Reality Check: Optimizing Electronic and Human Interactions in Radiology
The need for improving communications in radiology is well understood, but optimizing interactions with referring physicians is where it gets tricky. In a 772-bed tertiary-care teaching hospital and level I trauma center, the call for increased face time must be balanced, supported, and made optimal through the smart use of electronic tools. At Einstein Medical Center, Philadelphia, Pennsylvania, where Terence Matalon, MD, FACR, FSIR, is chair of the radiology department, multiple strategies are used to give referrers the information they need, in the format they prefer, in an appropriate time frame.
“Communication is a critical part of the work product of the radiologist. It’s not simply our job to interpret the images, but to ensure that the study that is being done is actually the correct exam, and that the message that we are trying to deliver is actually delivered to the appropriate person.”
—Terence Matalon, MD, FACR, FSIR
The 24-radiologist department reads about 280,000 exams annually—a figure that will jump to 350,000 in September, when the Einstein Healthcare Network (EHN) absorbs a smaller community hospital. Department radiologists currently interact with approximately 600 employed staff physicians and at least another 600 community physicians. At the center of EHN radiology communications is an electronic system for communicating critical and significant results that has been optimized by referrer and for severity. Other key communications strategies include a movement toward using report templates, participation in hospital committees, and various initiatives by which radiologists insert themselves in the diagnostic evaluation of the patient. The Nerve Center While many sites use three levels of acuteness to comply with Joint Commission requirements for critical-results communications, Matalon and his team chose to proceed with two levels: emergency-level results that must be communicated within one hour and significant results that must be communicated within three days. Last month, the team communicated approximately 600 significant results and 40 emergency-level results. “We felt there was some simplicity in distinguishing between something that needed to be done right away versus something that could be communicated within three days,” Matalon explains. “Based on that criterion as a function of our Joint Commission requirement to monitor compliance, we have about a 98% compliance rate for significant messages (because the leeway there is pretty long, at three days), and we have about a 70% or so compliance rate for emergency-level messages.” Not only is the communication of important results a regulatory issue, but it also is a crucible in malpractice defense. “If one looks at malpractice suits that involve radiologists, communication is a very frequent theme as the underlying root cause for the suit,” Matalon emphasizes. “Historically, its been reported to be a central issue in 30% to 40% of malpractice cases, so its unlikely that people overcommunicate findings.” Nonetheless, determining whether a finding should be communicated is up to the discretion of the radiologist, and knowing when and how to intrude into another physician’s workflow is an important call. “I hope that they would not bother somebody for something that is already a known fact,” Matalon says. “If there is pneumothorax that is well known, and we are just monitoring a chest radiograph, over time, that shows a static, nonchanging pneumothorax, unless there is a dramatic decrease or increase in that pneumothorax, there would be no reason to reach out to the clinician to let him or her know that there was a pneumothorax there. If the pneumothorax became larger, though, that might warrant a change in the management and therapy of the patient—and it would be significant.” The Right Touch Not all physicians are communicated with in the same way, and the primary differences are seen for two classes of physicians at Einstein Medical Center: emergency physicians and trauma surgeons in the emergency department, who almost always receive a phone call that is then documented within the critical-results–communication system used at Einstein Medical Center. A significant finding, on the other hand, is one that could affect the patient’s treatment. “It doesn’t necessarily have to be a critical result, and it doesn’t have to be a life-threatening result, but it might have an impact on a decision to change or institute therapy, and that represents something that we would always communicate,” Matalon explains. “We adhere to the ACR® standard from the standpoint of the requisite criteria for communication.” There are multiple ways to communicate critical results to referring physicians, and their preferred method is registered during the enrollment process: cell-phone number, office number, or 24-hour office line. “Some people choose to use a fax, which we strongly discourage, because if there is no one to receive a fax, then the fax is not going to get acted upon,” Matalon says. The process works like this: When a referring physician receives a result, he or she dials a toll-free number, punches in a case number, and is required to listen to the message dictated by the radiologist, in its entirety, in order to close the message. “At the conclusion of listening to the message, the referring physician has a number of options, if he or she chooses to exercise them,” Matalon explains. “The referrer can accept the message and close it; can reject the message and say, ‘This isn’t my patient’; or can ask the radiologist a question, and that would then be directed to the radiologist using the same application. The process is entirely electronic.” Escalation Opportunity Remarkably, 97% of the time that a significant result is communicated to the referring physician, there is absolutely no human intervention required on the sending end, other than the click of a button. Einstein Medical Center’s compliance rates of 97% for significant results