Critical Results - Brief Proposal: Difference between revisions

Revision as of 00:33, 1 September 2007

1. Proposed Profile: Critical Results

Proposal Editor: Kevin O'Donnell/Paul Nagy
Date: N/A (Wiki keeps history)
Version: N/A (Wiki keeps history)
Domain: Radiology/Cardiology/IT/Path?/Lab?

2. The Problem

Typically a referring physician, suspecting a particular pathology, orders an imaging exam to confirm or rule it out or to provide more detail. Current report distribution mechanisms work reasonably well for communicating such results however gaps remain:

Critical results such as findings that may imminently threaten the patients life (e.g. a pneumothorax) cannot wait for whenever the referring physician gets to the report but must need to be acted on quickly.

Important incidental results such as findings that may threaten the patients life in the future (e.g. a suspicious lung mass in an exam for a cracked rib) should not be overlooked and must be properly followed up.

In these cases, and even in cases where there are simply important results to be delivered in the normal report timeframe, the referring physician must be made specifically aware of the result, and the radiologist must be able to confirm its happened since they have a responsibility to try alternative methods until they succeed.

In an era of increasing pressures to interpret more images in less time, most radiologists are unable to spend the significant amounts of time needed to track down referring physicians and personally communicate findings.

However, the American College of Radiology has made clear in its practice guidelines that not only is such notification necessary, but that documented, verifiable records of such communication must be retained by the radiologist. Dozens of legal decisions have found radiologists responsible for damages in cases in which imaging results and reports were not communicated or in many cases in which such communications could not be verified.

Failure to communicate with referring physicians is believed to be responsible for significant numbers of adverse outcomes, and it is often implicated in liability claims.

There is currently no coordinated way to track receipt of clinical findings. The problem is compounded by the many different ways such findings can (and should) be communicated (particularly in urgent cases).

3. Key Use Case

A number of well attended presentations at SIIM 2007 emphasized the significance of this problem and presented desired behaviors.

Address notification that critical results exist, access to those critical results, and auditing notification/receipt of notification/receipt of results

(Need to work in discussions from SIIM, for example the multiple levels of urgency and correspondingly different notification channels appropriate to the urgency, as has been done at several institutions already. )

4. Standards & Systems

<List existing systems that are/could be involved in the problem/solution.>

<If known, list standards which might be relevant to the solution>

Paul Nagy and others have suggested that many of the relevant events already can be logged in the IHE ATNA audit log. Additional relevant events could easily be added. If this profile added a query interface to the Audit Repository, it could be an excellent mechanism for tracking/confirming notification and receipt of necessary information.

5. Discussion

<Indicate why IHE would be a good venue to solve the problem and what you think IHE should do to solve it.>

This topic has been raised before in Radiology and was referred to IT Infrastructure, however there has been no progress there. Should we renew pressure on them, or consider drafting a profile ourselves for transfer later (as was done with ATNA in the first place)?

"Future work should address decreasing lost to follow-up results in computerized systems without placing additional burdens on providers." In general, computerized alerts have been shown to improve the communication of critical lab results in the inpatient setting, Singh said.

"We believe electronic alerting systems have a promising future in improving response to abnormal imaging results in the outpatient setting," he said

