Report from SIIM: Demo illuminates path to better critical results communication

June 5, 2009

A routine patient admission for left lower quadrant pain leads to a malpractice lawsuit because a chaotic hospital system allows a malignant lung nodule, observed by a radiologist, to go unreported to the patient’s physician.

A routine patient admission for left lower quadrant pain leads to a malpractice lawsuit because a chaotic hospital system allows a malignant lung nodule, observed by a radiologist, to go unreported to the patient's physician.

The scenario, while hypothetical, probably is closer to the truth than many people realize, according to presenters during the opening session of the Society for Imaging Informatics in Medicine meeting.

Many facilities share the problems discussed in the session examining the reporting process. Too often systems rely on point-to-point, person-to-person communications that are time-consuming and prone to error. Scan findings, such as the reporting of an incidental lung nodule discovered on a CT scan for suspected diverticulitis, can fall through the cracks.

A team of SIIM members ran through a skit showing the usual process, and then they repeated it. The second run-through featured a sophisticated software-based monitoring system. The presentation devoted to the communication of critical test results was designed to show how informatics tools can help assure that critical results are delivered to parties who can act on them.

The first problem encountered under the traditional system was the use of a paper requisition form on which Dr. Emergency entered his pager number. It was transcribed incorrectly into the RIS, and problems cascaded after that. The resident who read the scan was unable to reach the doctor. A few hours passed before the emergency physician called the attending to inquire about the findings.

Luckily, the diverticulitis was uncomplicated and the delay did not jeopardize the patient's health. But by the time Dr. Emergency called for the report, the resident had moved on to a code blue contrast reaction and the attending didn't recall the details of the incidental finding.

Because the ER doctor had the information he needed to deal with the immediate reason for the admission, the 6-mm lung nodule finding in the report went unnoticed until several years later, when the patient developed lung cancer. The bad news was delivered to the medical team by attorney Howie Fleecem.

Replayed, the skit delivered a better outcome, this time with the help of a work-in-progress system that builds critical results monitoring into the RIS and hospital information system. As before, the CT scan results went to the resident, but this time the system already had Dr. Emergency's correct pager number and the ER doctor called back immediately for the results.

As before, Dr. Emergency didn't hear about the incidental lung tumor finding, but because it was entered into the critical results monitoring system, the ER doctor got an e-mail alerting him to the potential cancer. He was able to alert the patient's primary care doctor, and the lawsuit was avoided.

In a discussion after the skit, panelists noted the key to the critical results monitoring system is that it is fully integrated into the electronic hospital processes. Transmission and receipt of information require acknowledgement and are supported by documentation, thereby closing the loop in the communication process. Analysis tools allow users to tease out elements of the process to identify and correct bottlenecks and poor performance.

Although the critical results management system is a work-in-progress, it should be ready for release next month and will be available in the public domain, said Dr. Ramin Khorasani of Brigham and Women's Hospital. That facility, along with Beth Israel Deaconess Medical School and the University of Chicago Informatics Department, developed the program over the past six months. It was funded with a grant from the Harvard Trico Risk Management Foundation.

Dr. Emergency was played by Dr. Steven C. Horii of the University of Pennsylvania Health System. The resident was played by Dr. Luciano M.S. Prevedello of Brigham and Women's. The resident's attending was played by Dr. Paul J. Chang of the University of Chicago. The attorney was played by Dr. David L. Weiss of Geisinger Medical Center.