Filling the Communication Gap

The automated results notification market is ready to explode as regulations grow, technology advances, and hospitals adjust to the information highway.

If one were to ask a group of 20 radiologists how many are being sued in regard to results notification, you would expect to see some hands. It’s not an uncommon situation.

The radiologist spies something on an image that needs to be communicated to the physician for an active response. Steps are taken to communicate that finding, whether in the report (if not urgent) or by phone. However, the referring physician does not get the message. Perhaps they miss it in the report. Or perhaps it was never actually communicated but lost in a chain resembling the Telephone game. Whatever the reason, the patient goes untreated, possibly with devastating results. When the miscommunication is realized, the radiologist becomes involved in a lawsuit.

“About 75% of all malpractice cases in radiology have miscommunication as the causative factor,” says Tom White, vice president Veriphy with Nuance Communications, Burlington, Mass.

When St Mary’s Health Care System in Athens, Ga, found itself having to prove that radiology had communicated critical results (the detection of a lung nodule, for one patient), it lacked the necessary documentation. “We had the report the radiologist had created but no proof that it had gotten to the referring physician,” said Brian Duncan, RT(R)(CT), St Mary’s PACS administrator.

The situation served as impetus for the installation of an automated results notification (ARN) system. ARNs encompass critical test results management or CTRM solutions that provide notification paths specifically for critical results.

Other facilities have been inspired to convert to electronic results notification after failing the associated inspections of The Joint Commission. “The Joint Commission requires you have a process in place for critical notification but does not say what that system should be,” said Mark Halsted, MD, associate professor of radiology and chief of the Radiology Informatics Research Core at Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio. He contributed to the development of the RadStream ARN system before The Joint Commission made CTRM solutions a requirement.

The Joint Commission regulation is relatively new, and many facilities are discovering its impact only now, as they undergo a new round of Joint Commission surveys. Nearly two-thirds of hospitals last quarter were cited for not having critical test results systems, according to Jack Cornell, CEO of RADAR Medical Systems in Chagrin Falls, Ohio.

As a result, many institutions find themselves suddenly in the market for a results notification system. Fortunately, or unfortunately, it is not a very big market to negotiate at this time.

Slow to Adopt

“[CTRM] is relatively new for the amount of attention it is getting, and it hasn’t made its way onto the product map of most vendors. I suspect that 2 years from now, we will see a broader landscape,” said Paul Merrild, vice president of marketing for AMICAS Inc, Boston.

Commercialization of a system often takes that long or longer. Halsted notes the development of AMICAS’ RadStream began when the company acquired the license in 2006—it hit the market for general availability mid-year. “I’m very eager to see increased availability of systems like this in the marketplace because I think the marketplace will respond,” Halsted said.

Technological advances, information system penetration, and Joint Commission regulations are driving the new demand. “The market is reasonably sophisticated in terms of image management. As we get those basics down, we look to identify the parts of the radiology workflow that can be optimized,” Merrild said.

CTRM represents the newest step in this evolution of health care technology. Moving forward, Halsted expects companies to compete by their impact on workflow. “We want to make the system fit into the workflow of a radiologist as seamlessly as possible,” Halsted said.

Quick to Benefit

Without software, results notification generally interrupts the workflow of a radiologist. Radiologists can spend a significant amount of time trying to complete one call. Incorrect contact information and on-hold waits can add to the frustration.

“It’s stressful to go through a day constantly deciding whether to take 10 to 15 minutes to call someone when you are behind. Sometimes you don’t call and worry about it, and sometimes you do call and are behind,” Halsted said.

If the calls are not made, the radiologist may be interrupted by inbound calls. “We have fewer inbound calls looking for results because [our ARN system] proactively pushes the results out before the physician needs to call for them,” Halsted said.

Many question the cost-efficiency of paying radiologists to complete these administrative tasks. With an average salary in the $300,000 range, facilities would prefer that radiologists spend their time in the specialized tasks of imaging interpretation and radiology care, not results delivery.

CTRM can enable this. White estimates the average return on investment for an automated results notification system is about 8 months. That is due not only to the increased productivity (White notes that Veriphy can reduce physician time spent on calls by 95%) but also to a reduction in related legal expenses.

All communication is documented, providing an audit trail for legal, regulatory, and general business purposes. ARN users are better equipped to deal with lawsuits and customer complaints, which tend to decrease after the installation of an ARN.

“At end of day, radiology is very much a service industry to health care, and by automating results distribution, you are improving service and making it easier to do business with you,” Merrild said.

Many facilities find they communicate far more results after an ARN is installed than ever before. “We found our results conveyance increased by 400% after installation of the results notification system,” Halsted said. St Mary’s also saw an increase in the delivery of critical results after installation of its RadStream system.

Ultimately, the faster, more consistent service results in better patient care. “The goal in radiology is to provide some analysis of a study and give it back to the physician so they can put the patient on the proper care protocol. If they are not getting the results back, they may not know any pathology is present when in fact they need to take action,” Merrild said. Citing cancerous growths as an example, Merrild notes the consequences to a patient can be devastating if not addressed.

