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

• A patient undergoes a chest CT after a motor vehicle accident.
• The radiologist interpreting the study identifies a pulmonary nodule in the right upper lobe and recommends a follow-up CT in six months.
• The radiologist notifies the emergency room physician, and documents the finding as well as the notification in her report.
• In turn, the emergency room physician notifies the patient about the need for follow-up.
• As the patient also experienced fractures as a result of the accident and was incidentally found to have abnormal renal function, he follows up with trauma surgery, orthopedic surgery and nephrology multiple times over the next two years. He also sees his primary care physician, who is not notified of the pulmonary nodule as it was not documented in the discharge documents after the inpatient stay.
• No one orders the follow-up chest CT.
• Two years later, the patient presents to the emergency room again with worsening shortness of breath, and is found to have a 3 cm right upper lobe lung mass. He is diagnosed with metastatic lung cancer that is deemed incurable.

Because of the lack of workflow and integration steps to properly track and monitor these follow-up recommendations, the patient in the above scenario suffered serious adverse consequences.

Ideal workflow:

• 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 an actionable finding (or a finding which is automatically flagged as actionable) triggers a “follow-up needed” message to be created in the event tracker.
• The tracker sends information about the event to one or more designated notification receivers, which can include the ordering physician, the patient’s primary care physician, or the hospital’s critical event team.
• If appropriate follow-up or disposition does not occur within a defined time period, then the event is escalated according to pre-defined workflows for the finding’s level of criticality, notifying additional parties (e.g. patient, care management group).
• At the time of discharge, this action item (with specific modality and timing of follow-up in the case of imaging, or specific evaluation and timing for other tests) should automatically populate to an electronic discharge document and become part of the patient’s record for viewing by all subsequent providers who care for the patient.
• At subsequent encounters, an alert should be issued if the follow-up remains incomplete, especially after the recommended time interval (in this case, six months) has elapsed.
• Each notification includes an option for acknowledgement, whereby the user can acknowledge that they’ve received an alert. Ideally, there should also be a way to fully close the loop by specifying that the follow-up has taken place. This could be manual (e.g., a PCP says that the suggested follow-up is not clinically indicated, or a non-radiology care plan is in place) or automatic (a notification is sent that a follow-up study has been performed, or a result is generated from the suggested follow-up imaging study).

4. Standards and Systems

Relevant systems:

• Electronic health record (EHR)
• Tethered personal health record (PHR)
• Radiology information system (RIS)
• Clinical decision support system (CDS)

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

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