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 (UPenn)
- Profile Contributors: Steve Langer (Mayo),
- Domain: Radiology
<Summarize in a few lines the existing problem . E.g. "It is difficult to monitor radiation dose for individual patients and almost impossible to assemble and compare such statistics for a site or a population.">
<Demonstrate in a line or two that the key integration features are available in existing standards. E.g. "DICOM has an SR format for radiation dose events and a protocol for exchanging them.">
<Summarize in a few lines how the problem could be solved. E.g. "A Radiation Dose profile could require compliant radiating devices to produce such reports and could define transactions to actors that collect, analyze and present such information.">
<Summarize in a line or two market interest & available resources. E.g. "Euratom and ACR have published guidelines requiring/encouraging dose tracking. Individuals from SFR are willing to participate in Profile development.">
<Summarize in a line or two why IHE would be a good venue to solve the problem. E.g. "The main challenges are dealing with the chicken-and-egg problem and avoiding inconsistent implementations.">
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.
- 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.
- 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:
- 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)
- Report Mobile Alert (ITI-84) and Query for Alert Status (ITI-85)
- Would DSUB let the radiologist subscribe to be notified when the relevant followup report gets published.
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.
See also Critical Results - Detailed Proposal
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- Move the Summary section here to the end of Section 1 in your Brief Proposal
- Expand details in the Use Case Section of your Brief Proposal
- Distribute material in the Discussion Section of your Brief Proposal into the other bottom sections (5,6,7,8,9) here.
5. Technical Approach
<This section can be very short but include as much detail as you like. The Technical Committee will flesh it out when doing the effort estimation.>
<Outline how the standards could be used/refined to solve the problems in the Use Cases. The Technical Committee will be responsible for the full design and may choose to take a different approach, but a sample design is a good indication of feasibility.>
<If a phased approach would make sense indicate some logical phases. This may be because standards are evolving, because the problem is too big to solve at once, or because there are unknowns that won’t be resolved soon.>
<Indicate what existing actors could be used or might be affected by the profile.>
<List possible new actors>
<Indicate how existing transactions might be used or might need to be extended.>
New transactions (standards used)
<Describe possible new transactions (indicating what standards might be used for each).>
<Transaction diagrams are very helpful here. Go into as much detail as seems useful.>
Impact on existing integration profiles
<Indicate how existing profiles might need to be modified.>
New integration profiles needed
New Critical Finding Followup Profile (CFF)
Breakdown of tasks
<As the basis for the effort estimation, enumerate the tasks to develop the Profile text. E.g.>
- <Discuss/Confirm use case list (currently 5) to decide in/out of scope and details>
- Capture the "trigger" recommendation from report (either automatic parsing of report or manual step by radiologist)
- Triggered agent initiates an order and/or a reminder (nag-a-gram in the problem list for the patient)
- Needs to know which system to send the order to and what to put in the order
- Processes and send reminders to radiologist and referring at certain intervals
- The referring will be engaged with the problem list but radiologist will need an entirely different mechanism (maybe a reminder queue they see once a day in the reading room?)
- Might be good for the patient to be reminded too
- Capture the "trigger" for clearance of nag-a-gram or completion of order
- If going on completion of followup, this might use the same mechanism as searching for priors
- Three arenas
- Patient is in their "home" facility so order and followup are all local
- Patient is in an affiliated facility (e.g. XDS Affinity domain) so not technically local, but channels exist
- Raises questions about ordering privileges
- Patient is in an unaffiliated facility so no coordinated IT interface
- When does the nag-a-gram start working (e.g. for 6mo followup, does it start at 5mo or 6mo+1day)
- How far does it escalate
- Ask Radiologists where they consider their responsibility ended; is it the same as the referring?
- How does all this work in the more distributed arenas, e.g. where does the nag list live and how do you add/remove from it remotely
- Will orders be "accepted" from "outside"?
- Do we send the "proposed order" for someone else to place? Do we send the recommendation?
- Do we have to use a central repository where things get pushed to and participants have to pull from there (to keep IP Sec happy)?
6. Support & Resources
<List groups that have expressed support for the proposal and resources that would be available to accomplish the tasks listed above.>
<Identify anyone who as indicated an interest in implementing/prototyping the Profile if it is published this cycle.>
- Check with Paul Nagy (JHU), Harry Solomon (OHSU),
<List technical or political risks that will need to be considered to successfully field the profile. Demonstrate to the TC/PC your understanding/appreciation of the problem space>
8. Open Issues
<Point out any key issues or design problems. This will be helpful for estimating the amount of work and demonstrates thought has already gone into the candidate profile.>
- Consider potential issues around self-referral, need to have the referring physician properly engaged
9. Tech Cmte Evaluation
<The technical committee will use this area to record details of the effort estimation, etc.>
Effort Evaluation (as a % of Tech Cmte Bandwidth):
- 35% for ...