Transcript Communication Issues in Radiology

The Joint Commission, ACR and Plaintiff’s
Attorneys: New Rules, Standards and Legal
Precedents Mandating Critical Test Result
Management in Radiology
Richard M. Chesbrough, M.D.
President, Radiology Medical Consultants, P.C.
Founder, RADAR Medical Systems, LLC
April 2012
Communication Issues
Sign of the times…
April 2012
Communication Issues
Legal Facts
“Malpractice litigation alleging
radiologic miscommunication is
growing at a faster rate that any other
type of radiologic wrongdoing.”
Berlin, Diagnostic Imaging, Nov. 2007; 31
April 2012
Communication Issues
Legal Facts
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“25% of ACR members report being
involved in at least one malpractice claim
involving failure to communicate…”
Kushner, JACR 2005;2(1):15-21
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Average payment…$1.9 Million Dollars.”
Berlin L., Imaging Economics; Sept, 2005
April 2012
Communication Issues
New ‘buzzword” in healthcare
Critical Test Result Management
“CTRM”
April 2012
Communication Issues
The Paradox of Radiology
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Most advanced imaging technology and
computer skills in the world.
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Yet…still rely on “primitive” phone calls,
answering machines, faxes and loose
pieces of paper for communication of
critical results.
* “One-way” communication.
* Often no permanent documentation
April 2012
Communication Issues
Radiology:
We know things that others don’t….
April 2012
Communication Issues
Significant Findings:
How would you handle this?
57 yr old Outpatient:
History: “cough”
April 2012
Communication Issues
How would you report?
Communicate results?
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5:30 on a Friday afternoon?
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…and Monday is a holiday?
April 2012
Communication Issues
Actual Cases:
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Susan W. (Head Nurse)
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1997 Physical
CXR: “Nodule LUL,
needs f/u”
No follow-up
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Routine Physical
Report misfiled
Ordered by N.P.
2000 Cough/SOB:
CXR: 3.5 cm mass
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Settlement: $2.3 Million
April 2012
Communication Issues
What about unexpected
findings: “Incidentalomas?”
CT ABD: ER Patient: “R/O Appendicitis” Saturday 10:30 P.M.
Study “negative” for appendicitis. LLL nodule noted. Patient discharged home (2:30
AM)
Lung Nodule
April 2012
Communication Issues
Retained Sponge
Abdominal X-Ray: “abd. pain”
Retained Sponge
April 2012
Communication Issues
The Problem:
No policies ?
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The referring physician is not directly contacted
on urgent or significant findings in up to 60% of
cases.
PIAA-ACR Study, 1997
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Almost 20% of radiology departments do not
have an established policy to communicate
findings.
PIAA-ACR 1997
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85% of radiology malpractice suits are related
to issues of communication.
Berlin; Imaging Economics, Sept. 2005
April 2012
Communication Issues
The Problem: Referring Doctors ?
Referring Doctors and Radiologist’s advice:
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U. of Maryland Study
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56,083 imaging studies
1,650 abnormals – needing follow-up
Docs notified by phone
153 patients (9.2%) had no f/u
(Over 15 month study period)
Musk; RSNA 2007
April 2012
Communication Issues
The Problem: Patients ?
Patients and advice of doctors:
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2005 AMA Poll:
2,286 Adults
“52% chose not to comply with their doctor’s
order for a prescription, diagnostic test or
surgical procedure.”
AmMedNews 10/17/05
April 2012
Communication Issues
The Problem:
Recent Study
Communication is prone to errors
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Singh, H.
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190,799 Outpatient visits
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(J.AmMedInformAssoc; 2007;14:459-466)
20,680 Imaging studies
1,017 (0.5%) Abnormal Findings (needing F/U)
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Notification sent via EMR
45 patients (4.4%) not acknowledged by provider
(lost to F/U)
 Overall: 0.2% (45/20,680) of imaging studies
had abnormal results - not followed up.
April 2012
Communication Issues
Extrapolated to National Population
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National Statistics:
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12 Billion medical test results annually
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Lab, X-ray, Cardiology, etc…
500 Million of these = Imaging studies
(33,000 rads x 15,000 studies = 500M )
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0.5% “abnormal” = 2.5M
4.4% Lost to f/u:
= 110,000 per year (300 people/day)
April 2012
Communication Issues
Going to get worse!
Megatrends:
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increasing communication failures
24/7/365 Radiology
Teleradiology (Remote Reading)
After-hours “Nighthawk”
Increasing ER visits ER as “primary care”
Fewer clinician interactions
(Doctors coming through Radiology Department)
April 2012
Communication Issues
Why Radiologists Don’t Call ?
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Mentality: “Not my job”
Interrupts workflow
“Takes too much time”
3-11 minutes: to contact referring physician or their designee
- Personal Communications - Quantum Radiology, 2004
- HFHS Radiology Staff, 2004. WBH Staff, 2006
- Dr. Len Berlin, Rush North Shore Hospital
Average radiology practice:
 @4 calls per day & 7 minutes/call = 28 minutes/day.
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$187,000 lost income for an average size radiology practice
(ACR, 2003: 7 radiologists/avg. group)
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Large Group: (i.e. 42 radiologists) = $1,122,000 lost income
April 2012
Communication Issues
Is calling enough ?
