Criterion GP2.2 – Follow-up systems

Why this is important

The information gained from tests can affect the choices that a patient, the GP, and other clinicians make about the patient’s care. Clinically significant results need to be communicated quickly and appropriately so appropriate action can be taken, which can reduce the likelihood of an adverse patient outcome.

It is best practice to inform patients of clinically significant results in person, so the patient can ask questions and receive advice from the GP. When an in-person consultation is not possible, consider whether the use of telehealth platforms is appropriate to convey this information.

Using recalls and reminders to proactively contact patients about their care means that patients will be more likely to, for example, come back to the practice to discuss a test result or undergo a preventive activity, such as cancer screening. Failure to recall a patient may result in an adverse outcome and the responsible practitioner may face medico-legal action.

Meeting this Criterion

Timely review and action on tests and results

After a GP has advised a patient of tests or other required action and the consequences of inaction/refusal, and the patient has understood this advice, it is the patient’s decision whether or not to follow the GP’s recommendations.⁹ Some patients do not follow recommendations for a variety of reasons, which might include their particular circumstances, financial difficulties, fear, ignorance, personality traits, expectations, beliefs or cultural background.

GPs are obligated to ensure that results from all tests they have ordered are recorded and appropriately followed up with their patients.¹⁰

GPs need to review results and reports and take appropriate action in a timely manner. The speed with which GPs act on results or reports and the effort taken to contact the patient to discuss the results will depend on the:

• practitioner’s judgement of the clinical significance of the result or report
• context and duration of the clinical relationship.

Responsibility for follow up of non-GP-initiated tests

Clear systems and protocols for follow-up of tests and results are critical, especially given the increasing use of electronic communication and the potential for multiple healthcare professionals to be involved in a patient’s care. It is useful for GPs to have a complete record of all medical tests performed on a patient, and for this to be recorded in the patient’s health record. The RACGP encourages health professionals to work collaboratively when a patient needs tests, and for health professionals outside of the practice to inform the patient’s GP of tests they perform.

Responsibility for responding to test results can be complicated when tests are ordered by other health professionals outside of the practice¹¹ and the patient’s GP receives a copy of the results. Responsibility for the timely review and action on tests and results ultimately rests with the health professional who ordered the test, unless they have made a prior agreement with the GP. This includes pathology and diagnostic test results ordered by a specialist or other health professional that are sent back to the GP.

There may be situations where it is unclear whether the follow-up of results has actually occurred or who is responsible for the follow-up.¹¹ In addition, lines of clinical responsibility can become blurred when test results are automatically sent or ‘pushed’ to general practices on an automated feed. Once the GP sees the results, they may assume some clinical responsibility to act, particularly if they are unsure if the ordering clinician has acted on the results.¹²

It is good practice for a GP to assume that clinically significant test results ordered by others may not have been appropriately acted on. Ideally, the GP could contact the person who ordered the test and find out whether they recommend any follow-up,^11,12 and/or suggest to the patient that they follow-up themselves.

Sometimes it may be to the patient’s benefit if their regular GP acts on test results that have been initiated by another health professional. Clear lines of communication between the practice and external health professionals are essential when participating in collaborative care of a patient.

Clinical significance of results

The clinical significance of a result must be considered in the context of the patient’s history and presenting healthcare issues.

‘Clinically significant’ does not necessarily mean only ‘abnormal’ results. The GP makes a judgement as to whether information is or is not clinically important for a particular patient in the context of that patient’s healthcare. While a GP will generally decide that an abnormal result is clinically important and requires further action, they may also decide that a normal result requires further action. For example, a normal mammogram in a woman with a breast lump or a normal electrocardiogram in a patient with chest pain does not eliminate the need for further consultation, investigation and management. The follow-up system needs to accommodate different types of follow up that are based on the patient’s needs and clinical significance of the case.

Consider the following factors to determine if a result is clinically significant and therefore requires action:

• The probability that the patient will be harmed
• The seriousness of the harm

Recalling patients

You must have a process for recalling patients. A recall occurs when a GP decides that a patient needs to be reviewed within a specified period. For example, you might recall a patient:

• when you receive a clinically significant test result
• after significant referrals (eg after a mental health assessment by a psychologist or psychiatrist)
• after diagnosis of a significant condition, such as type 2 diabetes.

If you receive results that are adverse or unexpected, ask the patient to make an appointment with a practitioner or other appropriate health professional to discuss the results and their implications. You can also provide any necessary counselling during the consultation.

