Electronic messaging system for communicating important, but nonemergent, abnormal imaging results

Predictive Factors and Clinical Impacts of Delayed Isolation of Tuberculosis during Hospital Admission

Delayed isolation of tuberculosis (TB) can cause unexpected exposure of healthcare workers (HCWs). This study identified the predictive factors and clinical impact of delayed isolation. We retrospectively reviewed the electronic medical records of index patients and HCWs who underwent contact investigation after TB exposure during hospitalization at the National Medical Center, between January 2018 and July 2021. Among the 25 index patients, 23 (92.0%) were diagnosed with TB based on the molecular assay, and 18 (72.0%) had a negative acid-fast bacilli smear. Sixteen (64.0%) patients were hospitalized via the emergency room, and 18 (72.0%) were admitted to a non-pulmonology/infectious disease department. According to the patterns of delayed isolation, patients were classified into five categories. Among 157 close-contact events in 125 HCWs, 75 (47.8%) occurred in Category A. Twenty-five (20%) HCWs had multiple TB exposures (n = 57 events), of whom 37 (64.9%) belonged to Category A (missed during emergency situations). After contact tracing, latent TB infection was diagnosed in one (1.2%) HCW in Category A, who was exposed during intubation. Delayed isolation and TB exposure mostly occurred during pre-admission in emergency situations. Effective TB screening and infection control are necessary to protect HCWs, especially those who routinely contact new patients in high-risk departments.

Use of a Macro as Nudge Factor in Communication Between Radiologists and Referring Physicians

INTRODUCTION/METHODS

Radiologists provide value through communication of imaging findings. We outline a quality improvement effort using a dedicated dictation macro as a behavioral nudge to increase direct communication between radiologists and referring physicians. Use of the macro was encouraged by departmental leadership and publicised widely prior to implementation. Monthly data regarding the use of the macro and corresponding departmental volumes were acquired over a 24 month period.

RESULTS

Over the 24-month study period, there were 1,334,555 total exams performed and 52,276 total communications (3.90%; monthly range 2.21-4.67%). The greatest increase in adoption rate occurred during the initial 4-month period, with sustained rates of communication achieved after month 4. Results were more frequently communicated to a clinician when a resident trainee was involved in the dictation process. The greatest number of documented communications was for x-ray, followed by Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Ultrasound (US), and nuclear medicine. Inpatient studies (7.23%) were communicated at a statistically significantly higher rate than Emergency Department (ED) (3.86%) or Outpatient (OP) studies (1.31%), P < 0.0001 for all comparisons. The rate of documented communication steadily increased across all patient classes.

CONCLUSION

Our findings demonstrate that simple interventions to increase the rate of documented communication can have durable results, and highlight the critical role radiologists play in timely and effective patient care delivery. Introduction of a communication macro coupled with departmental nudges resulted in increased direct communication of imaging results. This effort has promoted mutual engagement between radiologists and their colleagues, and demonstrates the active role of radiologists in direct imaging consultation.

Difficulties and possibilities in communication between referring clinicians and radiologists: perspective of clinicians

Purpose

To investigate modes and quality of interprofessional communication between clinicians and radiologists, and to identify difficulties and possibilities in this context, as experienced by referring clinicians.

Patients and methods

Focus group interviews with 22 clinicians from different specialties were carried out. The leading question was: "How do you experience communication, verbal and nonverbal, between referring clinicians and radiologists?" Content analysis was used for interpretation of data.

Results

Overall, referring clinicians expressed satisfaction with their interprofessional communication with radiologists, and digital access to image data was highly appreciated. However, increased reliance on digital communication has led to reduced face-to-face contacts between clinicians and radiologists. This seems to constitute a potential threat to bilateral feedback, joint educational opportunities, and interprofessional development. Cumbersome medical information software systems, time constraints, shortage of staff, reliance on teleradiology, and lack of uniform format of radiology reports were mentioned as problematic. Further implementation of structured reporting was considered beneficial.

