department for assistance or visit our web site, www.omic.com, for our recommendation “Discontinuing Treatment for Financial Reasons and Noncompliance Guidelines.”
