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IMAGING VALUE CHAINGILES W. BOLAND, MDPAUL A. LARSON, MD

Communication of Actionable InformationGiles W. Boland, MD, Richard Duszak Jr, MD, Paul A. Larson, MD

Many health care stakeholdersconsider the radiologist’s centralrole to be that of creating timely,meaningful, and actionable reports.Attaining this goal is a complexprocess, requiring an operationalworkflow that is high-quality, safe,and efficient, which enables theradiologist to synthesize all relevantclinical information into a conciseand precisely structured document.The radiologist’s role, however,should not stop there. A reportcreates little value until it is deliv-ered, read, and correctly understoodby all appropriate stakeholders (notjust referring physicians butincreasingly patients, too). Onlythen can information be usedto have an impact on patientoutcomes.This series has used the concept

of the imaging value chain to helpradiologists understand the natureof their business, evaluate gapsin their workflow, and identifybest-practice solutions to deliverappropriateness, quality, safety, ef-ficiency, and patient satisfaction—the 5 pillars of Imaging 3.0. Thissegment focuses on the final link inthat chain, and one that is perhapsthe weakest: effective communica-tion of actionable information.

THE PROBLEMRapidly evolving knowledge and in-novations, the advent of precisionand personalized medicine, healthcare reform, and frequently changingprovider delivery systems and orga-nizational structures have all con-tributed to a relentless increase in thecomplexity of providing medicalcare. The imaging arena is often atthe nexus of these changes, harboringsome of the most innovative medicaltechnologies that often yield precisediagnoses within in a matter ofminutes. Imaging’s ever-increasing

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value has had a direct and positiveimpact on patient outcomes and is akey reason that it is central tomedicalcare—and that radiology depart-ments are so busy.The increased value of imaging

also means that referrers and pa-tients are now rightly expectingrapid communication and reportdelivery, which presents challengesfor ever-busy radiologists. Providerconsolidations are requiring radi-ology groups tomanage interactionswith a variety of hospitals andclinics, sometimes from differentorganizations with different physi-cian groups, practices, informationsystems, and workflows. Increas-ingly, radiologists use teleradiologyto cover these facilities—eitherentirely or to maximize interpreta-tion by offsite subspecialists—bymoving images within their groupduring the day and/or outsourcingoff-hours coverage. Given that re-ferrers can review images almostinstantaneously, radiologists some-times struggle to communicate in-terpretations in a similarly timelymanner. Despite these hurdles,report delivery systems and work-flows, for both routine and criticalfindings, must be rapid, seamless,transparent, and auditable.

THE SOLUTIONEffective and efficient report commu-nication begins with streamlinedoperations that expedite patientaccess and report interpretation.The report lexicon, format, andstructure are critical for conveyingpertinent and actionable informa-tion as succinctly and meaningfullyas possible. These report aspectshave all been topics of previousarticles in this series. Assumingthese have all been adjusted formaximal effectiveness, the action-able information must then be

an College of Radiology

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communicated to caregivers aseffectively and efficiently as possible.Sometimes, as in the case of criticalfindings (eg, tension pneumotho-rax or ectopic pregnancy), thiscommunication must occur withinmoments of image review. Yet, asurprising number of departmentsstill lack policies and procedures onwhat constitutes a critical findingand how such findings are to becommunicated. Even when policiesand workflows are in place, manydepartments are unable or unwillingto implement closed-loop commu-nication protocols and audit theprocess.

Many resources are available toguide radiologists on how action-able findings ideally should becommunicated. A recent publica-tion from the ACR provides aframework for policies and opera-tions [1]. Category-1 findingsrequire communication withinminutes, usually by direct verbalcommunication, with documenta-tion of the time, date, and indi-vidual to whom the informationwas relayed. Category-2 findingsrequire communication withinhours for conditions that mayrequire specific medical or surgicaltreatment but are less urgent thanCategory 1 (eg, unexpected intes-tinal obstruction or abscess).Although Category 3 applies tofindings that may only requirecommunication within a matter ofdays, rather than hours or minutes(eg, suspected malignancy or inci-dental findings requiring furtherwork-up), radiologists should al-ways strive to make reportspromptly available. Most referringphysicians, and increasingly pa-tients, would prefer—and oftenexpect—reports on the same dayas imaging. Ultimately, reportsshould be available when needed

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1020 Imaging Value Chain

by the referring clinician. Becauseradiologists usually do not knowthat timeframe in advance, allreports should be completedas rapidly as possible withoutcompromising their quality or theinterpretation of other more urgentstudies.Fortunately, information sys-

tems have dramatically trans-formed the imaging workflow. Theadvent of integrated voice recog-nition systems has simplified rapidreport delivery. Referring physi-cians, irrespective of location, cannow review reports and images ontheir desktop/laptop computersand even smart phones. Electronictext and e-mail alerts can nowinform referrers about reportscontaining unexpected or impor-tant findings (eg, new metastaticdisease). These same electronictools can confirm whether referrershave reviewed such reports, and ifthey have not, close the commu-nication loop by assigning dedi-cated individuals to locate andcontact referrers and deliver thekey information.This process becomes chal-

