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Total recall

7-Mar-2008

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It is essential that practices have a robust system in place to follow up test results. By Sophie McNamara THE GP removed a pigmented lesion and told the patient to return to have his sutures removed. But the patient didn’t return to the surgery and the GP never saw the biopsy result revealing melanoma. The result finally came to light two years later when the patient re-presented — with metastatic disease.

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Dr Sara Bird, medicolegal claims manager at MDA National, handled this case, which was settled out of court for a substantial sum.

Earn CPD Points The case shows that simply telling patients to return for their results is medicolegally not good enough, she says. Education Classifieds Subscriptions > Competitions

While doctors should encourage patients to take responsibility for their health and to follow up their test results, ultimately the legal onus is on doctors to review all test results and recall patients as required, Dr Bird says.

Clinical > Patient > Organisations > Government > Careers

“The most important strategy is for the patient to come back and get their results, but you do need more strategies because that on its own can fail,” she says. “The patient does have some responsibility to follow up test results. But that doesn’t absolve GPs’ legal responsibility — that if they order a test they have to follow it up.” Practice management consultant Mr David Dahm advises GPs to take an unconventional approach to ensuring patients follow up their results — warn them they will be charged a $5 fee if they don’t respond to the first recall notice. “It sometimes gets the patient a bit annoyed, but you can always waive it, and it does mean that they’ll pick up the phone and ring you,” says Mr Dahm, who is CEO of practice management company Health & Life. The $5 is recouped when the patient next attends the practice and Mr Dahm says it helps cover the cost of phoning patients or sending recall letters. “It sounds initially a bit draconian, but you need to be aware of patients who don’t respond, because they’re probably your biggest legal liability.” Medical defence organisations agree that recall systems, particularly for following up abnormal test results, are a key area of medicolegal risk for GPs (see first box below). They say either a computerised or paper-based recall system is fine, as long as it is robust. Dr Bird says GPs need a system to keep track of any tests or investigations they have ordered to ensure that all the results return to the practice. To ensure no results slip through the cracks, the RACGP accreditation standard says practices could simply keep a log book of high-risk cases to follow up. GPs in computerised practices can receive and review all pathology reports electronically and trigger a recall in the software package as required. They can also put a recall notice into the patient’s records to remind them to follow up tests or critical specialist referrals (see first box below). Medical Director can generate a list of all investigations that have been ordered, but this needs to be checked manually to ensure results have returned. Dr Lynton Hudson, chairman of the RACGP national expert committee on standards, says computerised recall systems are preferable to paper-based ones. However, the computer systems are not perfect and he hopes to discuss improvements with software manufacturers, such as the ability for software to automatically track test requests that have not yielded results. Experts are divided about whether a phone call or a letter is the better method of contact when practices decide they do need to recall a patient. However, in most cases a combination of both may be required. Experts agree that any attempted contact should be documented in the patient’s medical records, including copies of letters. Dr Paul Nisselle, general manager clinical risk management at Avant, recommends writing a letter and enclosing the test results. “The ultimate communication with the patient, in order to completely remove

