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Managing Tests

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Approved by Council: September 2019

Companion Resource: Advice to the Profession

This policy was approved by CPSO Council and published on September 20, 2019. As the policy contains new expectation that may require time for physicians to adjust how they manage their practice, the CPSO has implemented a transition period to allow physicians to align with any new expectations that were not previously set out in policy or where there has been a substantial change in the expectation. This transition period will end on Sunday October 20, 2019.

 

Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct.

Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.

 

Definitions

Test Result: Includes results for tests performed at laboratories, diagnostic facilities (including imaging facilities), and in physicians’ offices, and also includes pathology results.

Critical Test Result: Results of such a serious nature that immediate patient management decisions may be required.1

Clinically Significant Test Result: A test result determined by a physician to be one which requires follow-up in a timely fashion, urgently if necessary.  Physicians determine the clinical significance of a test result using their clinical judgment and knowledge of the patient’s symptoms, previous test results, and/or diagnosis.

Follow-up: Communication of the test result to the patient in an appropriate manner and taking appropriate clinical action in response to the test result.

 

Policy

Test Results Management System

  1. In order to ensure appropriate follow-up on test results can occur, physicians must have an effective test results management system that enables them to:
    1. record all tests they order;
    2. record all test results received;
    3. record that all test results received by physicians have been reviewed;
    4. identify patients who have a high risk of receiving a clinically significant result, and critical and/or clinically significant test results; and
    5. record that a patient has been informed of any clinically significant test results and the details of the follow-up taken by the physician.
  2. Physicians who are not responsible for choosing the test results management system must be satisfied that the system in place has the capabilities listed above.

Tracking Tests

  1. For patients who have a high risk of receiving a clinically significant test result, physicians must track their test results when they are not received when expected.2
  2. For patients who are not at high risk of receiving a clinically significant test result, physicians must use their professional judgment to determine whether to track a test result. In making this determination, physicians must consider the following factors:
    1. the nature of the test that was ordered,
    2. the patient’s current health status,
    3. if the patient appears anxious or has expressed anxiety about the test, and
    4. the significance of the potential result.
  1. Physicians must either personally track test results or assign3 this task to others.

Follow-up

  1. Ordering physicians must ensure that follow-up on test results received occurs in accordance with provisions 7 through 17.
    1. In certain health-care environments, the ordering physician may not be the same physician who receives the test result (e.g., in an emergency department or a walk-in clinic). In these situations, ordering physicians must either delegate, assign4 or otherwise ensure that there is another person that is responsible for coordinating the follow-up or that there is a system in place to do so.

Communication of Test Results

  1. When in receipt of a clinically significant test result, physicians must always communicate the test result to their patient and must do so in a timely manner.
  2. For test results that are not clinically significant, physicians must use their professional judgment to determine whether to communicate a test result, and if doing so, when to communicate the test result.
  3. Physicians must use their professional judgment to determine how to best communicate a test result; for example, over the phone or, at the next appointment. In making this determination, physicians must consider a variety of factors, including,
    1. the nature of the test,
    2. the significance of the test result,
    3. the complexity and implications of the test result,
    4. the nature of the physician-patient relationship,
    5. patient preferences/needs, and
    6. whether the patient appears anxious or has expressed anxiety about the test.
  4. Physicians must use their professional judgment to determine the circumstances where it makes sense for other health-care providers and/or non-medical staff to communicate test results. The factors physicians must consider include:
    1. the nature of the test,
    2. whether the patient appears anxious or has expressed anxiety about the test,
    3. the significance or implications of the test result, and
    4. whether communicating the test result would mean communicating a diagnosis.5
  5. When relying on others to communicate test results, physicians must have a mechanism in place that enables them to respond to any follow-up questions that the patient may have.
  6. Physicians must ensure that the communication of test results adheres to their legal6 and professional obligations7 to maintain patient confidentiality and privacy.
  7. Physicians must ensure that all attempts made to either communicate the test result to the patient and/or to book a follow-up appointment to discuss a test result are documented in the medical record.8