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Documentation ?
(who, what, when, how?)
“If it’s not documented it didn’t happen…”
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Permanent Record ?
(5 years from date of dictation)
April 2012
Communication Issues
Legal Precedent
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Merriman v. Toothaker
515 P.2d 509 (Wash App 1973)
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Cervical spine fracture
4-day delay - Permanent neurologic injury
Court: “Because of the serious
implications… “personal contact”
was required to insure prompt action.”
April 2012
Communication Issues
Legal Precedent
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Phillips v. Good Samaritan Hospital
416 NE 2d 646 (OH APP 1979)
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“Radiologists who provide indirect medical care
cannot escape liability by doing no more than relaying
information through ordinary hospital channels.”
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“The communication of the diagnosis… may be
altogether as important as the diagnosis itself.”
April 2012
Communication Issues
Legal Precedent
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Corteau v. Dodd
773 SW2d 436 (Ark 1989)
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Malpositioned Endotracheal tube
Routine report sent. No phone call
Patient suffered additional injuries
Court: “When a patient is in peril… it does him
little good if the [radiologist] has discovered his
condition, unless the [radiologist]…informs the
patient, or those responsible for his care...”
April 2012
Communication Issues
Legal Precedent
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* the future ?
Stanley v. McCarver
92 P3d 849 (Ariz 2004)
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Pre-employment CXR
Radiologist: “possible lung cancer”
 Report sent to Employer (nursing home)
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Patient not informed.
(Dx’d CANCER -10 months later)
Patient expires
 Radiologist and nursing home sued
 Nursing home declares bankruptcy
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April 2012
Communication Issues
Legal Precedent
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Stanley v. McCarver (cont.)
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Trial Court:
Dismissed case against radiologist.
Plaintiff appealed
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Appellate Court :
“If there is no referring physician, or the referring
physician is unavailable, the duty to inform the
patient shifts to the radiologist.” [italics added]
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Arizona Supreme Court :
Duty to inform is up to jury; case-by-case basis.
April 2012
Communication Issues
Joint Commission:
Joint Commission on Accreditation of
Healthcare Organizations
(Now – Joint Commission)
National Patient Safety Goals
No. 2: “Improve Effectiveness of
Communication Among
Caregivers.”
2A. Critical Test Results
2C. Measure Performance
April 2012
Communication Issues
JC: Communication Focus
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59% of hospitals were in compliance
with the Joint Commission national
patient safety goal #2 in 2008
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64% were compliant in 2007
….Problem not going away…
April 2012
Communication Issues
ACR Standards:
American College of Radiology: Standards of Practice: 2008
“Significant Unexpected Findings: “
[Radiologist must] “…communicate the findings to the referring
physician… in a manner that reasonably insures receipt of the
findings.”
(Requires “Direct communication”)
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In Person
By Telephone
“In radiology…[traditional reporting] or putting the
report into the RIS or EMR is inadequate.”
Chang P, Diagnostic Imaging, Oct. 2007; 40
April 2012
Communication Issues
New Alternatives:
American College of Radiology
Standards of Practice, effective Oct. 1, 2005
Communication of Findings, Section 5C:
New communications authorized:
“Other forms of [reporting] that provide documentation of receipt…to
demonstrate that the communication has been delivered and
acknowledged.”
 Text pager
 Facsimile (Fax)
 Voice messaging
 “Non-traditional approaches” (Email, PDA, Web)
April 2012
Communication Issues
HELP ?
April 2012
Communication Issues
Ideal CTRM Solution
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Time Sensitive
Acknowledgement receipt
Database:
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(two-way)
Tracking of results
Permanent Storage
Reminder notifications
(i.e. 3, 6, 12 month F/U)
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Ability to generate data
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Audit Trail
Searchable database
Compliance Reports (Joint Commission)
April 2012
Communication Issues
Ideal CTRM Solution
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Inexpensive
Easy to use
100% reliable
Enterprise-wide
Generate “Active” alerts
(Distinct from EMR – “passive alerts”)
April 2012
Communication Issues
Features & Benefits:
Problem
Feature
Ideal CTRM System
Benefit__
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Communication failure
“Closed-loop”
No lost results
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Time Sensitive
Activates in seconds
Urgent results
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“Lost” Patients
F/U tracking
No lost F/U’s
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Different locations
Web-based
Access anywhere
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Expensive
Nominal fee
No cost to users
(Hospital)
April 2012
(Physicians)
Communication Issues
CTRM: Provider Benefits
Improved Patient Outcomes
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Record of Notification
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Significant & Unexpected findings
Follow-Up recommendations
Permanent Record
Medicolegal Benefits
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Decreased Liability
Decrease Malpractice Premiums
April 2012
Confidential
Communication Issues
“The Single biggest problem in communication
is the illusion that it has taken place…”
- George Bernard Shaw
April 2012
Communication Issues
www.radarmed.com
Richard M. Chesbrough, M.D.
Founder, RADAR Medical Systems
(248) 514-9742
www.radarmed.com
April 2012
Communication Issues
April 2012
Communication Issues