Critical Finding Follow-up and Communication

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

• Proposal Editor: Felicha Candelaria-Cook, Michael Kopinsky, Amy Wang, Deb Woodcock (OHSU BMI 516 SU2015 team 3, Harry Solomon, instructor), Tessa Cook MD PhD
• Editor: tbd
• Domain: Radiology

2. The Problem

Patients often receive recommendations for follow-up evaluation (imaging, laboratory, pathology or clinical evaluation) as a result of observations on an imaging study. However, as radiologists, we have no way of knowing when a patient completes such evaluation, 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 or progression/complication of a fracture.

At present there is no way for a source of actionable findings to effectively communicate this to the EMR, or for either system to track whether the follow-up is completed, whether within the system or via results submitted from outside evaluation.

There are multiple potential underlying costs:

• increased cost of caring for a patient experiencing a complication (higher for advanced/inoperable cancer)
• potential malpractice costs associated with missed follow-up (which can be experienced by patient as well as provider and healthcare system).

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

Current Situation: A radiologist documents a suspicious finding in a text report for an imaging study. Paper and electronic copies of reports are sent out, but the patient is lost to follow-up and later diagnosed with advanced cancer. The patient dies from a potentially treatable cancer.

Ideal Situation: The radiologist documents suspicious findings using a form that supports text narrative but that requires structured documentation using terms mapped to standard reference terminologies. Documenting a critical event requiring follow-up or selecting a term mapped to a standard reference terminologies and in a critical event value set triggers an event tracker within the EHR system. The event tracker creates a critical event with a defined workflow for follow-up and disposition based on the suspicious findings. The timing and urgency for follow-up are based on a the level of criticality as defined in the critical event value set. The event tracker creates a level 3 CDA document with the critical event which can be sent to other systems, such as other EHR modules and outside EHRs. The tracker sends information about the event to one or more designated notification receivers, which include the hospital’s critical evsuspent team, ordering physician, and the patient’s primary care physician, if available. If appropriate follow-up or disposition does not occur within a defined time period, then the event is escalated, triggering more urgent communication. The documented and coded findings are also sent to the hospital’s clinical decision support system, if available, triggering appropriate care pathways. The critical findings are automatically added to a registry of critical findings.

4. Standards and Systems

Relevant systems: Electronic health record (EHR), radiology information system (RIS), clinical decision support system (CDS)

Relevant components of standards: FHIR, SNOMED CT, LOINC, HL7 messaging, CDA

5. Discussion

This is an initial draft placeholder. Updated version to be developed during class seminar August 17-21.

See also Critical Results - Detailed Proposal