Critical Finding Follow-up and Communication

1. Proposed Workitem: Actionable Finding Follow-up and Communication

Proposal Editor: Tessa Cook/Harry Solomon
Proposal Contributors: Felicha Candelaria-Cook, Michael Kopinsky, Amy Wang, Deb Woodcock (OHSU BMI 516 SU2015 team 3, Harry Solomon, instructor), Steve Langer, Kevin O'Donnell
Profile Editor: Tessa Cook MD PhD
Profile Contributors:
Domain: Radiology

2. The Problem

Patients often receive recommendations for follow-up evaluation (e.g., imaging, laboratory, pathology or clinical evaluation) as a result of findings on an imaging study. However, without manually searching for the results of follow-up testing or evaluation, radiologists have no way of knowing when or if a patient completes the recommendation, or what the results may be. This puts the patient at risk of being lost to follow-up and returning at a later date after experiencing an adverse event, e.g., diagnosis of an advanced cancer.

At present, there is no way for actionable findings to effectively be communicated to the EMR, or for either a RIS or EMR to track whether follow-up is completed within a particular health system or whether results of an evaluation outside the system are submitted.

There are serious potential consequences to missed follow-up:

increased personal and monetary cost to the patient experiencing a complication or adverse outcome
potential malpractice costs associated with missed follow-up and adverse patient outcomes

Every large hospital/health system has experienced at least one instance of a patient being lost to follow-up despite multiple interactions with the healthcare system during the time the follow-up should have been obtained. There is significant potential for cost savings for multiple stakeholders by addressing this problem.

3. Key Use Case

Clinical Scenario: Patient John Doe has a low-velocity motor vehicle. Since he complains of chest pain, Mr. Doe gets a chest X-ray and a chest CT at the nearby community hospital. He is found to have a 7 mm left lung nodule on his chest CT, and the interpreting radiologist recommends a follow-up chest CT in 6 months.

Problem:

The recommendation is communicated to the ER physician and verbally to Mr. Doe, but not documented in his discharge paperwork.
Mr. Doe never gets the follow-up chest CT. He sees other doctors in his health system and mentions his accident and imaging but does not recall the nodule or the follow-up recommendation. None of his doctors follow up to get the results of his imaging.
Two years later, he begins coughing up blood and has another chest CT, which shows a 2.5 cm left lung nodule, a left-sided pleural effusion and left-sided lymph nodes above his clavicle. He is diagnosed with unresectable lung cancer.

Solution:

The radiologist’s recommendation within the report is automatically translated by the EMR into a reminder in the patient’s chart.
If the patient does not routinely receive care within this health system, the reminder is communicated to the patient’s home EMR. Consideration will have to be given to whether the home EMR is within the same health system as the original treating hospital, within the same HIE, or neither.
The follow-up reminder produces gradually escalating alerts (both to the original reporting radiologist and the patient’s home EMR) until the follow-up is completed or the loop is closed by someone on the patient’s care team within the home EMR. The loop should be able to be closed manually (e.g., by the primary care physician who can certify it has been performed already or is not clinically indicated) or automatically when the recommended testing result is available in the EMR.

4. Standards and Systems

Existing systems: RIS/EMR at the treating hospital, EMR within the patient’s typical health system or within the system in which follow-up is expected to be obtained.

Relevant components of standards:

LOINC
HL7 v2.8 (especially ORU^R40 and ORA^R42)
ACR Actionable Reporting Work Group
DICOM part 20, section 9.8.10 (Communication of Actionable Findings)
FHIR, SNOMED CT
(Consider leveraging IHE ITI mACM and PCD ACM)

5. Discussion

At present within the University of Pennsylvania Health System, we are addressing this problem using structured reporting and an in-house coding system for focal masses as well as pulmonary nodules. However, an IHE profile is necessary to properly address this problem, because the scope is much larger than is realistically addressed with the approach we have taken. Ideally, the profile would dictate the structure of the reminder for a follow-up recommendation, how that reminder is communicated between systems, how often alerts surrounding this reminder are issued, how the reminder can be dismissed (i.e., when follow-up is considered “complete”), and how results are communicated back to the radiologist who made the original recommendation.