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.
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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