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The Tickler File: PACS Application
Alerts Radiologists When
Recommended Additional or Follow-up
Examinations are Rendered
Mikhail Nekhline, MD
Safwan Halabi, MD
Henry Ford Health System
Department of Radiology
Detroit, Michigan, USA
What is a Tickler File?
 Ordering provider: A file/list that is
maintained to alert health care providers if
and when a follow-up examination is
recommended for their patient
 Radiologist: A file/list that is maintained to
follow-up imaging recommendations and
patient outcomes
Examples of Paper Tickler Files
Reporting and Communication
 American College of Radiology (ACR) Guidelines
on Reporting
 Effective communication is a critical component of
diagnostic imaging
 Commitment and reciprocal duty of information
exchange between the ordering provider and radiologist
 Emphasizes the importance of suggesting additional or
follow-up studies when appropriate
 Mandates the necessity to review all available pertinent
previous reports and images
Radiology Report
 Clinical document that communicates the imaging
interpretation and recommendation of the
radiologist
 Clinical document that serves to guide patient care
 Patient’s document that resides in the permanent
medical record
 Legal document for medical malpractice liability
Radiology Report
 Cleary written and/or verbally communicated to
avoid ambiguity
 Includes comparison and correlation to prior
imaging when available
 Includes recommendation for appropriate
additional or follow-up examination
 Final signed report with interpretation and
recommendation delivered to the referring
provider or clinical service
Communication Shortcomings
 Radiology reports and communications are
not received by the responsible parties
 Significant delay between image acquisition
and image interpretation
 Prior imaging is not available at the time of
interpretation for comparison
Communication Shortcomings
 Referring provider assumes that other health care
personnel will follow-up with the radiology
recommendations
 Referring provider may misinterpret the clinical
significance of the imaging interpretation and/or
follow-up imaging recommendations
 Patient transferred care to a different facility, was
lost to follow-up or was non-compliant with
follow-up recommendations
Electronic Tickler File as a Solution
 Create exam follow-up lists and alerts
electronically at the time of image interpretation
and recommendations
 Ability to track all subsequent patient imaging to
ensure that recommendations were acted upon
 Provide feedback to the radiologist in regards to
follow-up imaging results and patient outcome
Electronic Tickler File as a Solution
 Enables the radiologist to become an active
participant in the care of patients
 Establishes a closer rapport with the referring
provider and clinical service
 Reduces burden on the referring provider
 Overall goal is to deliver better patient care and
enhance patient safety
Electronic Tickler File as a Solution
 Prevent duplicate imaging exams ordered from
different providers
 Guide patient care and close the loop to the
ordering provider and patient
 Radiologist interpreting the follow-up exam will be
in a better position to answer the clinical question
raised on the initial exam
 Limits malpractice claims
Malpractice Issues
 Negligence of hospital employees to deliver a
message or act upon it does not protect the
radiologist from a medical malpractice claim
 Failure to review prior exams for comparison or
correlation may be considered as negligence
 Failure to act on recommended studies may be
considered a breach of duty by both the referring
clinician and the radiologist
Henry Ford Health System
Electronic Tickler File Solution
 Illuminate plug-in (Softek Solutions, Inc.,Kansas
City, KS) developed for iSite Radiology PACS
(Philips, Foster City, CA)
 Advanced search and data mining plug-in with
functionality to create exam alerts
 Alert user when a key word is mentioned in a radiology
report
 Alert when follow-up imaging is performed on a specific
patient
Henry Ford Health System
Electronic Tickler File Solution
 PACS plug-in allows a radiologist to track a patient
when follow-up imaging is recommended
 Follow-up alerts can be filtered by specific imaging
modality
 Alert expiration date can be designated
