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Are There Alternatives to Addenda Sabotaging Productivity in Radiology?


The ability to consider and comment on prior imaging in the radiology report may help reduce extraneous addenda requests.

Last week, I wrote about finding better ways to do things after blundering through them badly. Sometimes the blundering is one’s own fault, but I mentioned that most of us in health care don’t have much control over the systems in which we work. Take your pick as to which you find more frustrating: leadership instituted bad plans or, as far as you can tell, there was no plan at all.

I wouldn’t presume to call this blog “art,” but life imitated it anyway. While last week’s blog was percolating in my mind (and partially committed to a word processor file), another fine instance of blundering into better ways crossed my path.

Even the newest of radiologists is familiar with the experience of making addenda to reports for all sorts of reasons. It is rarely, if ever, a joyful experience. At the very least, it takes a chunk of time out of the day that could have been spent doing other things. While the rad has to go and revisit a case that was already read, the onslaught of new cases (and the referrers demanding reads on them) doesn’t magically let up.

Meanwhile, unless the rad’s group has specifically enacted policies to the contrary, the time spent making addenda doesn’t count one iota toward a rad’s productivity. If you have an RVU quota, or if your paycheck is based exclusively on cases you have completed, you are effectively just spinning your wheels while you are making an addendum.

All of this compounds the sentiment that, for the most part, these addenda are a complete waste of time. They often demand statements from us that we feel were adequately addressed in our original reports. For instance, “You didn’t comment on the appendix,” when our impression stated “Normal study” and we specifically stated in the report body that the GI tract was unremarkable. Sometimes it is even more blatant. We did say the appendix was normal, and they just failed to read properly.

Our reading room tenure increases, and we gradually learn ways to diminish the frequency of these interruptions, some sooner than others. One is to reference prior studies. Even if we don’t see anything that requires comparison, mentioning that we compared to a previous scan prevents the “Make addendum comparing to prior study X” demand.

That is, at least, when we have a prior. One particular subtype of this request that has vexed me over the years is when there is a relevant prior, but it was performed elsewhere. Now, the current exam is on my work list, often with the “reason for study” specifically requesting comparison, or just saying things like “follow up.”

A conscientious rad receives such a case and goes about looking for the prior. That can be more of a hunt than you might think, depending on the complexity of the local health-care system. It can involve searching through multiple databases, even asking support personnel if they can figure out the location of the prior.

Of course, it would be nice if the referrer had made a smidge of effort, and written something about what was being followed, and where it was last investigated. Sometimes, there is no prior study at all. “Follow up” is just used as a generic term for surveilling their patient. Alternately, it may be known that the prior is irretrievable, that it may have been done 20 years ago, or in another country.

A rad not much bothered by addendum requests or one who hasn’t played this game long enough might just plow ahead and report the case without priors. Sometimes, he or she might get away with it. In the fullness of my career, however, I have had enough of these things boomerang back to me. Days or weeks later, the prior has turned up, and now I am asked to make an addendum for the comparison.

These addenda are probably the worst, because such cases are often following cancer (successfully treated or otherwise). There are multiple things to measure. I measured them all when I read the case without priors but have to do it all a second time when the priors arrive. I can easily double the time I have spent on the case.

It’s not just my time that is being wasted either. There are the techs who had to upload the case, the ancillary rad personnel going between the referrers and me, and even the referrer, who will now wind up with essentially two rad reports to review instead of one. Absolutely nobody benefits, least of all the patient.

So, having blundered into this situation enough times, I tried finding better ways. Until recently, my most effective approach was not to go ahead and read the case without priors (unless it was an emergency for some reason). Instead, I would have ancillary staff reach out to the referrer’s office, since they were the only ones who really knew if there were indeed prior studies, where they were, and whether they were at all likely to be retrieved. If so, the current study could be set aside until the comparison arrived.

Unfortunately, this hinges on the knowledge and conscientiousness of the ancillary staff involved. It’s the path of least resistance (bonus points if anybody remembers the blog where I talked about that!) for the referrer’s office or sometimes my own ancillary staff to make little/no effort before saying “Nope, no priors, please read as is.” I can say this because it is astonishing how frequently I have heard that, only to magically be presented with the prior just a day or two later. Indeed, that just happened this past week, prompting this blog.

Having blundered upon that weak link in the chain a little too frequently, my next step might be to enact a policy: any study that turns up with something resembling “follow up,” “restaging,” etc. in its referral triggers what I might call the priors protocol. Our clerks, or the techs, immediately check to see if we have priors. If we do, the exam proceeds. If we don’t, the referrer gets to decide whether we schedule the study after we have the outside prior in hand, or if the current scan will proceed, understanding that there will be no read until that prior is delivered. Of course, if the referrer feels strongly about another course of action, he or she is welcome to ask for it but referrers who make a habit of routinely ordering double reads in this way might lose that particular privilege.

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