Conclusion

Deepened face-to-face contacts between clinicians and radiologists were considered prerequisites for mutual understanding, deepened competence and mutual trust; a key factor in interprofessional communication. Clinicians and radiologists should come together in order to secure bilateral feedback and obtain deepened knowledge of the specific needs of subspecialized clinicians.

Whole-body MRI for preventive health screening: A systematic review of the literature

Background

The yield of whole‐body MRI for preventive health screening is currently not completely clear.

Purpose

To systematically review the prevalence of whole‐body MRI findings in asymptomatic subjects.

Study Type

Systematic review and meta‐analysis.

Subjects

MEDLINE and Embase were searched for original studies reporting whole‐body MRI findings in asymptomatic adults without known disease, syndrome, or genetic mutation. Twelve studies, comprising 5373 asymptomatic subjects, were included.

Field Strength/Sequence

1.5T or 3.0T, whole‐body MRI.

Assessment

The whole‐body MRI literature findings were extracted and reviewed by two radiologists in consensus for designation as either critical or indeterminate incidental finding.

Statistical Tests

Data were pooled using a random effects model on the assumption that most subjects had ≤1 critical or indeterminate incidental finding. Heterogeneity was assessed by the I² statistic.

Results

Pooled prevalences of critical and indeterminate incidental findings together and separately were 32.1% (95% confidence interval [CI]: 18.3%, 50.1%), 13.4% (95% CI: 9.0%, 19.5%), and 13.9% (95% CI: 5.4%, 31.3%), respectively. There was substantial between‐study heterogeneity (I² = 95.6–99.1). Pooled prevalence of critical and indeterminate incidental findings together was significantly higher in studies that included (cardio)vascular and/or colon MRI compared with studies that did not (49.7% [95% CI, 26.7%, 72.9%] vs. 23.0% [95% CI, 5.5%, 60.3%], P < 0.001). Pooled proportion of reported verified critical and indeterminate incidental findings was 12.6% (95% CI: 3.2%, 38.8%). Six studies reported false‐positive findings, yielding a pooled proportion of 16.0% (95% CI: 1.9%, 65.8%). None of the included studies reported long‐term (>5‐year) verification of negative findings. Only one study reported false‐negative findings, with a proportion of 2.0%.

Data Conclusion

Prevalence of critical and indeterminate incidental whole‐body MRI findings in asymptomatic subjects is overall substantial and with variability dependent to some degree on the protocol. Verification data are lacking. The proportion of false‐positive findings appears to be substantial.

Level of Evidence: 4

Technical Efficacy: Stage 3

J. Magn. Reson. Imaging 2019;50:1489–1503.

Use of Iterative Cycles in Quality Improvement Projects in Imaging: A Systematic Review

PURPOSE

Studies suggest that quality improvement (QI) projects in health care lack scientific rigor, but the actual frequency of use of proven scientific QI methodology is unknown. The purposes of this study are to (1) conduct a systematic review of QI projects in radiology journals on the frequency of use of iterative cycles, a marker of proven QI methodology, and (2) assess association of the use of iterative cycles with characteristics of these projects.

MATERIALS AND METHODS

We searched English-language radiology journals on MEDLINE between 2008 and 2015 for published QI studies. Three reviewers appraised studies and extracted data. Use of iterative cycles was identified, and results were summarized qualitatively. χ² Analysis evaluated associations of iterative cycles with other data elements.

RESULTS

Of 3,134 potentially eligible citations, 44 studies met inclusion criteria. Only 46% of these used iterative cycles to refine intervention. Use of iterative cycles were associated with projects designed to improve process, QI expert support, reporting of unintended effect of intervention, and explicitly stated use of iterative cycles. General lack of scientific rigor was represented by failure to report baseline data (9%), describe unintended effects (66%), and discuss limitations (36%).

