Reporting and Follow-up of Actionable Findings in Radiology Reports

1. Proposed Workitem: Reporting and Follow-Up of Actionable Findings in Radiology Report

• Proposal Editor: Tessa Cook, MD PhD
• Editor: TBD
• Date: N/A (Wiki keeps history)
• Version: N/A (Wiki keeps history)
• Domain: Radiology (RSNA, SIIM, ACR)

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 the dictation system 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 6 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 2 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. Ideally, the follow-up recommendation should be communicated to the EMR and automatically set up as a flag. 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, 6 months) has elapsed. Electronic notifications should be sent to relevant providers, and ultimately to the patient himself, while the follow-up remains incomplete.

4. Standards and Systems

This problem affects dictation/voice recognition systems for radiology, electronic medical records and patient health portals.

5. Discussion

IHE should develop a vendor standard that can be followed to more seamlessly communicate and track this information. At our institution, we have an initiative that 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 get involved.