6.0 Test Results Tracking & Follow-up (PCP)

Please be advised that some videos will contain both PCP and Specialist content.
Video Time: 8:20
  BACK TO LESSON LIST
  TAKE ASSESSMENT

Applicable to PCPs and specialists. Provider ordering the test is responsible for following up to clearly communicate information about test orders and test results to partner provider, or to patient when indicated. When specialist recommends tests for co-managed patient, ordering PCP is responsible for all follow-up and for clearly communicating test orders and test results to partner provider. 

6.1

Practice has test tracking process/procedure documented, which requires tracking and followupfor all tests and test results, with identified timeframes for notifying patients of results


PCP and Specialist Guidelines:

  1. Test tracking procedure must be in writing and identify all steps in process and timeframes

6.2

Systematic approach and identified timeframes are in place for ensuring patients receiveneeded tests and practice obtains results

PCP and Specialist Guidelines:

  1. Follow-up occurs with patients to ensure necessary tests are performed
  2. Communication processes are in place with testing entities as necessary, to ensure results are received
  3. Result are reviewed, signed, and dated by the physician and filed in the patient’s medical record

6.3

Process is in place for ensuring patient contact details are kept up to date

PCP and Specialist Guidelines:

  1. Patients are asked at every visit to confirm that address and phone numbers are current

6.4

Mechanism is in place for patients to obtain information about normal tests

PCP and Specialist Guidelines:

  1. Patients are informed about how to access normal test results
  2. Process may use any of the following mechanisms:
    1. Patient phone call to specific phone number at practice, with instructions to patient on when to call
    2. Phone call, text, or other secured messaging from practice to patient
    3. Mail from practice
    4. Direct conversation with patient
    5. Patient access via secure web portal (in conjunction with one of the above options for patients without internet access)
    6. Telling patients that “No new is good news” does not meet the intent of this capability. Patients must have clear understanding of how to obtain information about normal test results.

6.5

Systematic approach is used to inform patients about all abnormal test results

PCP and Specialist Guidelines:

  1. Systematic approach is in place to flag as high priority results where follow-up is essential and the risk of not following up is high, I.e., tissue biopsies, diagnostic mammograms, INR tests
  2. For high priority results, patient is contacted by phone (repeated attempts at different times of day, on different days if necessary; if necessary and acceptable to patient, email or patient portal may be used to request the patient call office; as a last resort, results may be sent by registered mail)
    1. For low priority results, such as minor lab abnormalities, contact may also be by letter
  3. Systematic approach is in place to ensure that practice is aware of and communicates to patients about all abnormal test results for all patients, in a timely manner, and that patient communication process is clear and patients understand implications of test results

6.6

Systematic approach is used to communicate with patients with abnormal results regarding receiving the recommended follow-up care within defined timeframes.

PCP and Specialist Guidelines:

  1. Patients requiring follow-up are flagged and follow-up timeframes are specified
    1. Provider makes at least 2 attempts to contact patient; for serious conditions, third attempt is made by certified mail Communication attempts are documented in patient’s medical record
  2. Cancelations and no-show appointments are tracked and assessed to determine whether any patients require follow-up
  3. Outcomes of follow-up action are filed in patient’s medical record.

6.7

Systematic approach is used to document all test tracking steps in the patient’s medical record

PCP and Specialist Guidelines:

  1. All phone calls, letters, and other communications with patient regarding testing and test results are documented in the patient’s medical record

6.8

All clinicians and appropriate office staff are trained to ensure adherence to the test-tracking procedures; all training is documented either in personnel file or in training logs or records

PCP and Specialist Guidelines:

  1. Practice unit or PO maintains record of training and can provide training content for review

6.9

Practice has Computerized Order Entry integrated with automated test tracking system

PCP and Specialist Guidelines:

  1. Test-tracking system has Computerized Order Entry system structured to log all test orders and is linked to automated tracking system that supports caregiver follow-up b. Test tracking system has the ability to electronically receive and track results

Practice uses a standardized tracking system to ensure needed tests are received, resultsare communicated in a timely manner, and follow-up care is received 

PGIP - Physician Group Incentive Program

An innovative incentive program through BCBSM that brings together physician organizations from across Michigan, to encourage information sharing about various aspects of health care. Program participants, including both primary care physicians and specialists, collaborate on initiatives designed to improve the health care system in the state.

PO - Physician Organization

An organization that partners with physicians or is a group of physicians that works with health plans on contracts and other mutual interests (i.e. incentive programs, transition programs, etc.) of their organization.

PHO - Physician Hospital Organization

An organization that partners with physicians and hospitals in order to obtain payer contracts and to further mutual interests (i.e. incentive programs, transition programs, etc.) within integrated delivery systems.

MPP - Physician Partners

An organization that is 50% owned by physicians and 50% owned by the Health System to negotiate payer contracts, assist with health plan enrollment, and provide guidance and support in mutual interests that promote evidence based care and overall well being of their customers "the patient".

SRD - Self Reporting Data

Twice a year (summer and winter) BCBSM requires PO/PHO to conduct assessments for PGIP participating offices which include review of office demographic information, office technology and PCMH initiative implantation within the office. This data is linked to PCMH nomination, PCMH designations and PGIP incentive monies.

PU - Practice Unit

The identification of a practice within the PGIP program.

PCMH Nomination

An office in PCMH nomination status is requesting review by BCBSM for PCMH Designation. An office can be nominated through their PGIP participating PO/PHO during the BCBSM Winter SRD submission.

Denominator

Total number of "current" patients in the practice.

Numerator

Total number of patients in the denominator with whom conversations have been held and partnerships established at any point in the past

4P or Pay for Performance

Claim payments based on quality and utilization scoring determined by the health plan. (Quality based payment structure)