lenging, however, when radiolo-gists report for other organizationsor when host organizations do nothave fully integrated and func-tional electronic medical records(EMRs) and communication sys-tems. This scenario often leavesradiologists to report nonroutinefindings on an ad hoc basisthrough referring physicians’ cellphones or personal e-mails. Suchinefficiencies mean that someactionable findings are communi-cated ineffectively, which in turncan adversely affect patient out-comes. Radiologists should thus bestrong advocates for standardizedintegrated electronic solutions thatfacilitate seamless communicationwith all referrers.Teleradiology services, particu-

larly those from remote companies,are rarely integrated with hospital

EMRs and electronic communica-tion systems. Many still rely on faxcommunication with reports thatare then manually scanned intohospital EMRs. Such inefficientmechanisms impede effective andtimely communication. Accord-ingly, these entities often relyheavily on direct verbal communi-cation or complex closed-loop sys-tems to ensure adequate reportdelivery. This situation is furthercomplicated by the fact that manyteleradiology companies provideonly preliminary reports because ofregulatory and billing mandates.These reports may be incompleteowing to lack of relevant clinicalinformation or insufficient priorimages and consequently may besuboptimal. Caregivers are thusoften required to make clinicaldecisions based on informationthat may change, sometimes sub-stantially, once a different radiolo-gist issues the final report. Whensuch changes occur, they should becommunicated to the referringphysician expeditiously—and thatcommunication itself should bedocumented.Even academic medical centers

are not immune to this dynamic.At many, the usual reportingworkflow requires residents andfellows to generate an initial report,which resides in the EMR, markedas preliminary, until it is reviewed,edited, and approved by a staffradiologist. Ideally, this approvalprocess is performed within mi-nutes or at most a few hours, but itcan introduce variable amounts ofdelay. The longer the gap, themore likely direct communicationwill be necessary to close commu-nication loops. Accordingly, manyacademic centers have now insti-tuted policies requiring staff radi-ologists to finalize preliminaryreports within a few hours.Other strategies to ensure

adequate and expedited communi-cation depend on the nature of the

individual clinical service. Manydepartments now embed radio-logists in or near emergencydepartments to facilitate botharound-the-clock report turnaroundand direct physician-to-physiciancommunication. Similarly, anincreasing number of multidisci-plinary clinics are embracing the useof on-site radiologists to facilitatereal-time information exchange be-tween caregiver teams. From a radi-ologist’s perspective, these processesmay seem inefficient, but suchmodels must be pursued to promotegreater radiologist visibility, clinicalinteractivity, collegiality, and ulti-mately better patient outcomes.

Finally, given increasing imper-atives for patients to have directaccess to their medical records,many organizations now offerelectronic patient portals, whichinclude radiology reports andsometimes images. Although somephysicians may have reservationsabout such initiatives, such toolsmust be embraced. In an era ofpersonalized medicine, they facili-tate an increasingly active patientrole in medical decision making fortheir own health, and thereforecannot be dismissed.

Such information transparencymeans that radiologists mustrecognize that patients and theirfamilies may be critical of evenminor report errors. Many of theseerrors are likely to be related tospeech recognition software, andradiologists must therefore bevigilant when editing reports.Some radiologists are beginning toembrace such transparency initia-tives, and to offer forums for pa-tients to discuss their reportfindings, either in person or elec-tronically. Although such servicesare not currently reimbursable (thissituation may change as paymentmodels move away from volume tovalue), they present opportunitiesfor radiologists to enhance theirvalue in overall care delivery.

Imaging Value Chain 1021

In summary, radiologists need toremember that they serve primarilyin an information business andrecognize that value will be createdonly when actionable reports aredelivered and communicated torelevant stakeholders. Toward thatend, they must interpret and finalizereports as expeditiously as possibleand advocate for integrated infor-mation systems to facilitate effective

and efficient report delivery. Theyshould take every reasonable step tocommunicate findings directly withclinical colleagues and to co-locateservices with clinical teams. As newmedical trends and expectationsevolve, radiologists increasingly willbe expected to take amore active rolein direct patient communication.The next and final article in this

series focuses on how the use of big

data, data mining, and businessintelligence tools will transform theradiologists’ landscape to enableever-increasing value and betteroutcomes for patients.

REFERENCE1. Larson PA, Berland LL, Kahn CE,

Liebscher LA. Actionable findings and therole of IT support: report of the ACRActionable Reporting Work Group. J AmColl Radiol 2014;11:552-8.

Giles W. Boland, MD, is from the Department of Radiology, Massachusetts General Hospital and Harvard Medical School,

Boston, Massachusetts. Richard Duszak Jr, MD, is from the Department of Radiology, Emory University School of Medicine,

Atlanta, Georgia. Paul A. Larson, MD, is from Radiology Associates of the Fox Valley, Neenah, Wisconsin.

Giles W. Boland, MD, Massachusetts General Hospital, Harvard Medical School, Department of Radiology, 32 Fruit Street,

Boston, MA 02114; e-mail: gboland@partners.org.