Download Hospital test results ok? (PDF 57Kb)
Just before Christmas I received an interesting email from Dr Peter Vujcich, a GP working in Kaikohe and as a GP Liaison Officer for the local DHB. He sought advice on the responsibility of GPs who receive copies of their patients' hospital-ordered test results. Dr Vujcich's query raised interesting issues about patient management, the wise use of resources, and the risk of medico-legal liability. I thought our correspondence deserved a wider audience.
Current situation
At present, GPs in the area do not have direct access to blood or radiological tests performed on their patients in hospital. A survey of local GPs indicated that 73% supported receiving the results of all hospital investigations performed on their patients. There were seen to be clear benefits for GPs receiving this information - including improved quality and safety of patient care, and reduction in public and private resource "wastage". However, some of the surveyed GPs were concerned about increased workload and potential liability in cases when notified of abnormal hospital-ordered test results; specifically, that the GP will end up being held accountable if the relevant hospital clinician does not take the appropriate action in response to the abnormal results.
Dr Vujcich asked whether there was a way to "mitigate unintended GP responsibility" if an abnormal test result is not followed up by hospital clinicians. He was concerned that despite the benefits to patient care, GPs would prefer not to receive such test results if they then bear responsibility for following up abnormal results. Such responsibility would be unduly onerous, leading to a significant increase in GP workloads.
Information flows
I thought that Dr Vujcich made a compelling case for the benefits of GPs receiving copies of the results of hospital-ordered tests performed on their patients. Indeed, it is arguable that this should already occur. After all, hospitals and their medical staff are subject to the duty in Right 4(5) of the Code of Health and Disability Services Consumers' Rights (the Code) to co-operate with other providers (eg, the patient's GP) "to ensure quality and continuity of services". Such information will help GPs provide care consistent with their patients' needs and assist with ongoing management.
With the increasing emphasis on good quality care in general practice, there is a strong case for better information flows from secondary to primary care. Most GPs would surely welcome the receipt of relevant laboratory and radiology advice from DHBs when their patients are transferred back to primary care. In the current environment, time in hospital is often short. Patients are generally discharged once acute illness has been controlled, with further follow-up through outpatient services and primary care.
Where does the buck stop?
But it is natural for GPs to worry about where the buck stops for following up results of tests ordered in hospital. The starting position is that primary responsibility for following up abnormal test results lies with the clinician who ordered the test. That clinician should ensure appropriate management of the apparent abnormality is in place.
The hard issue is whether there is any residual responsibility on the GP to check whether the hospital test result has been followed up. General practitioners, like all health professionals, owe their patients a duty to provide services with "reasonable care and skill" (Right 4(1) of the Code). That duty is qualified to the extent that a GP is only expected to take "reasonable actions in the circumstances" (clause 3(1) of the Code). Relevant circumstances include the provider's resource constraints.
In practical terms, as recognised by the GPs surveyed, it would simply not be possible for a GP to follow up all abnormalities reported on their patients' hospital-ordered tests. Quite apart from the GP's heavy workload, it will often be difficult even to find out who the ordering clinician was, and what has been done. In these situations, the clause 3 defence is likely to operate.
However, there may be some cases where a GP exercising reasonable care and skill (as measured by the established legal test of what a "responsible body of medical opinion" would recognise as acceptable practice) would not simply turn a blind eye to a significantly abnormal test result, on the basis that sole responsibility lies with the ordering clinician. In such cases, I consider that good medical practice dictates some action by the GP.
A rule of thumb
If I had to come up with some language to describe the residual responsibility of the GP, I would suggest the following rule of thumb:
"Although the primary responsibility for following up abnormal results of tests ordered in hospital lies with the clinician who ordered the test, if the abnormal results are reported to the patient's GP, the GP has a residual responsibility to check whether any significant abnormality that clearly needs follow-up has been followed up."
In practice, this duty could be fulfilled by the GP's practice nurse calling the patient and asking them to check with the hospital that the abnormality has been followed up, or by the GP calling the hospital clinician directly. The important point is that the GP is not assuming clinical management of the problem, but is acting as an extra safety net to check that a significant abnormality is being followed up. This is consistent with what most GPs would regard as good medical practice, and with patients' expectation of their GP.
Case examples
A recent case provided an example of a situation where a GP might be expected to follow up test results from a hospital. The patient had been admitted to hospital with back pain and during his admission had been X-rayed. The chest X-ray showed a shadow on his right lung. The registrar requested a repeat of the X-ray, but this was not done. The X-ray was not mentioned in the discharge documentation or reported until some time later. The radiology report (which confirmed that the shadow appeared to be a central carcinoma) was not sent to the patient or his GP. In my view, if the report had been sent to the GP, it would be reasonable to expect him or her to check with the patient that the hospital had followed up the abnormal finding, or to follow up with the hospital directly (see below).
In contrast, I would not expect a GP to follow up where a test is of little importance, eg mildly elevated creatinine in a test ordered by a renal clinic. There will of course be complex clinical situations that are less clear. A counsel of perfection is not called for, but the GP does need to pause and consider the potential significance of the result - is this a significant abnormality that clearly needs follow-up?
How to follow up?
Assuming that some follow-up does seem necessary, what should you do? Simply contacting the hospital test requester might seem the obvious step, however it may be better to identify and communicate with the clinician responsible for the patient's care. In some hospitals this can prove a daunting task. Other actions, such as contacting the patient to verify follow-up or to discuss options may be sensible - perhaps even taking over the care and investigations yourself. Obviously it also good practice to record what you have done.
It is significant that to my knowledge this situation, which must arise in practice, has never led to a complaint or ruling from HDC. If a complaint was received I would seek independent general practice advice about what peers would consider appropriate action from a GP in such circumstances. My primary focus would be on why the hospital-ordered test results were not reported and followed up from the hospital end. There is every reason for GPs to be pushing for better information on their patients from secondary care, to improve continuity of patient care and save unnecessary wastage of resources. GPs who focus on good care for their patients (rather than worrying about medico-legal risk) have nothing to fear from hospital-ordered test results.
Ron Paterson
Health and Disability Commissioner
New Zealand Doctor, 13 February 2008