Clear Communications

ARN solutions prevent this from happening by setting up automated systems that ensure information is delivered in the proper format to the appropriate individual and properly documented. Some systems focus solely on critical test results; others encompass all results. Users typically define the rules that determine how specific results are dealt with.

RadStream offers users two options when closing a report containing an abnormal result: one checkbox for the automatic conveyance of results through the office staff and another indicating the radiologist would like to speak with the referring physician directly.

“The radiologists are in control because they decide how the information is delivered. We are not forcing them to go into another system or to take on the additional administrative burden,” Merrild said. They can continue working while a physician is tracked down or a result communicated.

Worklists prioritize these tasks for office personnel. “The information comes up on a real-time worklist clearly displayed where no one has to look for it,” Duncan said. He notes the RadStream system is extremely customizable. Different colored flags represent different time frames for results delivery and follow-up.

Nuance’s Veriphy also offers customizability. Rules are set up during installation, during which time Nuance will also send a team to develop the client directory. “We communicate with all floors, stations, and departments and build specific contact profiles,” White said. Escalation ladders are created so that results that need to be delivered within 60 minutes to meet The Joint Commission’s regulations are actually delivered and documented within that time frame.

The process begins with the radiologist recording a message from the reporting environment and specifying the rules. This can be done using several options, including speech recognition systems, PACS, or even an outside line. “The process takes 15 to 30 seconds,” White said.

The message is stored in the Veriphy server, which contacts the referring physician according to the preference indicated by that physician. Options include pagers, cell phones, PDAs, e-mails, and faxes. The message tells them they have received a priority critical result using the color-coding system developed by the industry. The information includes the caller category, the author name and department, and the phone number (toll-free) and ID required to access the message.

When the referring physician calls in, they hear the patient and caller ID along with the actual message. If they hang up halfway through, the system will not recognize delivery and will continue to try to contact the referring physician. “So we have a legal phone record that shows who listened to the entire message,” White said.

Audit trails provide HIPAA protections. Most ARN systems offer this feature, including RADAR Medical Systems’ RADAR. The solution also matches others in customization, extending the capabilities beyond results.

“We’ve tried to make the system customizable by users so they can determine what events they want to communicate,” Cornell said. He offers a serious example regarding image quality alerts (the radiologist can let the appropriate person know about issues with equipment) and a less serious but illustrative example where everyone is alerted to pizza being served at noon.

Using user-based rules, Radar automatically creates an alert based on the test or report data and delivers it according to preferences. Escalating contacts help to assure that fast turnarounds are met. Similar to Veriphy, the system lets the recipient know they have a message but does not actually provide the information in the initial alert, in part to meet HIPAA requirements and in part to be able to track the results delivery.

An alert is tracked every time it is touched. A VoIP telephone system built into Radar can even record phone conversations for later access. “Two and a half years later, you can pull up the record with the date and time stamp and playback of calls,” Cornell said.

If the facility chooses, it can have a database of radiology work orders that integrates other information for use in risk management, quality assurance, and peer functionality. “You can drill down to any data point: what percentage of radiology orders result in red alerts? How many red alerts are diagnosed on the CT in hospital A? Who is not making the turnarounds?” White said.

This is accomplished through HL7 interfaces; the system was developed for compliance with all HL7-compliant systems. “We ask for a sample HL7 message and map our HL7 record to theirs, making installation very simple,” Cornell said.

Simple Hurdles

Integratability varies with the program. While Radar is HL7 compliant, AMICAS’ CTRM is designed to work on its PACS only. Because Veriphy is a Web-based hosted solution, it is easily downloaded for immediate use and designed to integrate with other systems.

Typically, a facility does not need to purchase special equipment outside of the program to implement a CTRM solution. RadStream is available on all of its new PACS systems; users choose whether to turn it on or not. Radar, which aims to provide solutions for small institutions as well as larger organizations, offers options that range from storing the software on the hospital’s server to use of Radar’s data centers. Radar Lite is designed for a single PC, and the company also expects to introduce a subscription service whereby users pay as they go to manage their alerts through Radar’s servers.

In many instances, people can create greater obstacles than the technology. Implementation of an ARN system requires a change in workflow for both the radiologist and the referring physician. More tech-savvy physicians will tend to resist less. If there is a lot of resistance, the facility will likely not see massive improvements in turnaround time.

However, the benefits can be used to sell the system to the team as long as there are resources in place to support it. “One of the things we try to get our customers to understand is that as they implement the technology, they will generate a list of critical results that someone must be responsible for,” Merrild said.

At St Mary’s, this responsibility went to existing file room employees whose workloads had been reduced by the transition to digital imaging. These employees manage the critical contacts, while another employee handles less urgent follow-ups. Eventually, the transcriptionist, whose workload has been reduced by conversion to voice recognition, will also assume some of the CTRM communication responsibilities.

The transition to automated results notification has been relatively painless for St Mary’s. Now, when a critical result needs to be communicated, the radiologist does not need to struggle with the decision to make a phone call. Patient care improves, legal liability is reduced, and the bottom line rises. Ask 20 radiologists if they would be interested in that and it would be surprising if they did not all raise their hands.

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Renee Diiulio is a contributing writer for Axis Imaging News. For more information, contact .