Don't fail to follow up on findings: Avoid suits
If a chest X-ray ordered by a specialist has suspicious findings requiring follow-up, the patient's primary care physician might not even be aware that the test was ordered. Still, in the event a malpractice lawsuit is filed, the primary care doctor could be held accountable for following up, says Marlene Nazarey, RN, MSN, CPHRM, risk control director at Chicago-based CNA HealthPro, a provider of insurance coverage for the healthcare industry.
"The specialist who ordered it needs to ensure the primary care doctor is aware of the result," she adds.
If the patient becomes symptomatic and has a chest X-ray in the future, or the radiologist compares previous X-rays with the patient's current one, it would then be discovered that the patient had an abnormality on a previous film that wasn't addressed, Nazarey says. "Now the patient is symptomatic, and the disease may have progressed," she says. "This could result in a delay to diagnose or failure to diagnose claim if it's not acted on at the time of the initial test."
To ensure that incidental findings aren't overlooked, physicians need a follow-up system with these components, advises Nazarey:
1. When physicians order tests, they should have a system in place which notifies them that the results have not been received.
"Sometimes the lab or imaging center may have a problem, and the results are not provided to the physician," says Nazarey. The system, whether paper or electronic, needs to flag physicians so it will become obvious to them that they didn't get a result back from tests that they ordered.
2. The physician needs to review all the results that come back to the office.
"If a physician misses an abnormal result, and it is just filed away in the medical record, it could go unaddressed," Nazarey says. "The system needs to make sure that the physician acknowledges and acts on any reports that need intervention."
3. If the test results need to be sent to another medical provider, the system should send the ordering physician an acknowledgement that the other provider received the results.
Nazarey says that in certain situations, the physician might want to communicate written or verbally with the specialist, to clarify which provider is going to take care of which aspects of the patient's care.
"I've seen cases where one provider thought the other was following up on a certain need of the patient, and vice versa," she says.
4. The patient needs to be informed of the results.
"The patient needs to know what he or she needs to do. It may be that the patient needs to come back to the physician for further evaluation, or needs a repeat test done in a week or month," says Nazarey.
Sharing results is key
Mistakes are rarely made and incorrect actions are rarely taken when a physician has all of the information needed to make a decision, says Timothy J. Ward, senior vice president of Marsh USA in Greenville, SC.
"In our current age, with incredible technology in both diagnostic testing and information technology, it still comes down to having clear roles in how this information will be shared," he says.
Physicians cannot have tunnel vision when looking at diagnostic studies, and must confirm that significant incidental findings are properly communicated to the patient and their primary healthcare provider, emphasizes Ward.
"When information is not properly communicated, it can't be acted upon," he says. "This leads to problems for the patient and the physician." (See related story on the role of EMRs in ensuring follow-up, below.)
Sources
For more information on liability risks of failing to follow up on incidental findings, contact:
- Marlene Nazarey, RN, MSN, CPHRM, Risk Control Director, CNA HealthPro, Chicago. Phone: (424) 206-9840. Fax: (424) 206-9870. Email: [email protected].
- Dennis Olson, CPHRM, Vice President, Risk Management, Physicians Insurance, Seattle. Phone: (206) 343-6501. Email: [email protected].
- Timothy J. Ward, Senior Vice President, Marsh USA, Greenville, SC. Phone: (864) 240-4366. Email: [email protected].
EMRs can flag lack of follow-up on findings Keep in mind: There also are risks If a referring physician asks another physician to do a test to look for a fractured left clavicle, the testing physician might focus on the left clavicle and make his finding with just a cursory overview of the rest of the test field, says Dennis Olson, CPHRM, vice president of risk management for Physicians Insurance in Seattle. Therefore, the testing physician might overlook or fail to comment on the small shadow in the bottom left corner of the lung. "Subsequently, two years later there is a cancer diagnosis, and a retrospective look at the initial test shows the shadow, which now is clearly identified as early signs of the cancer," says Olson. "Thus, a missed diagnosis claim ensues." Could an electronic medical record (EMR) system prevent this lawsuit from happening? "Certainly, there are alerts or other functional capabilities within an EMR system that could be configured to provide a physician with a checklist to consider when reviewing a scan," says Olson. "The challenge is the alerts are only as good as the programming." EMR systems allow for reminders of needing to follow-up on incidental findings along with suggested additional treatment options, and they can allow for automatic routing to all of the appropriate parties, including physicians and patients, he says. "They can provide documentation of when and where actions were taken, to establish timelines, chronology, and move responsibilities and accountabilities," Olson says. EMRs can be overwhelming, however, so the simpler the alerts or checklists, the more likely they are to be considered by an end-user physician, says Olson. Elke Kirsten-Brauer, executive vice president and chief underwriting officer for MGIS Underwriting Managers, a business unit of the Salt Lake City, UT-based MGIS Companies, says that EMRs can help physicians to "become more clinically consistent" in looking at lab results or reports and following up on this information. "However, EMRs can also work against the physician or practice, in cases where the system acknowledges the information was relayed, but no intervention or action was documented," says Kirsten-Brauer. |
If a chest X-ray ordered by a specialist has suspicious findings requiring follow-up, the patient's primary care physician might not even be aware that the test was ordered.
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