CONCLUSIONS

Our systematic review found fewer than half of the QI projects in radiology journals used iterative cycles to refine intervention, a scientific strategy central to many proven improvement methodologies. Use of iterative approach was associated with projects designed to improve processes, QI expert support, report of unintended effect, and explicitly stated use of iterative cycles.

Communicating Radiology Test Results: Are Our Phone Calls Excessive, Just Right, or Not Enough?

RATIONALE AND OBJECTIVES

This study aimed to determine the preferences of radiology and referring provider residents regarding direct communication of radiology test results.

METHODS

This Health Insurance Portability and Accountability Act-compliant quality improvement effort was exempt from institutional review board oversight. An anonymous survey was emailed to 44 radiology residents and 364 referring resident providers who routinely provide or receive direct communication of test results at our quaternary care medical center. The survey focused on the frequency, indication, clinical utility, and methods of direct communication of radiology results. Proportions were compared to chi-square or Fisher exact test.

RESULTS

The response rates were 86% (37 of 43) (radiology) and 41% (151 of 364) (referring providers). Approximately half of radiology residents (49% [18 of 37]) thought the frequency of direct verbal communication was excessive, and none (0 of 37) thought more communication was needed. In contrast, only 1.3% (2 of 151; P < .001) of referring providers felt the frequency was excessive, and 24% (36 of 151; P < .001) desired more. The majority (66% [100 of 151]) of referring providers felt phone calls from radiologists often or always added value beyond a timely radiology report, and 59% (44 of 74) felt it is the radiologist's responsibility to call about abnormal findings. Furthermore, 83% (125 of 151) of referring providers preferred to receive a phone call about non-emergent unexpected findings, although preferences varied for various example abnormalities. For outpatients with non-emergent unexpected findings, most providers (90% [64 of 71]) prefer written communication rather than a phone call.

CONCLUSIONS

Referring providers prefer direct communication of radiology results, even for non-urgent unexpected findings, whereas radiology residents prefer less direct communication and are more likely to consider radiologist-to-provider communication superfluous.

Error and discrepancy in radiology: inevitable or avoidable?

Errors and discrepancies in radiology practice are uncomfortably common, with an estimated day-to-day rate of 3-5% of studies reported, and much higher rates reported in many targeted studies. Nonetheless, the meaning of the terms "error" and "discrepancy" and the relationship to medical negligence are frequently misunderstood. This review outlines the incidence of such events, the ways they can be categorized to aid understanding, and potential contributing factors, both human- and system-based. Possible strategies to minimise error are considered, along with the means of dealing with perceived underperformance when it is identified. The inevitability of imperfection is explained, while the importance of striving to minimise such imperfection is emphasised.

TEACHING POINTS

• Discrepancies between radiology reports and subsequent patient outcomes are not inevitably errors. • Radiologist reporting performance cannot be perfect, and some errors are inevitable. • Error or discrepancy in radiology reporting does not equate negligence. • Radiologist errors occur for many reasons, both human- and system-derived. • Strategies exist to minimise error causes and to learn from errors made.

Does integrating nonurgent, clinically significant radiology alerts within the electronic health record impact closed-loop communication and follow-up?

OBJECTIVE

To assess whether integrating critical result management software--Alert Notification of Critical Results (ANCR)--with an electronic health record (EHR)-based results management application impacts closed-loop communication and follow-up of nonurgent, clinically significant radiology results by primary care providers (PCPs).

MATERIALS AND METHODS

This institutional review board-approved study was conducted at a large academic medical center. Postintervention, PCPs could acknowledge nonurgent, clinically significant ANCR-generated alerts ("alerts") within ANCR or the EHR. Primary outcome was the proportion of alerts acknowledged via EHR over a 24-month postintervention. Chart abstractions for a random sample of alerts 12 months preintervention and 24 months postintervention were reviewed, and the follow-up rate of actionable alerts (eg, performing follow-up imaging, administering antibiotics) was estimated. Pre- and postintervention rates were compared using the Fisher exact test. Postintervention follow-up rate was compared for EHR-acknowledged alerts vs ANCR.

