business of Medicine

toolkit

Onboarding Practice Managers Toolkit

Appointment scheduling/tracking and follow up

Missed, re-scheduled, and cancelled appointments

The patient’s failure to keep an appointment does not relieve the physician of his/her obligation to notify the patient of the need for follow-up care, abnormal findings or the consequences of failing to obtain care. Physicians should make a reasonable effort to contact the patient who missed a scheduled appointment or test. If the patient cancels the appointment, every effort should be made to reschedule the appointment as soon as possible. All follow-up attempts to contact the patient, and the patient’s stated reasons for missing appointments, should be carefully documented in the medical record.

Although it is reasonable for providers to expect a patient to share in the responsibility for their own care, juries nationwide have placed a significant amount of responsibility for follow up on the provider. It is prudent to document a patient’s failure to follow treatment advice, or keep appointments. If the patient’s failure to follow a mutually agreed upon treatment plan contributes to an injury which in turn results in a malpractice suit, it can usually be introduced as evidence in the doctor's defense. Documentation of patient failed appointments can provide a powerful defense to any lawsuit.

A reliable clinical tracking system is important to identify patients who fail to keep scheduled appointments for tests and consultations with specialists. Whenever possible, schedule referrals and follow-up appointments before patients leave the office. Failure to maintain a reliable clinical tracking system is one of the most frequently cited problems in medical malpractice cases where there is an allegation of delay in diagnosis and/or failure to supervise care.

Maintaining an effective clinical tracking system in your medical office the framework for safe and high quality patient care

Communication among the health care team and coordination of care is critical to improving patient outcomes and reducing professional liability claims.  Whether the practice utilizes an electronic medical record (EMR) or a manual system, reliable follow-up systems are an important factor in providing quality healthcare. Although providers should not be held responsible for the actions taken or not taken by patients, it is reasonable to expect the health care team to advise them of necessary tests, educate them about the risks and benefits of recommended treatments, keep them informed of the results, and provide follow-up as indicated.  This process of reconciliation and follow up is often called “clinical tracking” as it involves “tracking” or following patients throughout the process.

A reliable system of reconciling test results and coordinating care with other health care providers involved in the patient’s care is a fundamental responsibility. When these processes fail, the risk of an adverse outcome is significantly increased.  Even a simple process failure can have significant impact. 

Almost one quarter of medical liability claims originate from a medical office setting. In some medical specialties, such as general and family practice, almost 56% of the claims originate from care provided in the medical office[1].

From 2009 to 2013, among all the healthcare specialties combined, “improper performance” topped the list. This often involves issues pertaining to coordination of care. When a claim was filed, 30% resulted in a payment to the plaintiff. The average amount paid was $316,519.[2] Errors in diagnosis and failure or delay in consultation or referral are among the top reasons for medical liability claims.[3]

Although medical liability is an important issue, the most important reason to implement an effective clinical tracking system is to provide safer care to your patients.

Closed Claims Review

Consider how ineffective systems in a medical office affected the care of this patient. This closed claim involves the death of a middle-aged man four days after a visit to his primary care physician (PCP) due to undiagnosed and untreated diabetic ketoacidosis.

Case:

This 64 year old male complained to his PCP of nausea and vomiting, fatigue, sore throat, flu-like symptoms, increased thirst, and discomfort in his chest. The patient had no pre-existing health problems, no history of alcohol or cigarette abuse, and his BMI was normal. However, his last visit to his PCP was four years prior to this one.

His in-office blood sugar was 295. The PCP ordered an in-office urinalysis, but it was apparently not processed. The PCP made a diagnosis of diabetes mellitus. While in the office, the patient was given two insulin injections, and a prescription for Metformin 500 mg once a day. He was advised to return to the office in a week. Of note, it was later discovered the office glucometer had not been correctly used and may not been correctly calibrated.

The next day, the outside lab contacted the PCP’s office to report critical lab values: glucose 850, and potassium 7.9, and abnormal renal function labs (results unknown). The information was entered into the office’s laboratory system, and a task sent to the PCP’s medical assistant (MA). The office protocol was for the MA to promptly discuss all critical laboratory findings with the PCP, but this was not done.

Four days after his visit to the PCP, the patient was found dead at home. Unfortunately, the MA did not notify the PCP of the critical lab values until the day after the patient died.

Allegations:

The PCP failed to respond appropriately to signs of impending diabetic ketoacidosis, and to respond to critical laboratory results in a timely manner.

