Critical Finding Follow-up and Communication

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

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

Scenario 1: a patient within the same health system

• Patient John Doe undergoes a chest CT after a motor vehicle accident.
• Radiologist Dr. Smith interpreting the study identifies a pulmonary nodule in the right upper lobe and recommends a follow-up CT in six months.
• Dr. Smith notifies the emergency room physician, Dr. Jones, and documents the finding as well as the notification in her final report.
• In turn, Dr. Jones notifies Mr. Doe about the need for follow-up.
• As Mr. Doe 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 within the same health system 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, Mr. Doe 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.

Scenario 2: a patient within a connected health system (e.g., within the same HIE)

• Patient John Doe has a low-velocity motor vehicle accident three hours into a four-hour drive to the beach with his wife. They are transported to the nearest community hospital, which is affiliated with the health system in which Mr. Doe normally has his medical care.
• Since he complains of chest pain, Mr. Doe gets a chest X-ray and a chest CT at the community hospital.
• He is found to have a 7 mm left lung nodule on his chest CT.
• Dr. Smith, the interpreting radiologist, recommends a follow-up chest CT in 6 months according to the Fleischner Society criteria.
• Dr. Smith communicates this to Dr. Jones, the emergency department physician, and documents the finding and communication in her report.
• Dr. Jones mentions the nodule to Mr. Doe and documents it in his discharge paperwork.
• Dr. Jones instructs Mr. Doe to give the paperwork to his primary care doctor when he gets home.
• Sometime during the trip, Mr. Doe’s discharge paperwork is lost, and the follow-up for his nodule is never communicated to his primary care doctor.
• Two years later, Mr. Doe 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.

Scenario 3: a technologically “unknown” patient (i.e., not within the same or an already connected health system)

• Patient John Doe is visiting his grandchildren in California, and has a motor vehicle accident and is transported to the nearest Level 1 trauma center.
• He has a CT of the chest, abdomen and pelvis to evaluate his injuries.
• He is noted to have a 1.5 cm mass in his liver, but has no other injuries related to his motor vehicle accident.
• Radiologist Dr. Smith identifies the liver mass, and communicates it to Dr. Jones in the trauma bay, in addition to documenting it in her report.
• Mr. Doe is evaluated overnight and discharged the next morning. He flies home to New York the following week.
• No information about his care in California is communicated to his primary care physician in New York.
• Three years later, after gradually worsening abdominal pain and jaundice for a few months, Mr. Doe undergoes an abdominal ultrasound that shows a 3 cm mass and additional 1-2 cm masses in his liver. He is diagnosed with hepatocellular carcinoma and begins extensive treatment. The report of his prior study from California is obtained via fax after a few weeks.

Because of the lack of workflow and integration steps to properly track and monitor these follow-up recommendations, the patients in the above scenarios 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
• (Consider leveraging IHE ITI mACM and PCD ACM)

5. Discussion

IHE should develop a vendor standard that can be followed to more seamlessly communicate and track this information. At the University of Pennsylvania, an initiative uses structured reporting and a separate home-grown system to track these patients, but this is not an ideal solution. There is definitely an opportunity here for IHE to become involved.

(Langer) Key IT points are that regardless if patient is local, in same HIE or unknown, the desired behavior is:

• the first Radiologist makes a followup recommendation
• the EHR adds a reminder to the Radiologist watch list that keeps nagging (configurable)
• the EHR takes the followup recommendation as an order
• If the followup order is completed, that nag comes off the Radiologists watch list

See also Critical Results - Detailed Proposal