Getting the Message
How can radiologists best communicate critical test results?
Nearly every radiologist has been there: you discover an incidental finding that requires prompt clinical attention.
But figuring out who to alert, and how to alert them, can be a difficult act. You contact the emergency department physician, who is too busy to reply — plus, the patient has already been admitted, and no one seems fully responsible for the patient just yet. Hours later, a series of missed pages and voicemails have only interrupted your daily workflow without yielding tangible results. What's more, the failure to convey critical test results could have dire consequences for patient care.
Critical test results management (CTRM), the process of communicating important imaging findings for future action, can be challenging due to its several-step process. First, you have to figure out the finding's level of importance, including the time frame during which communication is vital. Next, you must decide to whom you should communicate that result. Finally, you have to choose the best method of communication — from phones and pagers to secure email and automated alerts. Even then, it's not always easy to figure out how to find the correct number or means of contact, thus ensuring the information is passed on and the communication loop is closed.
Despite these obstacles, CTRM is extremely important within radiology. The failure to communicate findings properly can harm the patient or lead to malpractice claims. Today, many hospitals have adopted CTRM systems to help ensure no critical finding falls through the cracks.
Categorizing the Response
The Joint Commission's National Patient Safety Goals include "report[ing] critical results of tests and diagnosis procedures on a timely basis." This goal relies on the fact that radiologists can seamlessly determine what constitutes a critical result. According to Tessa S. Cook, MD, PhD, assistant professor of radiology at Perelman School of Medicine at the University of Pennsylvania in Philadelphia, "CTRM really demonstrates the role of the radiologist at every step in the process: before, during, and after interpretation and management of findings from the study. I think it's so important that we take some ownership of these recommendations." In this sense, CTRM also helps fulfill the ACR Imaging 3.0™ campaign goals to standardize communication and provide quality care to patients.
"Understanding what's urgent and what's not is the easy part," says David S. Hirschorn, MD, director of radiology informatics at Staten Island University Hospital in Staten Island, N.Y. From there, published guidelines can offer recommendations on how to respond. In a recent JACR® article, the ACR Actionable Reporting Work Group categorized the time frame during which it's crucial to report an actionable finding into three groups: communication within minutes, communication within hours, and communication within days. The article splits different findings into these three categories, in an appendix table found here.
The JACR article authors emphasize that they did not intend to create formal guidelines for actionable findings management, but rather, a paper to "support local practices in their efforts to develop such categories and processes." The article suggests that radiologists consult their hospital's policy before determining which results are critical and how quickly they should be conveyed.
Other radiologists have also met success in defining and communicating critical test results. At Virginia Commonwealth University, radiology department staff implemented a new CTRM process and presented a poster at RSNA about their findings. Presenters found that their prioritization process was overly complicated because of more than 50 time-frame designations, ranging from "ASAP (within 4–6 hours)" to "Life threatening (1 hour)" to vague options like "Soon," "Stat," and "Today." Radiologists at the university successfully condensed the list to a handful of more concrete designations and created a daily auditing system to ensure timely reporting of critical results.
Whom to Contact (And How)
After categorization, the next step, Hirschorn says, is to figure out to whom you should communicate a critical result. And it's not always the attending physician or the primary care physician who ordered that particular test. According to Hirschorn, sometimes it's a resident or intern who's taking care of the patient and knows his or her status. "There's a lot of hoopla involved with figuring out who is taking care of a patient," says Hirschorn, who adds that the process of finding that clinician differs greatly based on whether the patient is in the emergency department, admitted to an inpatient facility, or is an outpatient.
For inpatient facilities, Cook believes part of the problem is maintaining an accurate directory of providers. At teaching institutions, there's an opportunity each July to update the directory as new trainees arrive and old ones graduate. "Even among the faculty, we are required to update our contact information annually," Cook says.
In the outpatient setting, an electronic medical record can typically connect you with the referring physician who ordered the imaging test. At Cook's practice, radiologists have the ability to send notifications about critical results through the dictation system: "You can leave a voicemail and receive almost instant acknowledgement of the finding," she says, adding that the greatest benefit of this system is it barely disrupts the radiologist's workflow.
Brian D. Gale, MD, MBA, managing member of Safer MD, LLC, and director of radiology informatics at the SUNY Downstate Medical Center in Brooklyn, N.Y., says not to overlook the importance of double-checking the patient's status — especially emergency department patients — which can help determine if the patient has changed departments since being admitted.
"How to communicate is still a big challenge," Gale adds, "because clinicians can be in many places: seeing a patient, traveling between patients, or on a day off." Once you determine the correct person to contact, it's hard to know whether you should pick up the phone, page them, email them, or use an automated alert system — none of which are sure-fire ways to reach the physician. However, manually relaying critical results isn't the only option. Many hospitals have adopted CTRM systems, which help ensure the smooth flow of information between radiologist and physician.
Tools of the Trade
Gale says he has previously worked at hospitals that have implemented CTRM systems. The first step if you are considering implementing one is, he says, "to get buy-in from your clinical staff and administration. Implementation is incredibly important, and you want confirmation that everyone is going to use this system."
CTRM systems have a wide set of features, most of which are customizable based on your needs. Some alert the proper physician directly when there is a critical result, asking for confirmation that the message was received. Others alert administrators, who then put the radiologist and physician in contact with each other directly to speak about results via phone or in person. All of these systems exist to help radiologists and physicians close the communication loop when it comes to CTRM, and radiologists can work directly with staff and other departments to determine what features will work best for them.
Despite many benefits, some worry about the automation of communicating such critical information. However, Hirschorn says it's important to remember that all systems require the human touch too: "Technology is not going to solve the problem for you by itself. CTRM systems require a human being to interact with them and flag a result as critical. They require staff to oversee them and to make sure the physicians gets the individual messages."
Gale agrees: "It's not really automated. A radiologist has to use his or her judgment to figure out how urgently something needs to be communicated, and to whom it needs to be communicated. It's not a machine doing all the work, and that is how radiologists can continue to add value."
Learn More at ACR 2015
If you want to learn more about CTRM systems, David S. Hirschorn, MD, and Tessa S. Cook, MD, PhD, are presenting a session at ACR 2015. The session, "Critical Test Result Management: The Battle to Close the Communication Loop," will feature three speakers, addressing such questions as, What constitutes a critical result? What are the ways to deliver critical result messages? and, What are the challenges and successes of using CTRM systems?
Hirschorn states that the main learning objectives will be to understand the basics of CTRM and explore the capabilities and limitations of the systems on the market today. He emphasizes, "We're going to talk about real-world experiences, what has and has not worked, and future directions and ways to improve CTRM." More information here.
By Alyssa Martino, freelance writer for the ACR Bulletin