Disposition:

The case was settled for a very large amount of money.

Risk Management Commentary:

This PCP seems to have operated on the assumption that his MA would notify him of critical laboratory results. Relying solely on his staff to follow through and communicate with him had a bad outcome. We were unable to find any expert support for this PCP’s care.

  [1] Physician Insurers Association of America. Data Sharing Project. Rockville, MD,  2015.

[2] Physician Insurers Association of America, 2015.

[3] ibid

Reconciling test results

Communication among the healthcare team and coordination of care is critical to improving patient outcomes and reducing professional liability claims. Whether the practice utilizes an electronic medical record or a manual system, reliable follow-up systems are important for providing safe care. While providers should not be held responsible for the actions taken or not taken by patients, it is reasonable to expect the healthcare team to advise patients of necessary tests, educate them about the risks and benefits of recommended treatments, keep them informed of the results, and provide follow-up as indicated. Documentation of the process is necessary to demonstrate that the patient was informed.

This involves maintaining reliable processes to follow-up with patients who are undergoing screening or diagnostic testing, as well as those who are referred to other providers for further evaluation and treatment.

Providers are encouraged to design reliable processes that recognize and address opportunities for system failures. In doing so, the practice will be better equipped to improve patient safety and reduce the risk of a professional liability claim. A well-designed tracking system includes:

  • a patient follow-up process
  • a test tracking management system
  • a referral management system
  • a mechanism for documenting informed agreement and/or refusal

A test results management system identifies all essential screening and diagnostic tests ordered and performed (within or outside the office.) Tests performed outside the office tend to be the most problematic to track.

Essential tests include the following:

  • all tests ordered during the work-up of a critical or acute problem.
  • tests ordered where subsequent follow-up is essential, and the risk for not following-up is high.
  • tests ordered to monitor medication levels with known adverse effects such as INR levels for patients on anticoagulation therapy. Other examples include diuretics, cholesterol-lowering drugs and certain antibiotics.
  • tests ordered in which the specimen (blood, pathology, etc.) is obtained in the office but sent elsewhere for testing.

Components of a well-designed test management system include:

  • a process where the patient is involved in the identification process prior to any specimen collection and using two forms of patient identification, excluding the room number.
  • a process for tracking pending lab results that ensures their receipt by the practice as well as a method for identifying test results that are not received.
  • a mechanism to ensure that test results are reviewed and acknowledged by the provider.
  • a process for patient notification of test results and for such notification being documented in the medical record.
  • a process that ensures follow-up of any additional testing/monitoring required/needed.

Maintaining a reliable and effective clinical tracking system requires teamwork and an ongoing willingness to monitor performance and process issues. Because of its significance in reducing the risk of adverse patient outcomes and professional liability risks, practices are advised to routinely evaluate the effectiveness of its systems, identify potential system failures, and address any opportunities for improvement. Maintaining an effective clinical tracking system is the most labor intensive processes within a medical office, yet one that can most effectively ensure quality patient care.

Referrals and consultations

There will be times when some patient’s clinical problems may be beyond a physician’s expertise or specialty, and the use of a consultant is warranted. Below are listed some of the most common situations when a consultation is needed.

  • It is advisable for a physician to obtain a consult when he/she is uncertain about the diagnosis or treatment, especially when the patient’s problem is outside of the physician’s specialty or when the patient’s particular condition is ordinarily treated by another specialty or subspecialty.
  • If an adverse outcome is anticipated, seek the advice of a second physician.
  • If the patient or family requests a second opinion, get a consultation.
  • Use a consultant if an alternative or combined therapy involving another specialty can be considered.
  • When the handling of a case is questioned, obtain a consultation.
  • Obtain a consultation when the patient does not respond to treatment as expected.

After a physician decides a consultation is needed, it is suggested that the physician take certain measures to ensure communication between the providers. The following guidelines are recommended:

  • Document the reason for the consultation in the patient’s chart.
  • Explain to the patient the need for and purpose of the consultation.
  • Communicate orally with the consultant, especially in serious and urgent cases.
  • Provide the consultant with a complete history and records of the case along with an opinion.
  • Document the rationale for the treatment if it is different from the consultant’s recommendations.
  • Ensure there is a clear understanding among the patient, primary physician and consulting physician, as to who is responsible for the patient’s continued care.
  • Track to make sure the patient keeps the consultative visit.

