Improving Imaging
Quality and safety
with
e-communication
Ronald Arenson, MD
Magnitude of the
Safety Problem
• 22% Americans claim family member suffered mistake Commonwealth Fund
• Medical errors cause 44,000 - 98,000 deaths / year in US - IOM
• Eighth leading cause of death ahead of vehicle accidents and breast
cancer - AHRQ
• 2% of admissions experience medication errors costing $2 billion / yr IOM
• Preventable medical mistakes cost $17 - 21 billion / year - IOM
• Second only to med errors, patient falls occur in 2-4% of patients and 26% result in significant injury - JCAHO
Patient Care depends
on Imaging
• We perform procedures on many patients each day
(500,000 procedures per year at UCSF)
• CT and MR have become extensions of the physical
examination
• Triage role
• Acute versus chronic
• Surgical versus medical
Perfect Aims to Avoid
Safety Problems
• Patient mis-ID
• Allergy
• Equipment - failure
• Injection - wrong material / dose /
extravasations
• Reading - misinterpret
• Fall - patient fall
• Environment - spill
• Communication
• Test - wrong exam /
complication / excess
radiation
• Metal - in magnet
• Side - wrong side
E-Communication
• What is it?
• Computer-based, non-paper, non-FAX communication
• Components
•
•
•
•
Web services or Service Oriented Architecture
EMR note – official medical record
Secure email
SMS (Short Messaging Service) = Text message (with
security)
• “Full duplex” – acknowledgement or verification
Information business
• Medical Care and Radiology in particular in the
information business
• Access to and integration with EMR
• Two major points of communication
• Study requests – order entry (clinical indication) – to be
discussed by Keith Dreyer, MD
• Access to EMR for context, labs, meds
• Reporting results – get results to our referring MDs
• Make sure we have the correct target individual
• Bob Wachter, MD: “Cannot do Quality and Safety
without IT”
Other communication
challenges
• Protocoling – electronic, standardization
• Messages to technologists – RIS
• Patient interactions
• Medication / laboratory conflicts
• Sending reports to patients
• Management reporting: mining for quality and safety
• QA “tagging”
• Computer Aided Diagnosis – will not be covered in this talk
• Mammography, High-res chest CT, skeletal bone age, diabetic
retinopathy
Patient
Misidentification
• Performing a procedure on the wrong patient
• Giving the wrong patient injections / drugs
• Technologist placing the wrong patient
identifiers on images
• Transcriptionist mixing up patients
• Radiologist reading images for the wrong
patient
• RIS/PACS/transcription or voice recognition
integration avoids most of these
Selecting Proper
Patient ID
Barcode or RFID
Solution
• Patient ID bracelets with either barcodes or RFID
• Readers associated with imaging equipment to choose
from patient worklists
• Portable readers for portable exams using CR which
provide patient ID to plates to be read by scanners
Tech worklist
Select search by MRN
Barcode removes
other patients
Appropriate
Examination
• Electronic Order Entry systems - CPOE
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•
•
•
•
Speed transmission to Radiology
May provide more patient history
May improve physician and patient satisfaction
Standardized order sets very helpful
Can include decision-support tools that improve
appropriateness
• Decision-support order entry for Radiology will be in a
separate presentation
Reporting
Communication issues
• Unexpected acute findings or new neoplastic diagnosis
•
ACR standard for “direct” communication
• “Wet readings” – wet read module
•
•
Resident interpretations at night
Accuracy and audit trail
• Outside priors and curbside consults for outside studies
• Poorly constructed reports – mixing up right and left, confusing abbreviations
•
•
Smart reports – voice recognition
Structured reporting
• Misunderstood report findings – standard terminology like Radlex and
reference information
• Reporting and tracking sub-critical findings
• Alex Rybkin, MD, project at SFGH
Wet Read Module
• Add-on to PACS
• Provides immediate preliminary interpretations to ED,
ICUs, others
• Uses PACS displays and PDAs
• Built-in feedback to referring MDs and QA for
attending changes after resident interpretations
Wyatt Tellis, Kathy Andriole, J Digit
Imaging. 2004 Jun;17(2):80-6. Epub 2004
Mar 25
Wyatt Tellis, Kathy Andriole, J Digit
Imaging. 2005 Dec;18(4):316-25
Entering wet-read
Entering QA review
PDA GUI
Wet-Read Alert
Wet-Read & Full
Report Display
ED Patient List
RIS Query Panel
Reporting errors
Safely Performed
• Patient Safety is a major concern for all but Radiology
particularly vulnerable because
•
•
•
•
we perform a very large number of procedures daily
we are not very familiar with our patients
there are many steps involved in the process of care
we utilize drugs, contrast, radiation, needles, catheters, and
other devices that can cause harm
• Radiation exposure especially in CT now a major
concern
• Variation in dose for same examination
• Large number of CT exams especially in children
Protocoling
Protocol GUI
Scanned Requisition
Radiation monitoring
• Now important to capture radiation exposure from
each exam (available from newer CTs / DR)
• Should accumulate dose for each patient
• Should share the accumulated dose with other
organizations
• National repository?