 User can be alerted when an exam is not rendered
by a certain date or time period
Alert Options
 Alerts can be received by the radiologist and
other providers via different electronic
methods including: plug-in inbox, e-mail,
text message, and pager
 Alerts may contain the follow-up imaging
report or a link to the report
PACS Plug-in Demonstration
Use Case: Abnormal CXR
Use Case: Abnormal CXR
Illuminate
Main Menu
LLL Collapse
Setting the Alert
Set the Alert
Setting Alert Options
Set Expiration
Chose Modality
Set the Memo
Chose Alerts
Receiving Alert: Plug-in Inbox
Receiving Alert: E-mail
Time-limited Alerts
 Follow-ups can be time-limited by creation of alert
expiration to ensure patient care loop closure
 Alert expiration depends on the inherent nature of
the suspected process, level of suspicion and
radiologist preference
 If no imaging of the selected modality is obtained
within the allotted time period, the overdue alert
notice is generated
Receiving Overdue Alert
Time-limited Alerts
 Alerts can be forwarded to the patient’s provider as
a reminder that the recommended follow-up
examination has not been rendered
 Currently, only users of the Illuminate PACS plugin can receive the alert
 Radiologist acts as the “Tickler” for the referring
physician
Notifying Referring Provider
Send a message
to clinician
Forward Alert to Provider
Forward referring provider
the report text and link to
the images
Benefits of the
Electronic Tickler File
 Convenient method to electronically track followup recommendations at the time of interpretation
 Redundant alerts can be set via various
communication methods (e-mail, pager, SMS)
 Alerts can be forwarded to the health care team
(clinician, medical director, case worker)
 Interesting studies can be tagged and archived to
create a teaching file or for research purposes
Benefits of the
Electronic Tickler File
 Allows radiologists to read the reports and view
the images of their recommended follow-up exams
 Evaluates accuracy of the radiologist’s initial
interpretation and validity of follow-up
recommendations
 Delivers feedback about the patient to the
radiologist
 Exposes the radiologist to the radiologic course of
a disease process
Future Role of Alerts
 Radiologist actively participating in care of the
patient redefines role of radiology in clinical
medicine
 Establish call center to centrally handle all
communication between the radiologist, referring
physician and patient
 Enhance radiology trainee education with the
ability track the outcomes of their interpretations
and patient outcomes
Centralized Radiology Call Center
 Communicate critical results, unexpected
findings, and missed follow-up exams to the
referring physician
 Reduce burden on the radiologist to track down
the referring physician and maintain a central
Tickler File
 Document and audit all communication between
the radiologist and referring provider
Radiologist as Clinical Asset
 Tickler File empowers the radiologist to actively
participate in patient care
 Transfer burden of Tickler File maintenance from
the ordering provider to the radiologist
 Reduce malpractice risk for the hospital and the
radiologist by closing the communication loop
 Add value to the radiology group to avoid risk of
radiology service outsourcing
References
1.
2.
3.
4.
5.
6.
ACR Practice Guideline for Communication of Diagnostic Imaging Findings
(Revised 2010)
Berlin L. Failure of Radiologic Communication: An Increasing Cause of
Malpractice Litigation and Harm to Patients. Appl Rad 2010, Jan-Feb, 17-23
Cascade PN and Berlin L. Malpractice Issues in Radiology. AJR 1999;173:14391442
Chesbrough R. Critical Results: Communication Management in Radiology.
http://imaging-radiation-oncology.advanceweb.com/features/article3/critical-results-communication-management-in-radiology.aspx (posted
4/6/2010, accessed 10/1/2011)
Berlin L. The Duty to Communicate. AJR 2011;197 W962
Towbin AJ, Hall S, Moskovitz J, Johnson ND, Donnelly LF. Creating a
Comprehensive Customer Service Program to Help Convey Critical and
Acute Results of Radiology Studies. AJR 2011;196:W48-W51
Correspondence
Mailing address:
Henry Ford Hospital
Department of Radiology, K3
2799 West Grand Boulevard
Detroit, MI 48202-2689
E-mail:
Mikhail Nekhline: mikhailn@rad.hfh.edu
Safwan Halabi: safwanh@rad.hfh.edu
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