A new tool helps minimize errors and maximize communication to benefit ED patients.

It’s 3 o’clock in the morning. A patient comes into the emergency department with an injury and requires radiology services. A resident radiologist covering on-call hours interprets the images, and no fractures or other significant findings are noted. An emergency department physician reviews the images and agrees with the resident’s conclusion. The patient is treated and sent home.

Two hours later, a radiologist begins his day reviewing the evening’s films. He notices a subtle fracture overlooked by the resident and the emergency department physician. Following the institution’s protocol, he documents the variance and enters the data into whatever information system is in use, expecting the next steps to occur as protocol dictates.

Depending on the system in use, however, it is sometimes possible that the variance report is lost: it may not be properly flagged for follow-up; it may not be properly followed up; or the patient may prove difficult, even impossible, to locate. “Our patient population sometimes gives phone numbers that are no longer in service or makes them up,” said Scott Wagner, MD, chairman of emergency medicine for South Jersey Healthcare, serving the southern region of New Jersey.

Fortunately, variance occurs very infrequently, with estimates below 2%. Unfortunately, the lost communication is representative of the challenges that have developed as disparate information systems have been implemented. Homegrown solutions have often been developed and put in place to fill in gaps.

“When our department went filmless and paperless, similar to other departments across the country, we put in a HIS and a RIS and a PACS and started installing sophisticated electronic equipment to help with patient care. The one piece that was missing was the communication tool, which is so key to being able to provide the best patient care,” said Kristen DeStigter, MD, radiologist and vice chairwoman of the department of radiology at Fletcher Allen Health Care, which operates in alliance with the University of Vermont College of Medicine and College of Nursing and Health Sciences in Burlington.

The Solution

To fill this gap, Sarasota, Fla-based peerVue launched QICS, a Qualitative Intelligence and Communication System designed to monitor all related workflow activity, collect clinical information, and perform real-time analyses using an advanced, customizable rules engine. Configured to address specific gaps in care delivery, QICS alerts appropriate personnel to specific situations or events on an escalating schedule to prevent potential issues.

Installed at Fletcher Allen, the system has become a necessary fundamental. “Instead of a HIS and a RIS and a PACS, you now need a HIS and a RIS and a PACS and a QICS to have the full solution, where you have a closed-loop communication and reporting solution within your imaging patient care,” DeStigter said.

The peerVue QICS is based on the basic exam life cycle broken down into six segments: registration; scheduling; image acquisition and display; report creation; report distribution; and coding and billing. These have been translated into six functionalities: error prevention and patient safety; rapid, intra-departmental and cross-departmental error resolution; urgent or emergent communication of findings; regulatory and quality assurance; revenue maximization and assurance; and business intelligence and reporting dashboards.

Error Prevention and Patient Safety

Registration and scheduling provide a prime opportunity to match patient history with potential problems to prevent issues that could result in harm to the patient. With QICS, allergies to contrast media or high radiation dose history is immediately flagged. In the past, the individual information system, such as the RIS, may have recognized the issue, but the information had no visibility. This problem is alleviated during scheduling with QICS.

Departmental Error Resolution

The same issue could sometimes arise in discrepancy management. “With our old system, there were questions about how reliably every study was getting into the [discrepancy] folder,” Wagner said. Simple misadjustments, such as the time frame for monitoring, could lead to missed variances.

The radiologists, therefore, sometimes spent time reviewing every folder to be sure nothing had fallen through the cracks. With QICS, variances are automatically placed into one folder and remain there until resolved. Institutions may choose to activate the alert function to sound whenever a discrepancy report enters the folder, which can help further speed response even more and avoid follow-up issues related to locating patients.

“Without timely communication, the patient could get lost to follow-up or, if the finding is clinically significant, it could be too late to help the patient,” DeStigter said.

Communication of Findings

Timely communication is also imperative when it comes to critical results and unexpected or incidental findings. These areas have more industry-based guidelines than discrepancy reporting and therefore more rules to meet. The Joint Commission regulates critical results reporting, and the American College of Radiology provides guidelines on critical results reporting and unexpected/incidental findings.

However, although both recommend specific time frames, individual institutions are left to develop facility-specific plans to achieve these turnaround and notification goals. “You will find that for 20 institutions, there are 20 different ways of critical reporting,” DeStigter said.

QICS streamlines that communication with a critical results reporting tool. The closed-loop system ensures that the necessary results are both communicated to and acknowledged by the correct personnel.