‘No News is Good News’ Strategies

  1. Physicians must only use a ‘no news is good news’ strategy for managing test results if they are confident that the test result management system in place is sufficiently robust to prevent test results from being missed and that no news really means good news.
  2. Physicians must use their professional judgment to determine when a ‘no news is good news’ strategy is appropriate in each instance and must consider the following factors in making this determination:
    1. the nature of the test that was ordered,
    2. the patient’s current health status,
    3. if the patient appears anxious or has expressed anxiety about the test, and
    4. the significance or implications of the potential result.
  3. Physicians must inform patients as to whether they are using a ‘no news is good news’ strategy and must tell patients that they have the option to personally contact the physician’s office or make an appointment to come into the office to hear their results.

Clinically Appropriate Action Following Receipt of Test Results

  1. When physicians receive a critical and/or clinically significant test result for a test that they have ordered, they must take clinically appropriate action. The timeliness of these actions will depend on the significance of the test result.  Physicians can take clinically appropriate actions personally or they can assign or delegate this task to others.9

Receiving Test Results in Error

  1. Physicians who receive a critical or clinically significant test result in error (e.g., same or similar name or contact information) must inform the laboratory or diagnostic facility of the error.

Communication and Collaboration with other Health-Care Providers

  1. Physicians in receipt of a test result must use their professional judgment to determine if it is necessary to share a patient’s test result with other relevant health-care providers whose ongoing care of the patient would benefit from that knowledge and, if sharing the test result, the timeliness with which to share it.10 The timeliness of the communication will depend on the degree to which the information may impact patient safety, including exposure to adverse clinical outcomes.
  2. Physicians whose role is to interpret and report test results (e.g., a radiologist, pathologist, laboratory medicine physician) must contact the health-care provider who ordered the test when there is an unusual, unexpected or urgent finding to ensure that this information is communicated quickly and that it does not go astray.11

Patient Engagement

  1. When ordering a test, physicians must inform patients of the significance of the test, the importance of getting the test done (in a timely manner, as appropriate), and the importance of complying with requisition form instructions.

Availability and Coverage

  1. Physicians must comply with the expectations relating to availability and coverage for test results as set out in the Availability and Coverage policy.
 

Endnotes

1. See the Advice to the Profession document for more information.

2. Tracking could include following-up with a laboratory and/or diagnostic facility, or the patient to find out where the test result is.

3. If the task does not include a controlled act, the physician would be assigning the task to the other person.

4. If a task includes performance of a controlled act, then the physician may delegate it to another person.  When delegating a controlled act, physicians must comply with the College’s Delegation of Controlled Acts policy. One of the controlled acts under the Regulated Health Professions Act, 1991 S.O. 1991, Chapter 18 (RHPA) is “communicating a diagnosis”.  Specifically, the wording in the RHPA states: “Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis”.  Please also see footnote 3.

5. Please see footnote 4.

6.  The Personal Health Information Privacy Act S.O. 2004, Chapter 3 Schedule A (PHIPA) sets out requirements with respect to collecting, using and disclosing a patient’s personal health information.

7. See the College’s Medical Records and the Confidentiality of Personal Health Information policies for more information.  The Confidentiality of Personal Health Information policy states that “the College advises physicians that messages left for patients on a voice mail that is not private or with a third party should not contain any personal health information of the patient, such as details about the patient’s medical condition, test results or other personal matters”.

8. Including those attempts made by staff on behalf of the physician.

9. Please see footnotes 3 and 4.

10. Under the PHIPA physicians can assume they have consent to share relevant test results with those in the patient’s circle of care unless consent to do so has been expressly withdrawn by the patient.

11. For example, a physician interpreting a prenatal ultrasound where there is a risk to the fetus would phone the referring health-care provider in addition to generating a written report.