<Try to keep the proposal to 1 or at most 2 pages>

@@ Line 3: / Line 3: @@
 ==1. Proposed Profile: Critical Results==
-* Proposal Editor: Kevin O'Donnell
+* Proposal Editor: Kevin O'Donnell/Paul Nagy
 * Date:    N/A (Wiki keeps history)
 * Version: N/A (Wiki keeps history)
@@ Line 11: / Line 11: @@
 ==2. The Problem==
-''<Summarize the integration problem. What doesn’t work, or what needs to work.>''
+Typically a referring physician, suspecting a particular pathology, orders an imaging exam to confirm or rule it out or to provide more detail.  Current report distribution mechanisms work reasonably well for communicating such results however gaps remain:
-(Need to work in discussions from SIIM, for example the multiple levels of urgency and correspondingly different notification channels appropriate to the urgency, as has been done at several institutions already. )
-(Taken from PACSWeb Article)
-Referring clinicians failed to electronically acknowledge over one-third of abnormal imaging results in an outpatient setting, even when a computerized test result notification system designed to alert referring physicians was used, according to a paper from Texas. Providers were unaware of critical imaging results in 4% of cases as long as four weeks after reporting.
-"Our findings suggest that a computerized test result notification system with standardized policies and procedures does not altogether prevent lack of physician awareness of abnormal imaging results and subsequent loss of appropriate follow-up," said lead author Dr. Hardeep Singh of the department of medicine at Baylor College of Medicine.
-The study analyzed 1017 outcomes of abnormal imaging alerts in an ambulatory multispecialty clinic that were transmitted to providers via the electronic medical record but were not electronically acknowledged by the referring clinicians (J Am Med Inform Assoc 2007;14(4):459-466. Epub 2007 Apr 25).
-Singh was unable to evaluate how follow-up rates may have improved with the implementation of the electronic notification system since data about abnormal report communication outcomes prior to using the electronic system are unavailable.
-Failure to communicate with referring physicians is believed to be responsible for significant numbers of adverse outcomes, and it is often implicated in liability claims. In response to the increased recognition that delayed communication in radiology is a major cause for litigation in the U.S., the American College of Radiology updated its guidelines for communicating critical diagnostic imaging findings in 2005.
+* Critical results such as findings that may imminently threaten the patients life (e.g. a pneumothorax) cannot wait for whenever the referring physician gets to the report but must need to be acted on quickly.
+* Important incidental results such as findings that may threaten the patients life in the future (e.g. a suspicious lung mass in an exam for a cracked rib) should not be overlooked and must be properly followed up.
-Singh said their high tracking reliability allows electronic notification systems address two factors that can lead to malpractice claims against radiologists:
+In these cases, and even in cases where there are simply important results to be delivered in the normal report timeframe, the referring physician must be made specifically aware of the result, and the radiologist must be able to confirm its happened since they have a responsibility to try alternative methods until they succeed.
-* failure to directly contact the referring physician
+In an era of increasing pressures to interpret more images in less time, most radiologists are unable to spend the significant amounts of time needed to track down referring physicians and personally communicate findings.
-* failure to document any attempt to make contact
-Providers face constraints such as time and workload that could affect the communication process, Singh said.
+However, the American College of Radiology has made clear in its practice guidelines that not only is such notification necessary, but that documented, verifiable records of such communication must be retained by the radiologist.  Dozens of legal decisions have found radiologists responsible for damages in cases in which imaging results and reports were not communicated or in many cases in which such communications could not be verified.
-"Much needs to be learned about why abnormal test result alerts remain unacknowledged and why imaging results get lost to follow-up despite confirmed transmission to referring providers," he said. "Future work should address decreasing lost to follow-up results in computerized systems without placing additional burdens on providers."
+Failure to communicate with referring physicians is believed to be responsible for significant numbers of adverse outcomes, and it is often implicated in liability claims.
-Although other automated test result notification systems are emerging, little is known about their performance and outcome. In general, computerized alerts have been shown to improve the communication of critical lab results in the inpatient setting, Singh said.
-"We believe electronic alerting systems have a promising future in improving response to abnormal imaging results in the outpatient setting," he said
+There is currently no coordinated way to track receipt of clinical findings.  The problem is compounded by the many different ways such findings can (and should) be communicated (particularly in urgent cases).
 ==3. Key Use Case==
-''<Describe a short use case scenario from the user perspective.  The use case should demonstrate the integration/workflow problem.>''
+A number of well attended presentations at SIIM 2007 emphasized the significance of this problem and presented desired behaviors.
 Address notification that critical results exist, access to those critical results, and auditing notification/receipt of notification/receipt of results
+(Need to work in discussions from SIIM, for example the multiple levels of urgency and correspondingly different notification channels appropriate to the urgency, as has been done at several institutions already. )
 ''<Feel free to add a second use case scenario demonstrating how it “should” work.  Try to indicate the people/systems, the tasks they are doing, the information they need, and hopefully where the information should come from.>''
@@ Line 63: / Line 52: @@
 This topic has been raised before in Radiology and was referred to IT Infrastructure, however there has been no progress there.  Should we renew pressure on them, or consider drafting a profile ourselves for transfer later (as was done with ATNA in the first place)?
+"Future work should address decreasing lost to follow-up results in computerized systems without placing additional burdens on providers."  In general, computerized alerts have been shown to improve the communication of critical lab results in the inpatient setting, Singh said.
+"We believe electronic alerting systems have a promising future in improving response to abnormal imaging results in the outpatient setting," he said
 ''<Try to keep the proposal to 1 or at most 2 pages>''