• Requires sharing data with other institutions
• RSNA contract with the NIBIB
Communicating
Urgent Findings
• Radiologists expected to immediately communicate
with referring MDs for urgent and unexpected findings
• Sometimes difficult to reach referring MDs and
sometimes their staff do not effectively communicate
with them
• Subcritical findings also a problem
• Non-calcified nodule on CT, recommend f/u
• Commercial systems such as VA View Alert and
Vocada’s VoiceLink attempt to assist in process and
documentation
• Shifts responsibility away from Radiology
Referring MD
Miscommunication
• Poor clinical history on request
• No indication of reason for ordering procedure
• Selection of the wrong type of procedure or the wrong
side
• Be sure someone talks with the patient before proceeding
• Inadequate preparation of the patient for a procedure
• Not reading reports carefully / no proper follow-up
Communications with
other institutions
• In the United States, few “closed” systems, e.g. Kaiser,
VA
• Typical community environment
• Hospitals and physicians separate entities
• Incomplete or fractional EMR
• Challenge of identifying patients across separate
institutions and enterprises
• This issue includes inpatient versus outpatient
• Challenge of identifying the “relevant” clinician
Management
Reporting
• Quality and Safety require careful monitoring
• Effective management reporting is essential for this
monitoring
• “Dashboard” concepts can be useful in Radiology for
high level view
Report Turn-around Times
October - Median Hours
18
16
14
12
10
8
6
4
2
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Comp-Dict
Prel-Final
RSNA efforts
• Integrating the Health Care Enterprise (IHE)
• Structured Reporting
• Radlex vocabulary
• NIBIB Image Sharing Contract
• Radiation reporting
Integrating the
Healthcare Enterprise
IHE for Merger of Exams
/ Reports
IHE for Processed
Images
IHE and Shared
Context
• Effective integration of separate systems requires
sharing context for patient, exam, and event status
• Most systems support patient ID (MRN) but do not
currently support beyond that level
• Radiation exposure is now an IHE profile
Structured Reporting
and Lexicons
• Structured reporting
• Can improve on the quality of communication with
referring MD
• Facilitates retrieval by findings / diagnosis
• Provides opportunity to measure accuracy
• Lexicons
• BIRADS from ACR
• RadLex from RSNA
• RSNA now launching structured reporting project
• Best practice Radiology template
RadLex by RSNA
• Standardized lexicon
• Ontology for radiology terminology
• By subspecialty
• Procedures
• Playbook – specific protocols rather than just CPT
• Findings
• Structured report and searchable terms
Image sharing project
• NIBIB sponsored contract with the RSNA
• Six institutions sub-contracted
• Patients control who has access
• Avoids HIPAA issues
• Uses IHE standards for image transmission
• Facilitates availability of patients’ prior images when in a
new institution
• Technique applicable to other types of data
Accumulated radiation dose
Other clinical information
Research data and images
Hospital/Imaging Center
Edge
Device
RIS
Patient
Identity
Source
PHR
Clearinghouse
PIX Manager
RSNA ID
Map
RSNA
ID Map
PACS
Report
DB
Temp
Image
Storage
Document
Source
Document
Registry
Register Document Set [ITI4]
Pid=RSNA+2nd Factor
Document
Repository
Document
Consumer
Conclusions
• Variety of possible patient safety problems in
Radiology
• Quality and Safety in Radiology can be greatly
enhanced by the application of information
technology
• Further development and deployment of IHE
are key to achieving these gains in Safety and
Quality