and about 70% for emergency-level results, however, were not achieved immediately upon the system’s implementation, six years ago. “In general, over time, we have developed the ability to get to these physicians very directly,” Matalon says. “We hope to become more intimate with our referring physicians as time goes on, and as they see the value of improving our ability to communicate with them. Unfortunately—or fortunately—what generally causes change is an adverse event.” Every time someone goes out of town, and there is a significant result that he or she does not receive, it triggers what Matalon calls an escalation opportunity to improve communications. When a message reaches noncompliance (beyond one hour for emergency-level results and beyond three days for significant results), that is the signal to reach out physically to that clinician, the clinician’s office, or the clinician’s partner to ensure that the communication is made (even if it is out of compliance, from a time perspective). “At that point, it may become evident why the clinician did not respond,” Matalon explains. “It may be because of a changed cell number that he or she didn’t give us or a fax-number change; whatever it was, at that point, corrective action can be taken.” The Acceptance Process While Matalon reports that overall, satisfaction with the process is very high in the referring-physician community, it did not start out that way. “Initially, and occasionally even now, we will receive feedback that someone doesn’t want to participate,” Matalon says. If, after the patient-care benefits and Joint Commission requirements have been explained, the physician still refuses to participate, Matalon lets the referrer know that he is certain that he or she can find an alternative provider of imaging services that is less committed to quality than Einstein Medical Center’s radiologists are. “Once they hear that, they know we are serious,” he says. “We may have lost some business over the years, but I don’t think that’s really the case.” Matalon also makes the key point that the large majority of findings that must be communicated are not emergency-level findings, and that clinicians can pick up those findings at their convenience. “If I were reading the case and had no other system, I would have to insist on interrupting a referrer who is with a patient or doing a procedure to communicate something that is really not vital to communicate at that moment,” Matalon notes. “The ability to receive significant messages at their leisure is very well received by the clinicians.” Improving the Product Another communications strategy employed at Einstein Medical Center is moving to the use of report templates (for 70% to 80% of complex studies) to produce a final report that is more repeatable and consistent, from the standpoint of presentation of the information about a particular exam. “This format (as opposed to a long, dense paragraph about a particular or multiple different aspects of a case, which is the way we would previously dictate something) improves the ability of a clinician to extract the relevant information from a report,” Matalon says. For a CT exam of the abdomen and pelvis, there is a section on technique, history, and signs/symptoms, followed by sections on the lower chest, the liver, the gallbladder and biliary tree, the pancreas, the spleen, the adrenal glands, the kidneys, and the bowel. “Each of those sections will represent a separate area within the report, so that a clinician could easily focus on a particular organ, if he or she had a concern about it,” he says. “They are templates that are continuously evolving. They probably came from somewhere, but we have modified them, over time, and we continue to modify them as we see opportunities to improve the way that we can set up information for people.” Practicing Human Interaction Still, Matalon says, the department struggles with the increasing distance that technology has imposed on radiologists. “The PACS and these electronic communications systems, to some degree, distance us from our clinical colleagues,” he says. For that reason, when Matalon sends messages within the critical-results–communication system, he tries to be as personal with physicians as possible, perhaps calling them by their first names. Einstein Medical Center’s radiologists participate in dozens of weekly conferences for other subspecialty organizations in the network and, on a one-to-one basis, frequently answer questions about the proposed diagnostic workup of a particular clinical problem. In addition, Einstein Medical Center’s radiologists have launched multiple initiatives through which they insert themselves into the diagnostic evaluation of the patient, including a quality initiative to reduce radiation dose in the pediatric population. “Any exam in the pediatric population must be prescreened by a radiologist,” Matalon says. “During that process, we evaluate the appropriateness of the radiation dose, as compared with replacing it with a diagnostic procedure that does not use ionizing radiation and that might yield similar (or even better) information, based on the indications for the study.” In the department’s main reading area, a clinician-review area features a simulated reading station with a very large screen that is suitable for use by groups of 10 to 20 people; there, the ICU team, the neurologists, and the neurosurgeons can look through all of their patients’ images as part of their rounds procedures, with the support of a designated radiologist. Communications is not an afterthought at Einstein Medical Center, but is a central part of the radiology product. “It is something increasing attention is being focused on, both from a regulatory perspective and from a value perspective (it’s always been there, from a legal perspective),” Matalon notes. “To some degree, our value in the equation is going to be weighed by how well we communicate.” Cheryl Proval is the editorial director of Radinformatics.com and the editor of Radiology Business Journal.