Regulatory and Quality Assurance

QICS not only offers functionality regarding results regulations and recommendations but also regarding reviews—peer reviews, resident reviews, and technologist reviews. The system is key to Fletcher Allen’s efforts to train residents and monitor new hires.

Every time a resident is on call, QICS tracks the cases that individual has read and the concordance that goes along with those cases. “Residents can go into a queue, see how they read the case, how the emergency department read the case, and how the final interpreting radiologist read the case. And they can do it all within one system so they can get immediate feedback on how they did in the learning moment,” DeStigter emphasized.

In the case of new hires, the tool enables observation of their transition to a new environment where they may be on a learning curve. Through a proctoring program, every 10 or 20 cases read by new department members are peer reviewed for a specified period of time. “We want to make sure they are meeting or exceeding the standard of care for our practice,” DeStigter said.

Maximizing and Assuring Revenue

QICS can also help a practice meet or exceed its revenue goals through two primary functions in this area: coding and billing discrepancy management; and PQRI bonus opportunity alerting and facilitation. The system is designed to catch omissions resulting from incomplete dictation, such as when a provider reports an ultrasound examination without mentioning the gallbladder. With QICS, the user is prompted to include all relevant information to maximize reimbursement.

The system will also streamline the identification and resolution of billing issues to further ensure appropriate reimbursement. With rapid resolution, all claims are made within the necessary time frame and rejections due to late submission are reduced or eliminated entirely.

Business Intelligence Reporting and Dashboards

In all of these instances, performance monitoring, quality documentation, and regulatory reporting are easily managed, reducing the risk and indemnity that can result from issues and resulting litigation. The gap QICS fills in discrepancy reporting is an excellent example of this function.

With no system in place, if a discrepancy was determined significant and required follow-up, there was no real way to be sure that the report had reached the right person or that it had any impact on patient care. peerVue’s dashboard feature clears the mystery, displaying everything relevant to that patient encounter and image.

“I’m able to look at a dashboard and see for that ankle x-ray the patient had: what the resident said, what the emergency department said, what the radiologist said, how and when the report was communicated to the emergency room and to whom, and what that person did with the information. All of that appears in this one communication tool,” DeStigter noted.

With extensive customization capabilities, the system is easily tailored to institutional and departmental needs. South Jersey Healthcare utilized macros to capture frequent responses and save typing time for physicians with drop-down menus. The lists included options such as “patient was admitted and will be addressed as inpatient,” “patient was discharged and called,” and “patient was discharged and variance is not significant.” “By clicking one checkbox, physicians could resolve the variance,” said Wagner.

The peerVue system allows even further customization within an institution. Radiologists and emergency department physicians at Fletcher Allen see very different drop-down menus, each more suited to its specific needs. “In the emergency department, there is one imaging review station all of the doctors have to use. So that drop-down menu—which had to permit each person using the system to look at [their] own cases of patients in the emergency department—had to be different than in radiology where we each sit at our own workstation and bring up cases, one after another,” DeStigter said.

Information is then available for data mining, whether assuring physicians perform within standards of care or developing quality metrics for process and business improvement aims. Fletcher Allen has seen a return on its investment with its original peerVue system, and DeStigter expects to see another with the implementation of the QICS solution—”not only financially, but in patient care. And how can you put a value on that?” said DeStigter.

Renee Diiulio is a contributing writer for Axis Imaging News.

A Small but Potentially Significant Role in Suicide Prevention

The emergency department and radiology department must frequently work together to properly diagnose and accurately treat patients who seek care through this route. Sometimes, this collaboration is not focused on images.

A recent Joint Commission Sentinel Event Alert sought to warn the medical community about the occurrence of suicide in non-psychiatric patients in emergency departments, as well as medical/surgical inpatient units. Suicide is one of five serious events reported to The Joint Commission. Risk factors for this population include dementia, traumatic brain injury, chronic pain or intense acute pain, poor prognosis or terminal diagnosis, and substance abuse.

The Alert targeted health care providers in the emergency department, but radiology is not isolated from these events. Although it is not a typical situation, it is possible a patient could begin to spontaneously make relevant remarks or discuss their mood, said Robert Wise, MD, a medical advisor to The Joint Commission.

If a technologist were to notice a significant or worrisome change in or commentary from a patient, the information should be reported to the attending or nurse in charge of the patient, advised Wise. Ideally, the institution will have implemented training per The Joint Commission’s recommendation for relevant staff in the emergency department and other frontline care positions, and therefore these personnel will know how to proceed.

—R. Diiulio