The consultant also has communication responsibilities to the patient and physician. These responsibilities are listed below.

  • Inform the responsible physician and the patient of complications that might arise from procedures the consultant carries out.
  • Communicate the findings and recommendations to the referring physician and patient in a timely manner.
  • Provide a complete copy of the consultant’s report to the referring physician.
  • Notify the referring physician if a patient does not keep an appointment with you, the consultant. If a referring physician doesn’t receive correspondence from the consultant within a designated time frame, he/she should check with the patient first to determine patient compliance. Document the conversation with the patient, and proceed according to your office policy or system protocols. Usually, Risk Management recommends up to three separate reminders per patient in high risk situations and/or when providers are in diagnostic pursuit.

MagMutual Risk Management and Patient Safety Consultants invite our policyholders’ questions. If you wish to discuss issues related to this article, or have other questions please call us at 1-800-282-4882, and ask for Risk Management.

Recommended Reading: NCQA Patient-Centered Medical Home NCQA Standards Workshop 2011, PMCH 5B Referral Tracking and Follow-Up. pp. 20-23 Accessed 8/20/2012

The importance of patient follow-up

Doctors are busy. They don’t have time to chase after patients and ensure they are taking their medications, getting the prescribed tests, and proceeding with the discussed treatment plan. With no show rates falling anywhere between 5 and 55 percent[1], doctors are struggling to get their patients in for appointments. When it comes to patient adherence and follow-up, who is responsible?

According to an article in the American Medical News, medical liability experts believe missed appointments and failures to follow up are a great legal risk for physicians[2]. While experts work on systems to make follow-up more streamlined, we wanted to provide some actionable advice you could implement now.

  1. Make reminder calls – Patients are busy too, sometimes they need to be reminded about an appointment they made a few weeks back.
  2. Reduce wait times – This isn’t always an easy one. We understand that doctors need to spend as much time as necessary with a patient to get to a diagnosis and develop a treatment plan. But reduced wait times, often leave a better impression on the patients mind, making it more likely they will return for follow-up appointments
  3. Create a welcoming reception area – This may sound superficial, but if a patient has to spend more than 5 minutes waiting for their appointment to begin, it’s better they do so in an aesthetically pleasing environment. Again, this helps leave a better impression on the patient, making it more likely they will return.

Though the aforementioned tips may increase the likelihood that a patient will keep their appointment and come in for their follow-up, they won’t help in the event that patient doesn’t show. While there may not be an absolute solution for eliminating your liability risk in regards to patient follow-up there are a few things that are important to keep in mind.

  1. Documentation – Keeping thorough documentation of your emphasis on the importance of a follow-up test, or prescription and the patient’s understanding of that importance is something all experts agree can help protect physicians.
  2. Reasonable attempts to contact – If a patient misses an appointment or skips a recommended test, even if the doctor has documented the importance of said test or appointment, the doctor is not relieved of legal implications. You must make an effort to contact the patient and reschedule or reinforce the importance of the required test. Be sure to document each attempt to contact the patient and any explanation the patient may give.

With few hours in the day, many appointments scheduled, and numerous patients to see, the patient follow-ups may slip through the cracks. It’s important, however, to develop a system that works for you and your organization to ensure that they don’t. You can’t make a patient proceed with a treatment plan, follow up with tests, or take prescribed medication, but you should attempt to contact and thoroughly document those attempts in the interest of your patient and yourself.

Further Reading

Saboo, Alok. 2015, January 8. Best practices for improving care with patient follow-up. http://www.fiercehealthcare.com/node/124161/print

Lerner, M.D., Barron H. 2014, November 2. When Patients Don’t Follow Up. http://well.blogs.nytimes.com/2014/11/13/when-patients-dont-follow-up/?_r=0

Gallegos, Alicia. 2013, July 15. Medical Liability: Missed follow-ups a potent trigger of lawsuits. http://www.amednews.com/article/20130715/profession/130719980/2/

 

 [1] Lerner, M.D., Barron H. 2014, November 2. When Patients Don’t Follow Up. http://well.blogs.nytimes.com/2014/11/13/when-patients-dont-follow-up/?_r=0

[2] Gallegos, Alicia. 2013, July 15. Medical Liability: Missed follow-ups a potent trigger of lawsuits. http://www.amednews.com/article/20130715/profession/130719980/2/

Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.