Your recall process could be explained in a written policy, including:

• a definition of clinically significant results
• a statement that the patient’s GP is responsible for reviewing results and deciding whether they are clinically significant
• how to recall a patient, clearly outlining the roles and responsibilities of different members of the practice team, including what information different team members can convey and how to convey it. For example, if reception staff members are responsible for contacting patients with clinically significant results to make an appointment, explain the best type of language to use in such a conversation (eg ‘Your doctor wants you to make an appointment this week to discuss the results of your recent tests’)
• guidelines about what information needs to be recorded (eg clinical discussions and outcomes) in patient health records
• standard forms and letters for recalling patients
• guidelines that ensure tests and results are reviewed and acted upon in a timely manner.

Your practice can also document your recall system, including who is responsible for monitoring and follow-up of recalls.

Your induction process must cover the recall system.

Some software allows you to flag recall appointments so you are prompted to contact patients who do not return as expected.

If your practice uses one system for billing and appointments and another system to record patients’ healthcare details, set them up so they exchange follow-up information where required.

Record all attempts to contact and recall patients about clinically significant tests and results in the patient’s medical record.

Communicating tests and results to patients

If you need to initiate follow-up contact with a patient, determine the number, frequency and nature of the attempts you will make to contact the patient. For example, it would be good practice to make up to three telephone calls at different times of the day and then attempt to contact the patient via mail and/or email. Document each attempt in the patient’s health record.

Your practice needs to be able to identify unexpected significant results when they are received, particularly if the significance of such results was not discussed with the patient during the consultation. In these circumstances, you need to consider how to sensitively inform the patient, who may not anticipate or understand the significance of the results.

Your explanation must be clear when explaining test results to the patient, and you must check that the patient understands what you are telling them. When the patient understands the information, they can give legally effective informed consent or exercise their right to a legally effective informed refusal. A patient who makes a decision based on insufficient or unclear information is not making an informed decision.

Reminders

A reminder occurs when a patient is added to a recommended preventive activity list that is managed on a periodic basis. Reminders are used to help manage preventive care and can be set up before or during a consultation by noting in a patient’s health record when the patient is due to return to the clinic for a routine check. Reminders help to ensure patients have preventive health checks. For example, your practice could send an email, letter or text message to patients who are:

• in the high-risk age bracket for influenza, prompting them to come in and have the vaccine before the start of the influenza season
• due for immunisations, including children and high-risk groups
• due for a routine screen, such as a Pap smear or mammogram.

Some medical software will display a prompt when a patient’s health record is opened so the practitioner is informed that the patient is due for a preventive or clinical activity. Consider having your information system automatically generate text messages, emails or letters to patients.

If your practice sends a reminder to a patient and the patient does not make an appointment, the practice is not required to follow up, although it is good practice to record the reminder in the patient’s health record.

Follow up of high-risk (seriously abnormal and life-threatening) results identified outside of normal opening hours

Your practice must manage seriously abnormal and life-threatening results identified outside of normal opening hours so you can provide prompt and adequate follow-up.

Your practice must have a process so that pathology and diagnostic services can contact the practice in urgent circumstances so information about the patient can be accessed.

You need to explain to deputising doctors what you expect them to do if they receive urgent and life-threatening results for one of your patients, as they have a responsibility to contact the general practice in such circumstances. This could be documented in a formal agreement between your practice and the service providing after-hours care.

Meeting each Indicator

GP2.2 A Pathology results, imaging reports, investigation reports, and clinical correspondence that our practice receives are:

• reviewed
• electronically notated, or, if on paper, signed or initialled
• acted on where required
• incorporated into the patient health record.

You must:

You could:

• have a policy and/or documented procedures for reviewing and managing results.

GP2.2 B Our practice recalls patients who have clinically significant results.

You must:

You could:

• have a practice team member who is responsible for the recall process
• have a recall policy for practice team members to follow
• maintain templates in a clinical software program to trigger recalls
• include recall responsibilities in relevant position descriptions
• have recalls sent through the clinical information system.

GP2.2 C Our patients are advised of the practice’s process for follow-up of tests and results.

You must:

• have a practice team member who is responsible for the recall process
• maintain templates in a clinical software program to trigger recalls and reminders
• have a recall policy document.

GP2.2 D Our practice initiates and manages patient reminders​.

You could:

• document in patient health records when reminders have been initiated by the practice and acted upon by the patient
• document the recall and reminder system, including who is responsible for monitoring and follow-up
• maintain templates in a clinical software program to trigger recalls and reminders
• educate the practice team so they can tell patients about the process of sending out reminders
• have reminders sent through the clinical information system.

GP2.2 E High-risk (seriously abnormal and life-threatening) results identified outside normal opening hours are managed by our practice.

You must:

You could:

• educate practice team members about how anyone who provides diagnostic services or receives high-risk results outside of normal opening hours can contact the practice team member/s who have access to the patient’s health record
• provide current contact details to diagnostic services
• provide the contact details of the practice team members who can be contacted outside of normal opening hours when a diagnostic service receives high-risk patient results outside of normal opening hours.