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your liability, is to write, ‘This is the test result, this is what it means, this is what I recommend, and this is what could be the consequence if you don’t follow my recommendation’,” Dr Nisselle says. “If the patient ignores that advice, then that in effect becomes informed refusal.” Dr Bird says a phone call can be useful because it allows for dialogue that ensures the patient understands the consequences of the result. She says it is often prudent to follow the call with a letter, especially in cases of informed refusal. Ms Liz Fitzgerald, clinical risk manager at MIGA, advises GPs to be careful of leaving voicemail messages about test results or recalls due to confidentiality concerns. While practice management staff commonly make the phone calls, post the letters and monitor the recall systems, ultimately the doctor who orders the test is likely to be responsible for following it up. Ms Fitzgerald says practices should have their recall and reminder policy documented so staff are clear about their roles, and practice staff should not give patients results over the phone. “It’s a huge area of risk —wrong patient, wrong results, misinterpreted results. It is the doctor’s responsibility at the end of the day,” she says. There is nothing set in stone about how far GPs should go to recall difficult-tocontact patients. The RACGP standard says while all test results need to be reviewed, only clinically significant results need to be followed up. It says some situations may warrant up to three phone calls — at different times of the day — followed by a letter. Dr Bird says the courts would look at whether a doctor has made a “reasonable” effort to contact patients in the circumstances. If a test showed, for example, a normal cholesterol level, there would be no need to recall the patient. If a test showed elevated cholesterol, one letter to the patient may suffice. However, if a test revealed something serious, such as a melanoma, and the patient had not returned, the GP should take definite steps such as making several phone calls and sending a letter by registered mail. “I would hope the GP would be contacting their medical defence organisation to discuss some strategies if they still couldn’t contact the patient,” Dr Bird says. Dr Nisselle says if mail is returned and the phone is disconnected, all the GP can do is document that they took reasonable steps to contact the patient. RECALL SYSTEMS IN ACTION THE 2007 RACGP general practice of the year, Longford Medical Services, near Launceston in Tasmania, uses a fully computerised recall and reminder system. GP Dr Fiona Joske, one of the practice principals, says the seven GPs at the practice receive and review all test results electronically. If the result is abnormal, the GP marks an action in Medical Director, such as ‘see patient again’. Practice staff monitor each action until it is completed. A staff member goes through each test ordered and crosses it off when results return. Each month the GPs receive a list of investigations that haven’t yielded results and decide how to follow up each case. Dr Joske keeps track of critical specialist referrals or investigations by using the ‘recall’ option in the ‘clinical’menu in the patient files in Medical Director. The practice also uses this recall option to send out reminders for preventive checks. Practice staff also carry out data searches in Medical Director to identify particular patients for reminders. For instance, when the Gardasil vaccine became available, the staff sent a notice to all their female patients in the correct age group. ISSUES OF CONSENT THERE are no consent issues related to recalling patients about test results. However, practices do need consent from patients to include them on reminder lists for screening tests such as Pap smears or mammograms. Dr Sara Bird, of MDA National, says she recently heard of a case where a Pap smear reminder was mistakenly sent to a patient who did not want her parents to know she was having Pap smears. While the patient had told the practice she wanted to opt out of the reminder system, the practice nurse did not notice this note in the patient’s records. “Because of the cultural issues in the family, it caused this enormous fracas and a lot of upset,” Dr Bird says. Practices do not have a duty to send reminders to patients. It is simply a service, as well as a sound business decision, that practices can offer. However, Avant’s Dr Paul Nisselle says once practices decide to start issuing reminders they have a responsibility to ensure their system is working properly. “A patient is entitled to rely on that undertaking of, ‘I will contact you’.” BENCHMARK CASE ON FOLLOW-UP

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IT is 10 years since the benchmark court case that clearly set the ground rules about doctors’ responsibility to follow up test results. Dr Peter Malycha, a surgeon in SA, did a biopsy of an armpit lump in patient Mrs Jayne Kite and sent it to pathology. He told the patient to ring for the results. She never did and also missed a follow-up appointment. The pathology report showing that the lump was cancerous was returned to Dr Malycha’s surgery but he did not see it or chase it up. The SA Supreme Court found Dr Malycha had a duty to inform himself of the result and to offer appropriate treatment. The court found Mrs Kite had not contributed to the negligence. The judge said that “the simplest of systems”, such as a running sheet of investigation requests, would have been sufficient for Dr Malycha to be alerted to the abnormal result. “It is unreasonable for a professional medical specialist to base his whole follow-up system, which can mean the difference between death or cure, on the patient taking the next step,” the judge said. “Mrs Kite was entitled to assume that if the cytology report was adverse, she would be told about it.”

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Australian Doctor - Total Recall 7.03.2008