Richard M. Chesbrough, M.D. President, Radiology Medical Consultants, P.C

April 2012 Communication Issues

The Joint Commission, ACR and Plaintiff’s Attorneys: New Rules, Standards and Legal

Precedents Mandating Critical Test Result Management in Radiology

Richard M. Chesbrough, M.D.

President, Radiology Medical Consultants, P.C.

Founder, RADAR Medical Systems, LLC


Sign of the times…


Legal Facts

“Malpractice litigation alleging radiologic miscommunication is growing at a faster rate that any other type of radiologic wrongdoing.”

Berlin, Diagnostic Imaging, Nov. 2007; 31


Legal Facts

“25% of ACR members report being involved in at least one malpractice claim involving failure to communicate…”

Kushner, JACR 2005;2(1):15-21

Average payment…$1.9 Million Dollars.” Berlin L., Imaging Economics;

Sept, 2005


New ‘buzzword” in healthcare

Critical Test Result Management

“CTRM”


The Paradox of Radiology

Most advanced imaging technology and computer skills in the world.

Yet…still rely on “primitive” phone calls, answering machines, faxes and loose pieces of paper for communication of critical results.

* “One-way” communication.

* Often no permanent documentation


Radiology: We know things that others don’t….


Significant Findings: How would you handle this?57 yr old Outpatient: History: “cough”


How would you report?Communicate results?

5:30 on a Friday afternoon?

…and Monday is a holiday?


Actual Cases: Routine Physical

Susan W. (Head Nurse)

1997 Physical CXR: “Nodule LUL,

needs f/u” No follow-up

Report misfiled Ordered by N.P.

2000 Cough/SOB:

CXR: 3.5 cm mass Settlement: $2.3 Million

http://www.ajronline.org/content/vol184/issue2/images/large/00_04_0470_02a.jpeg


What about unexpected findings: “Incidentalomas?”CT ABD: ER Patient: “R/O Appendicitis” Saturday 10:30 P.M.Study “negative” for appendicitis. LLL nodule noted. Patient discharged home (2:30 AM)

Lung Nodule


Retained SpongeAbdominal X-Ray: “abd. pain”

Retained Sponge


The Problem: No policies ?

The referring physician is not directly contacted on urgent or significant findings in up to 60% of cases. PIAA-ACR Study, 1997

Almost 20% of radiology departments do not have an established policy to communicate findings. PIAA-ACR 1997

85% of radiology malpractice suits are related to issues of communication. Berlin; Imaging Economics, Sept. 2005


The Problem: Referring Doctors ?

Referring Doctors and Radiologist’s advice: U. of Maryland Study

56,083 imaging studies 1,650 abnormals – needing follow-up

Docs notified by phone 153 patients (9.2%) had no f/u

(Over 15 month study period)

Musk; RSNA 2007


The Problem: Patients ?

Patients and advice of doctors: 2005 AMA Poll: 2,286 Adults “52% chose not to comply with their doctor’s

order for a prescription, diagnostic test or surgical procedure.”

AmMedNews 10/17/05


The Problem: Recent Study

Communication is prone to errors Singh, H. (J.AmMedInformAssoc; 2007;14:459-466)

190,799 Outpatient visits 20,680 Imaging studies

1,017 (0.5%) Abnormal Findings (needing F/U) Notification sent via EMR 45 patients (4.4%) not acknowledged by provider

(lost to F/U) Overall: 0.2% (45/20,680) of imaging studies

had abnormal results - not followed up.


Extrapolated to National Population

National Statistics: 12 Billion medical test results annually

Lab, X-ray, Cardiology, etc…

500 Million of these = Imaging studies (33,000 rads x 15,000 studies = 500M )

0.5% “abnormal” = 2.5M 4.4% Lost to f/u:

= 110,000 per year (300 people/day)


Megatrends: increasing communication failures

24/7/365 Radiology Teleradiology (Remote Reading)

After-hours “Nighthawk” Increasing ER visits ER as “primary care”

Fewer clinician interactions (Doctors coming through Radiology Department)

Going to get worse!


