2024 MIPS IA_CC_2: Implementation of improvements that contribute to more timely communication of test results

Activity ID

Activity Weighting

Subcategory Name

Care Coordination

Activity Description

Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.

Objective

Reduce risk of patient harm that occurs when abnormal test results are not delivered in a timely way.

Suggested Documentation

Evidence of a process that reduces the time needed before communicating test results to the patient. The eligible clinician may define the population of patients within their practice for the improvement based on specific test ordered, patient diagnosis, or another factor. Include all of the following elements:

1) Population identified – Characteristics of the population targeted and methods for capturing the entire population within your practice; AND

2) Documentation of method/s of communication and benchmark for timeliness of communication – The benchmark for timeliness of communication can be determined and measured in a variety of ways and should be defined by the eligible clinician in a way that will best meet the goals of the activity (e.g., actual times from an electronic health record or improvements in customer service reviews); AND

3) Improvement strategies – The strategies used to improve timeliness are defined and must be documented by the eligible clinician.

Example/Information

• An internal medicine eligible clinician chooses to follow their population of diabetic patients with a focus on the HbA1c blood test. Traditionally, they do not communicate those test results outside of patient visits. The plan to meet the activity is to communicate normal results with a congratulatory note by email or mail and to communicate abnormal results by phone to ensure the patient understands the need for management of blood sugar more effectively. In this case, the eligible clinician improved the timely communication to meet the activity and also added context relevant to the patient population.
• A radiology group that has a busy mammography practice routinely communicates normal mammogram results within 1-2 weeks and abnormal results are followed up with a phone call by a nurse. The radiology group decides to focus on all patients with a prior diagnosis of breast cancer. They develop a process to capture 100% of patients with prior history at the time of their mammogram and they provide real-time results to those patients by the radiologist. They improve the time to results on the identified population and significantly reduce the anxiety of waiting for a group of patients who are most prone to anxiety.