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. Speaker: Christian Hermansen, MD Downtown Family Medicine Lancaster, PA

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. 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. 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. 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. The Reasoning
NCQA PCMH 2011 Requirements

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. 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. NCQA Nitty Gritty – Element 5

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. 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. 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. Do I NEED EMR To Do
This Stuff?

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. Test Tracking
Developing a System

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. 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. 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. Notify Patients of Normal Results
Patient at DM goal

19. Copy of That Letter

20. Follow-up with patients on abnormal results
Action plan notes

21. Sample Letter to Patient

22. Flagging Overdue Lab Results
Providers in the
practice

23. Sample Letter to Patient
Reminder re: Overdue Labs

24. Flagged Abnormals
Yellow bar
indicated
abnormal value
Sent electronically to
ordering physician’s
InBasket

25. Our Policy

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. Our Policy

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. Referrals
Developing a System

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. 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. 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. 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. 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. 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. Origination – at Referral Screen –
and some clinical and admin detail
Admin detail with insurance info
Clinical detail

37. Tracking Status

38. Tracking
Consultant report is returned to
the practice

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. DFM Referral Tracking Report
If not on
an
EMR,
you
could
do this
by hand
in a log
book….
uggh

41. Our Policy

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

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

45. 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

46. 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

47. 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

48. Medical
Neighborhood
Agreement
http://www.cms.org/uploads/Primary-CareSpecialist-Compact-Level-1-5.pdf

49. Screenshot of Specialist Communication

50. 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!

51. 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

52. Questions or Comments?