Radiologists, meet your EMR ‘reference librarian’

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 - Jeffrey B. Mendel, MD
Jeffrey B. Mendel, MD

Jeffrey B. Mendel, MD, former Chair of Radiology and Chief of Radiology Informatics at, respectively, Tufts-affiliated St. Elizabeth’s Medical Center in Boston and Harvard-affiliated Beth Israel Deaconess Medical Center in Boston, shares an anecdote.

Earlier this year, a radiologist interpreting an emergency chest CT found himself puzzled by findings in the thoracic spine. The only clinical history was of a patient with chest pain. Lacking any other clue to contextualize what he was seeing on PACS, the radiologist contacted the ED physician. The clinician quickly clarified the order. The patient, it turned out, had fallen down a flight of stairs and the chest pain was really mid-back pain. Equipped with that additional insight, the radiologist quickly and confidently made the diagnosis: a subtle, acute spinal fracture requiring immediate neurosurgical intervention.

The anecdote encapsulates the utility of Conserus Imaging Fellow, a solution from Change Healthcare. It does a deep dive into records stored in the EMR, extracts clinically relevant information, and displays it in the PACS.

“The main pain point with the EMR is that most radiologists don’t want to go anywhere near it,” says Mendel, who now teaches at Tufts Medical School, practices radiology for two community hospitals in New Hampshire, and serves as a Senior Health and Policy Advisor for the international medical charity Partners In Health. “The EMR is foreign territory to most radiologists. It has tons of information that may or may not be useful during an interpretation but the information is almost always poorly integrated with the display of information we view with their PACS.”

Maximally leveraged EMR

It was specifically with EMR-averse radiologists in mind that Conserus Imaging Fellow was developed, Mendel explains. This web-based solution sifts through the inevitable reams of data that make searching through the EMR so challenging for time-pressed radiologists. Imaging Fellow can selectively extract everything from contrast allergies and medication side-effects to lab reports and visit notes, from health-problem lists to pathology reports, and, of course, prior radiology reports. The radiologist chooses how they want to view the information on their PACS—expandable panes, movable widgets, full or partial screens, etc—adapting the configuration to suit preferences at the site and enterprise levels.

The tool is optimized to find and present clinical content that may aid image interpretation for any given case—and only case-specific content, Mendel stresses. In fact, he likens its “findings” to Goldilocks’s preferences in the lair of the three bears: not too much, not too little but just the right amount of information.

“When a patient comes in after falling off a bicycle and breaking a wrist, there’s nothing much else you need to know unless the patient has cancer or some other condition that might have caused the wrist to break in a particular way,” Mendel says. “In most cases, you just need to read a wrist x-ray. That’s very different from reading the exam of a patient who comes in with abdominal pain, has a history of two different cancers, and is on three or four medications that might cause bowel problems.”

Lacking a tool like Imaging Fellow, he says, the radiologist in the second scenario would likely give a less clinically useful differential or need to reach out to the ordering clinician before arriving at a definitive diagnosis—a proposition that impacts productivity of both the clinician and the radiologist. “The fewer times we interrupt clinicians in their day to have them deal with things that we could have taken care of as “consultant” radiologists, the more we are going to be appreciated.” Mendel says.

Rightly allocated resources

Clinicians are under the same time pressures as radiologists. “As a radiologist, you can’t assume the current treating doctor is aware of a note in the EMR, from 10 years ago, that mentions the same nodule you’re looking at now,” he explains. “Having clinically pertinent information at your fingertips at the time of image interpretation puts you, the radiologist, in the position of being a valuable clinical colleague rather than just somebody who is checking a box and ordering additional studies that might not be needed.”

There are also significant cost savings to be considered. For a new patient or a patient with a complex medical history, clinicians may not have every aspect of clinically relevant EMR data at their fingertips. If the clinician has not conveyed the all the key details of the patient’s EMR data, Mendel notes, the radiologist’s interpretation may be imprecise and economically wasteful. “The least expensive medical test is the one that gets you to the diagnosis first,” Mendel says. Imaging Fellow can help radiologists maximize their value as diagnosticians and consultants to referring clinicians and the healthcare enterprise

“Any time you can shorten the workup and be more specific in your diagnosis, you’re going to take a load off the caring clinicians, off the nurses, and off the hospital system,” he adds. “Getting to the best diagnosis without delay can also reduce avoidable downstream expenses.” These potentially include costs racked up by readmissions, extended lengths of stay, medical errors, and malpractice suits.

While clinicians ordering imaging frequently know if their patients have, for example, allergies to contrast agents, that is not always the case, Mendel points out. Sometimes “contrast allergies” are not significant and sometimes a contraindication to a specific imaging study isn’t uncovered until the patient has returned for a contrast study and the technologist goes through the preconditions checklist, “discovering” an allergy or contraindication to a contrast examination. “That’s a waste of half a day in the hospital, of the CT or MRI scan slot, and of the transport and other resources—and of the patient’s workday or family time”, Mendel says. “All those things add up to delay in diagnosis and an unsatisfactory experience for that particular patient.”

Better care at lower cost

Reflecting on how all of this worked in the long-gone days before PACS, Mendel recalls that summaries written on film jackets communicated context to radiologists in an elegantly simple fashion. “In a few seconds, you could get a quick summary of all the positive findings on patient’s past imaging studies aiding accurate and rapid image-interpretation” he says. “That’s what we have lost. We’ve lost the ability to quickly see what’s going on with the patient. Imaging Fellow is bringing that ability back and more.”

In this high-tech return to basics, Mendel sees an outstanding opportunity for radiologists to leverage clinical information buried in the EMR.

“The EMR itself is like a library with no card catalog,” he says. “You would have to go and search shelf after shelf to find what you need. Imaging Fellow is like the reference librarian who can tell you exactly which book you need and lead you right to it.”

“Being able to get clinical information without interrupting clinicians, knowing that the conclusions you are making are valid based on the actual clinical situation, and being able to come to the best differential diagnosis or recommendation for follow-up at the time you read the study is very, very valuable,” Mendel says.

Citing recent research showing that radiologists spend about an hour a day scrambling to find clarifying clinical information, he predicts Conserus Imaging Fellow will soon become as indispensable to radiologists as PACS itself. “It’s going to save radiologists time,” he says. “It’s going to save hospitals money. And it’s going to improve patient care.”