RESULTS

Five thousand nine hundred and thirty-one alerts were acknowledged by 171 PCPs, with 100% acknowledgement (consistent with expected ANCR functionality). PCPs acknowledged 16% (688 of 4428) of postintervention alerts in the EHR, with the remaining in ANCR. Follow-up was documented for 85 of 90 (94%; 95% CI, 88%-98%) preintervention and 79 of 84 (94%; 95% CI, 87%-97%) postintervention alerts (P > .99). Postintervention, 11 of 14 (79%; 95% CI, 52%-92%) alerts were acknowledged via EHR and 68 of 70 (97%; 95% CI, 90%-99%) in ANCR had follow-up (P = .03).

CONCLUSIONS

Integrating ANCR and EHR provides an additional workflow for acknowledging nonurgent, clinically significant results without significant change in rates of closed-loop communication or follow-up of alerts.

Communication breakdowns and diagnostic errors: a radiology perspective

Timely and accurate communication is essential to safe and effective health care. Despite increased awareness over the past decade of the frequency of medical errors and greater efforts directed towards improving patient safety, patient harm due to communication breakdowns remains a significant problem. Communication problems related to diagnostic testing may account for nearly half of all errors made by typical primary care physicians in their medical practices. This article provides an overview of communication breakdowns in the context of radiology related diagnostic errors. In radiology, communication breakdowns between radiologists, referring clinicians, and patients can lead to failure of critical information to be relayed, resulting in delayed or missed diagnosis. New technologies, such electronic health records (EHRs), contribute to the increasing complexity of communication in health care, but if used correctly, they can provide several benefits to safe and effective communication. To address the complexity of communication breakdowns, a multifaceted sociotechnical approach is needed to address both technical and non-technical aspects of health care delivery. The article also provides some future directions in reducing communication breakdowns related to diagnostic testing, including proactive risk assessment of communication practices using recently released SAFER self-assessment guides.

Delays and errors in abnormal chest radiograph follow-up: a systems approach to promoting patient safety in radiology

RATIONALE, AIMS AND OBJECTIVES

This study aimed to apply the 'systems approach' to patient safety in order to identify causes for delays and errors in lung cancer diagnoses following an abnormal chest radiograph.

METHODS

In the first part of this study, the systems approach to patient safety was comprehensively reviewed by three radiologists and seven patient safety experts. In the second part of this study, a retrospective review was performed of all patients referred to the lung cancer multidisciplinary team (MDT) meeting over a 1-year period. All abnormal chest radiograph reports were examined and a root-cause analysis performed of cases where errors and delays in diagnoses were deemed to have occurred.

RESULTS

A total of 124 cases were reviewed, of which 36 (29%) patients had an abnormal preceding chest radiograph prior to MDT referral. In six cases, serious errors from delay and lack of follow-up were identified. These are analysed and discussed in detail in this article. Application of the systems approach to each case identified poor communication and lack of clinical action as prime causes.

CONCLUSIONS

Both reporting radiologists and referring clinicians have a responsibility to ensure appropriate action following an abnormal chest radiograph. The main error lies in communication between the referring clinicians and the radiologists. Direct electronic communication is potentially a more robust method to overcome this.

The role of a radiology electronic notification system in the emergency department setting and its impact on patient care

Background

To determine the impact of a radiology electronic notification system (ENS) on emergency department (ED) patient care.

Materials and Methods

A retrospective review of de-identified patient data for a 2-year period (1 year prior to and 1 year following ENS implementation) was approved by the hospital’s institutional review board. The effect of a radiology ENS on ED patient care was investigated by analyzing the intervals between completion of a chest radiograph and the times antibiotics were ordered/administered on patients presenting with symptoms of community acquired pneumonia (CAP). The square root transformation of the means was analyzed with an ANOVA model to determine statistical significance.

