Risk Management:
Patient Self-Referrals
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If the patient does not have a physician to refer the results to, the official report as well as the simplified report should be sent directly to the patient. The radiologist could be viewed as the physician of record for patients who do not have a physician to refer results to and would have a responsibility to follow-up with the patient. Although radiologists may elect to give self-referred patients a list of physicians in the area to contact, there is no guarantee that patients will follow-up. The radiologist should stress to the patient the need for further consultation with a physician, if necessary, and follow-up with the patient and/or physician 3-4 weeks later to ensure compliance with follow-up care. The patient’s record and/or tracking logs should document this process.
Though it is permitted in the state of New Jersey to accept self-referred patients, with the exception of mammography, it is not required. Radiologists may want to consider requiring patients to have and provide proof of a physical examination and/or pretest clinical evaluation prior to any scans, screens, or ultrasounds, to aid in diagnostic imaging interpretation and to enhance continuum of care. This will ensure that there is a physician that can be made aware of the procedure results and may limit the radiologist’s liability for follow-up care.
Primary/Specialist Considerations
The physician, once the report is received, should call the patient and send a letter, along with a copy of the report, to the patient. The letter should indicate the importance of a comprehensive assessment, including a physical examination (i.e. breast exam) and clinical evaluation, as well as a review of the results, especially if an abnormality is discovered. It should also stress the need for proper follow-up care, if necessary, including the need to call the office to make a follow-up appointment to further discuss the results. If the patient does not respond within an allotted time frame given the result of the test, a certified letter should then be sent. A physician who receives results will need to follow through on the findings, including making appropriate referrals for the patient, managing and monitoring care. It is essential that the physician document in the medical record any discussions with the patient, the radiologist and other specialists.
Additional Risk Considerations
The issue often arises that patients do not return phone calls and/or accept regular or certified mail. What is reasonable in terms of follow-up on patients that do not respond? Claims experience indicates that a consistent follow-up process and supporting documentation are key elements in the defense of a claim. The documentation, rather than a specific number of times communication is made - although, more than one attempt should be made - provides supporting evidence that reasonable efforts were made to communicate with the patient. Both radiologists and physicians should document in the medical record every telephone communication, made to, and received from, patients, including the date, time, caller’s name, and information given/discussed. Copies of all regular and certified letters, including attachments and corresponding receipts, should be placed in the patient’s medical record as well. Radiologists and physicians should also consider establishing a policy and procedure for their office practice staff to adhere to with regards to tracking and follow up of test results to ensure there is a consistent process.
Summary
Communication, follow-up, and documentation are essential elements in order to provide safe, quality patient care and minimize liability for the radiologist and physician, especially with regards to self-referrals. The informed decision-making and consent discussion between radiologists and self-referred patients are also important to ensure the patient understands what a comprehensive assessment entails and the need for accurate information to assist with follow-up care and compliance. Princeton’s Physician Office Practice Tool Kit, which is available to our insureds, contains guidelines and sample forms for “Tracking Test Results, Consultative Referrals, and Follow-Up” and “Informed Consent.” The guidelines and forms are applicable to the physician office and imaging center settings.
This article is not intended as legal advice. Readers should consult professional counsel, who is familiar with federal and state laws, for guidance with specific legal, clinical or ethical questions.
Resources
Study Identifies Trends in Self-Referred Imaging. Radiology. 2003. July 29. Available at www2.rsna.org/pr/target.cfm?ID=142. Accessed March 21, 2007.
ACR Practice Guideline for Communication of Diagnostic Imaging Findings American College of Radiology Practice Guideline. Pages 3-7.
ACR Practice Guideline for the Performance of Screening Mammography. American College of Radiology Practice Guideline. Pages 393-404.
Standard: Performance of Screening Mammography. Maine Board of Licensure in Medicine. Medical Board Rules. Available at www.docboard.org/me/rules/allch092.htm. Accessed March 16, 2007.
Fenton, MD, Joshua J. and Deyo, MD, MPH, Richard A. Patient Self-Referral for Radiologic Screening Tests: Clinical and Ethical Concerns. Journal American Board Family Practice. 2003. November-December. Vol. 16 No. 6. Pages 494-501.
