Unscheduled Radiologic Examination Orders in the Electronic Health Record: A Novel Resource for Targeting Ambulatory Diagnostic Errors in Radiology

Fast and Frictionless: A Novel Approach to Radiology Appointment Scheduling Using a Mobile App and Recommendation Engine

Many outpatient radiology orders are never scheduled, which can result in adverse outcomes. Digital appointment self-scheduling provides convenience, but utilization has been low. The purpose of this study was to develop a "frictionless" scheduling tool and evaluate the impact on utilization. The existing institutional radiology scheduling app was configured to accommodate a frictionless workflow. A recommendation engine used patient residence, past and future appointment data to generate three optimal appointment suggestions. For eligible frictionless orders, recommendations were sent in a text message. Other orders received either a text message for the non-frictionless app scheduling approach or a call-to-schedule text. Scheduling rates by type of text message and scheduling workflow were analyzed. Baseline data for a 3-month period prior to the launch of frictionless scheduling showed that 17% of orders that received an order notification text were scheduled using the app. In an 11-month period after the launch of frictionless scheduling, the rate of app scheduling was greater for orders that received a text message with recommendations (frictionless approach) versus app schedulable orders that received a text without recommendations (29% vs. 14%, p < 0.01). Thirty-nine percent of the orders that received a frictionless text and scheduled using the app used a recommendation. The most common recommendation rules chosen for scheduling included location preference of prior appointments (52%). Among appointments that were scheduled using a day or time preference, 64% were based on a rule using the time of the day. This study showed that frictionless scheduling was associated with an increased rate of app scheduling.

Collaborative Case Review: A Systems-Based Approach to Patient Safety Event Investigation and Analysis

OBJECTIVES

The aims of the study were to assess a system-based approach to event investigation and analysis-collaborative case reviews (CCRs)-and to measure impact of clinical specialty on strength of action items prescribed.

METHODS

A fully integrated CCR process, co-led by radiology and an institutional patient safety program, was implemented on November 1, 2017, at our large academic medical center for evaluating adverse events involving radiology. Quality and safety teams performed reviews for events identified with other departments who maintained their existing processes. This institutional review board-approved study describes the program, including percentage of CCR from an institutional Electronic Safety Reporting System, percentage of CCR per specialty, and action item completion rates and strength (e.g., stronger) based on a Veterans Administration-designed hierarchy. χ2 analysis assessed impact of clinical specialty on strength of action prescribed.

RESULTS

Seventy-three CCR in 2018 generated 260 action items from 10 specialties. Seventy percent (51/73) were adverse events identified through Electronic Safety Reporting System. The specialty most frequently associated with CCR was radiology (16/73, 22%). Most action items (204/260, 78%) were completed in 1 year; stronger action items were completed in 71 (27%) of 260. Radiology was responsible for 61 action items; 25 (41%) of 61 were strong versus all other specialties with strong action items in 46 (23%) of 199 (P < 0.01).

CONCLUSIONS

An integrated multispecialty CCR co-led by the radiology department and an institutional patient safety program was associated with a higher proportion of CCR, stronger action items, and higher action item completion rate versus other hospital departments. Active engagement in CCR can provide insights into addressing adverse events and promote patient safety.

Electronic Health Record Closed-Loop Communication Program for Unexpected Nonemergent Findings

Background Reliance on examination reporting of unexpected imaging findings does not ensure receipt of findings or appropriate follow-up. A closed-loop communication system should include provider and patient notifications and be auditable through the electronic health record (EHR). Purpose To report the initial design of and results from using an EHR-integrated unexpected findings navigator (UFN) program that ensures closed-loop communication of unexpected nonemergent findings. Materials and Methods An EHR-integrated UFN program was designed to enable identification and communication of unexpected findings and aid in next steps in findings management. Three navigators (with prior training as radiologic technologists and sonographers) facilitated communication and documentation of results to providers and patients. Twelve months (October 2019 to October 2020) of results were retrospectively reviewed to evaluate patient demographics and program metrics. Descriptive statistics and correlation analysis were performed by using commercially available software. Results A total of 3542 examinations were reported within 12 months, representing 0.5% of all examinations performed (total of 749 649); the median patient age was 62 years (range, 1 day to 98 years; interquartile range, 23 years). Most patients were female (2029 of 3542 [57%]). Almost half of the examinations submitted were from chest radiography and CT (1618 of 3542 [46%]), followed by MRI and CT of the abdomen and pelvis (1123 of 3542 [32%]). The most common unexpected findings were potential neoplasms (391 of 3542 [11%]). The median time between examination performance and patient notification was 12 days (range, 0-136 days; interquartile range, 13 days). A total of 2127 additional imaging studies were performed, and 1078 patients were referred to primary care providers and specialists. Most radiologists (89%, 63 of 71 respondents) and providers (65%, 28 of 43 respondents) found the system useful and used it most frequently during regular business hours. Conclusion An electronic health record-integrated, navigator-facilitated, closed-loop communication program for unexpected radiologic findings led to near-complete success in notification of providers and patients and facilitated the next steps in findings management. © RSNA, 2021 See also the editorial by Safdar in this issue.

Closing the Loop on Unscheduled Diagnostic Imaging Orders: A Systems-Based Approach

Objective:

To: 1) describe a System for Coordinating Orders for Radiology Exams (SCORE) which aims to manage unscheduled orders for outpatient diagnostic imaging in an electronic health record (EHR) with embedded computerized physician order entry (CPOE), 2) assess the impact of SCORE and other related factors (e.g., demographics) on rate of unscheduled orders, and 3) assess the clinical necessity of orders canceled, expired, scheduled and performed.

Methods:

This Institutional Review Board-approved retrospective study was conducted in a large academic institution between 10/1/2017–7/1/2019. The design and implementation of SCORE is described, including people (e.g., competencies), processes (e.g., standardized procedures) and tools (e.g., EHR interfaces, dashboard). Rate of unscheduled imaging orders was compared pre-SCORE (10/1/17–9/30/18) and post-SCORE (10/1/18–6/30/19) using chi-square analysis. For 447 randomly selected orders, mode of resolution was obtained from the EHR and factors related to order resolution were assessed via multivariable analysis. Finally, clinical necessity was manually assessed by two physicians.

Results:

Pre-SCORE, 52,204/607,020 exam orders were unscheduled (8.6% of orders), compared to 20,900/475,000 exam orders (4.4% of orders) post-SCORE (χ², p<0.00001), a 49% reduction in unscheduled orders. Among 447 randomly selected orders, orders were addressed via cancellation (57%), expiration (21%), scheduling (1%) and performance (11%). Order resolution was not significantly associated with other factors. 31.9% of cancellations and 27.7% of expired orders remained clinically necessary and were attributed to scheduling and patient-related factors.

Conclusion:

SCORE significantly reduced unscheduled diagnostic imaging orders. This patient safety initiative may help reduce errors resulting from diagnostic delays due to unscheduled exam orders.