Patient Self-Referrals
By Donna Knight, Princeton Insurance Healthcare Risk Consultant
and Amy Slufik, Princeton Insurance Physician Risk Representative

Printable Version of this Article

Tracking and follow-up of screening results following patient self-referred testing is a risk issue for physicians and imaging centers. Feedback from imaging centers and physician practices indicate that the following scenarios are all too familiar. 

•  The home address provided by the patient is incorrect and there is no primary / specialty physician (here-in referred to as “physician”) documented on the imaging center intake form to whom results should be sent.
•   The patient provides a physician name on the intake form and the physician receives a copy of the test result; however, the physician may not have seen the patient in years.  

In this article we address the potential patient safety, quality of care and liability issues associated with follow-up of patient self-referred imaging results.

With a national focus on disease prevention, there are several screening techniques for which patients may self-refer at imaging centers. Examples include the full-body health scan, a comprehensive series of CT scans that can detect certain abnormalities of the lungs and organs of the abdomen and pelvis, and the coronary heart scan screens for coronary atherosclerosis. In addition, the Mammography Quality Standards Reauthorization Act of 1998 allows women over the age of 40 to self-refer for a screening mammography without the need for a physician referral and/or prescription.

A major risk issue in the utilization of self-referred screenings is the public’s lack of perception of the limitations of the techniques in providing a comprehensive assessment of a patient’s risk for major diseases. For example, standards of care recognize that a mammography used alone may be inappropriate for breast cancer screening. Breast self-exams, breast examinations by a clinician, patient/family history and other imaging techniques are needed to provide a clearer picture of a patient’s individual risks. The question then is who is responsible for follow-up to assure a comprehensive assessment of the patient’s risk -- the radiologist or the patient’s physician? The answer is both.  

Radiologist’s Considerations

When a radiologist provides a service to a self-referred patient, they establish a physician-patient relationship. Once the relationship has been established, the radiologist is responsible for communicating the results directly to the patient and informing the patient’s physician. 

To ensure proper care and follow-up, the radiologist should obtain the current address, phone number, name of the physician to whom the patient would like the report sent and the date the last time the patient was seen by that physician. This information should be updated at every visit. In addition, an informed decision-making and consent discussion should be held with the patient, making sure the patient understands the test, stressing the limitations, risks, benefits, and uncertainties of the procedure, including the uncertain clinical benefits and potential hazards of indiscriminate testing of low-risk patients, screenings without appropriate pretest clinical evaluations, irradiation against lifetime allowance and false positives. At the time of the procedure, patients should also be informed that they will receive the results directly and a copy will be forwarded to their designated physician. It is important to stress to the patient that if they do not receive the results, they should contact the imaging center. The informed decision-making process described above should be documented in the patient’s medical record.

Once the procedure has been completed, the imaging report should then be forwarded to the identified physician for follow-up. A report in lay terms should be sent directly to the patient. When clinically indicated (positive results, strong suspicion or change since last screening), the physician and patient should also be contacted as soon as possible via telephone and sent the information by certified mail.