CHARLOTTE, NC - Many imaging facilities might dismiss the new generation of IT software for managing critical test results as an expensive and unnecessary hassle. But such a purchase could be far cheaper than settling the lawsuits that could result if critical radiology results aren't received by the correct recipient.
That was the message of a presentation at this week's Society for Imaging Informatics in Medicine (SIIM) meeting that addressed the need for better integration between critical test reporting and PACS software.
The process of conveying critical radiology results in a timely manner faces many of the same communication hurdles that existed a decade ago. Although hand-written paper requisitions for diagnostic imaging procedures are starting to be replaced by computerized physician order entry (CPOE) systems, CPOEs may not interface directly with radiology information systems. The need for clerical staff to manually enter information from one electronic system to another is still inefficient and can result in the same types of mistakes as with paper-based systems.
Pager numbers of ordering physicians can be juxtaposed, for example. This simple error -- which can result in a physician failing to receive a critical page -- can easily disrupt timely delivery of patient care and inject havoc into a radiologist's day.
Because automated critical test results management (CTRM) systems are used by only a small number of PACS-enabled radiology departments, the responsibility of notifying one or more referring physicians of critical findings is typically still done by telephone or pager. This task remains an inexact process and an inefficient time waster. And when the referring physician doesn't receive the message, both a patient's health and the professional reputation and financial well-being of a radiologist may be in jeopardy.
Dr. Ramin Khorasani, vice chair of radiology and director of medical imaging information technology of Brigham and Women's Hospital in Boston, challenged SIIM attendees to identify and implement informatics solutions that automated the questions of what, who, when, and how to present radiology report findings that are timely and will not be ignored or overlooked.
Consider the context
The first challenge is to identify critical results in the context of a patient's history. While making a diagnosis of diverticulitis for an emergency physician, for example, a radiologist might identify a lung nodule. The emergency physician needs to receive a confirmation of the primary diagnosis to start immediate treatment, but who should be notified about the lung nodule? And if the lung nodule is unchanged since a prior exam, does this finding merit critical status?
When should communication of findings begin? How long should a radiologist wait before escalating the urgency of conveying a critical finding? How should it be delivered? Should a referring physician be disrupted with a phone call or a page, or can a less disruptive method of communication, such as an e-mail, be used? What happens if the findings are not acted upon? How is this documented? How is information receipt verified?
"Informatics delivery of critical report results based on well-defined policies has the potential to manage this process and eliminate performance gaps," Khorasani said. "But, as with PACS, you have to define the workflow with respect to who gets what information when. This process may not be simple or straightforward."
But it may save a life, as well as the millions of dollars it would take to settle lawsuits. Khorasani noted that radiologists are increasingly named in lawsuits relating to overlooked critical results. Brigham and Women's Hospital spent between $35 and $40 million during a five-year period resolving lawsuits that involved radiologists. Failure to communicate findings represented 20% of the lawsuits, with the potential for death or significant morbidity at a high risk for 47% of the findings and of medium risk for 50%.
The majority of critical findings that are overlooked are not life-threatening or ones that should be acted upon rapidly: It is the ones that require future follow-up in six months or a year that are most often overlooked.
"The state of monitoring critical results is woefully inadequate. The $35 to $40 million paid to compensate mistakes could be used to purchase information technology systems that would prevent many lawsuits from happening. IT will play a critical role in optimizing communications of current performance gaps," Khorasani said.
A four-hospital consortium including Brigham and Women's has been testing a compliance-measurement system that will be made available in the public domain this summer. Once Brigham and Women's started measuring critical report results performance, a 93% compliance rating was achieved and maintained.
Change is coming
The Obama administration's focus on reducing healthcare costs will force changes rapidly with respect to how critical results are delivered, according to Dr. Paul Chang, professor of radiology and vice chair of radiology informatics at the University of Chicago Medical Center in Illinois. He predicted that performance metrics will soon be required, accelerating the deployment of interactive informatics using automated pop-up notifications to remind physicians of information that needs to be acted upon.
One of the reasons that this has been a relatively ignored area of imaging informatics is the mindset of radiologists who perceive their job as generating a report for other clinicians to act upon, according to Chang. Stressing that such an attitude marginalizes the role of the radiologist, Chang emphasized that the ability to provide a timely reminder that a follow-up imaging procedure was due added value to radiology professional services.
He noted that the challenges associated with identifying the right physician or physicians were not easy or straightforward. It is necessary to know all physician proxy relationships. Obtaining the schedules of residents and attending physicians is difficult.
Yet this information is needed for a critical results reporting system. Tracking resident handoffs could be done with an electronic scut list. An incentive to make life easier for the resident could help provide this information. "By offering a carrot, such as easy access to lab reports of patients made available upon sign in, you can entice residents to give you the information you need," Chang said.
A patient may have multiple physicians who need critical results information. Emergency physicians and orthopedic surgeons preparing to treat a patient with a fracture are not the physicians who need to be informed that a lung nodule needs follow-up. Chang suggested that physician/patient relationships be identified through automated analysis of the billing system.
He noted that automated delivery of critical results could activate an audible noise that a computer would generate in an emergency department. To stop the noise, the responsible member of the emergency team would need to log on to read the message.
Development of automated critical results reporting and long-term follow-up managed by RIS/PACS will enhance the proactive contribution and value that radiologists can offer to their peers, he believes.
By Cynthia E. Keen
AuntMinnie.com staff writer
June 5, 2009
Related Reading
New search tool finds the needle in PACS haystack, May 1, 2009
PACS software tool boosts clinical follow-up, December 15, 2008
Using informatics to meet communication challenges, February 7, 2008
Communicating abnormal findings to clinicians may not ensure follow-up, November 28, 2007
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