Results

During the 24-month study protocol, 1,341 patients who were evaluated in the ED met the study eligibility criteria. The least square estimates of the mean times from when the chest radiograph was completed to when antibiotics were ordered prior to and after the implementation of the ENS were 89 and 107 minutes, respectively (P < 0.01). The least square estimates of the mean times from when the chest radiograph was completed to when antibiotics were administered prior to and after the implementation of the ENS were 115 and 132 minutes, respectively (P = 0.02).

Conclusion

The implementation of a radiology ENS does have advantages for the radiologist in streamlining the communication and documentation processes but may negatively impact time to treatment and thus patient care.

Incidentally detected lung nodules: clinical predictors of adherence to Fleischner Society surveillance guidelines

OBJECTIVE

The objective of this study was to determine adherence to incidentally detected lung nodule computed tomographic (CT) surveillance recommendations and identify demographic and clinical factors that increase the likelihood of CT surveillance.

MATERIALS AND METHODS

A total of 419 patients with incidentally detected lung nodules were included. Recorded data included patient demographic, radiologic, and clinical characteristics and outcomes at a 4-year follow-up. Multivariate logistic regression models determined the factors associated with likelihood of recommended CT surveillance.

RESULTS

At least 1 recommended surveillance chest CT was performed on 48% of the patients (148/310). Computed tomographic result communication to the patient (odds ratio [OR], 2.2; P = 0.006; confidence interval [CI], 1.3-4.0) or to the referring physician (OR, 2.8; P = 0.001; CI, 1.7-4.5) and recommendation of a specific surveillance time interval (OR, 1.7; P = 0.023; CI, 1.08-2.72) increased the likelihood of surveillance. Other demographic, radiologic, and clinical factors did not influence surveillance.

CONCLUSIONS

Documented physician and patient result communication as well as the recommendation of a specific surveillance time interval increased the likelihood of CT surveillance of incidentally detected lung nodules.

An evaluation of the impact of clinically embedded reading rooms on radiologist-referring clinician communication

The aim of this study was to investigate whether locating reading rooms in clinical areas at a large tertiary care, academic hospital in the United States corresponds with increased rates of direct communication between radiologists and clinicians. Data recorded included the frequency, form, duration, and general purpose of communications. Two-tailed Fisher's exact tests were used to determine the statistical significance of differences between the frequencies of communication methods for the reading rooms included in the study. During the observation period, there were a total of 175 episodes of communication between radiologists and referring providers in the 4 study reading rooms. There was a highly significant difference (P < .0001) in the percentage of visits and critical test result management messages sent between embedded and nonembedded reading rooms, while the differences in the proportion of calls both to and from referring providers was not significant (P = .4468). Although the purpose of this study was to assess the impact of reading room location on radiologists' communications with referring providers, several alternative hypotheses could also explain the results. The value of this study emerges from the documentation of the high degree of variability among institutions in communication practices among different kinds of radiologists and referring physicians. The extent of these different practices among the 4 reading rooms has important implications for future studies of communication patterns between radiologists and referring providers as well as for designing effective interventions to enhance the role of radiologists as consultants.

The future of the radiology information system

OBJECTIVE

Today in the hospital setting, several functions of the radiology information system (RIS), including order entry, patient registration, report repository, and the physician directory, have moved to enterprise electronic medical records. Some observers might conclude that the RIS is going away. In this article, we contend that because of the maturity of the RIS market compared with other areas of the health care enterprise, radiology has a unique opportunity to innovate.

CONCLUSION

While most of the hospital enterprise spends the next several years going through the digital transformation converting from paper to a digital format, radiology can leap ahead in its use of analytics and information technology. This article presents a summary of new RIS functions still maturing and open to innovation in the RIS market.