Why Radiologists Don’t Call ?

Mentality: “Not my job” Interrupts workflow “Takes too much time”

3-11 minutes: to contact referring physician or their designee - Personal Communications - Quantum

Radiology, 2004

- HFHS Radiology Staff, 2004. WBH Staff, 2006

- Dr. Len Berlin, Rush North Shore Hospital

Average radiology practice: @4 calls per day & 7 minutes/call = 28 minutes/day.

$187,000 lost income for an average size radiology practice (ACR, 2003: 7 radiologists/avg. group)

Large Group: (i.e. 42 radiologists) = $1,122,000 lost income


Is calling enough ?

Documentation ?(who, what, when, how?)

“If it’s not documented it didn’t happen…”

Permanent Record ?(5 years from date of dictation)


Legal Precedent

Merriman v. Toothaker 515 P.2d 509 (Wash App 1973) Cervical spine fracture 4-day delay - Permanent neurologic injury

Court: “Because of the serious implications… “personal contact” was required to insure prompt action.”


Legal Precedent

Phillips v. Good Samaritan Hospital

416 NE 2d 646 (OH APP 1979)

“Radiologists who provide indirect medical care cannot escape liability by doing no more than relaying information through ordinary hospital channels.”

“The communication of the diagnosis… may be altogether as important as the diagnosis itself.”


Legal Precedent

Corteau v. Dodd 773 SW2d 436 (Ark 1989) Malpositioned Endotracheal tube Routine report sent. No phone call Patient suffered additional injuries

Court: “When a patient is in peril… it does him little good if the [radiologist] has discovered his condition, unless the [radiologist]…informs the patient, or those responsible for his care...”


Legal Precedent * the future ?

Stanley v. McCarver92 P3d 849 (Ariz 2004)

Pre-employment CXR Radiologist: “possible lung cancer” Report sent to Employer (nursing home)

Patient not informed. (Dx’d CANCER -10 months later)

Patient expires Radiologist and nursing home sued Nursing home declares bankruptcy


Legal Precedent

Stanley v. McCarver (cont.) Trial Court:

Dismissed case against radiologist. Plaintiff appealed

Appellate Court : “If there is no referring physician, or the referring physician is unavailable, the duty to inform the patient shifts to the radiologist.” [italics added]

Arizona Supreme Court :Duty to inform is up to jury; case-by-case basis.


Joint Commission:

Joint Commission on Accreditation of Healthcare Organizations (Now – Joint Commission)

National Patient Safety Goals

No. 2: “Improve Effectiveness of Communication Among Caregivers.” 2A. Critical Test Results 2C. Measure Performance


JC: Communication Focus

59% of hospitals were in compliance with the Joint Commission national patient safety goal #2 in 2008

64% were compliant in 2007

….Problem not going away…


ACR Standards: American College of Radiology: Standards of Practice: 2008

“Significant Unexpected Findings: “[Radiologist must] “…communicate the findings to the referring physician… in a manner that reasonably insures receipt of the findings.”

(Requires “Direct communication”) In Person By Telephone

“In radiology…[traditional reporting] or putting the report into the RIS or EMR is inadequate.”

Chang P, Diagnostic Imaging, Oct. 2007; 40


New Alternatives:

American College of RadiologyStandards of Practice, effective Oct. 1, 2005 Communication of Findings, Section 5C:

New communications authorized: “Other forms of [reporting] that provide documentation of receipt…to

demonstrate that the communication has been delivered and acknowledged.”

Text pager Facsimile (Fax) Voice messaging “Non-traditional approaches” (Email, PDA, Web)


HELP ?


Ideal CTRM Solution

Time Sensitive Acknowledgement receipt (two-way)

Database: Tracking of results Permanent Storage Reminder notifications

(i.e. 3, 6, 12 month F/U) Ability to generate data

Audit Trail Searchable database Compliance Reports (Joint Commission)


Ideal CTRM Solution

Inexpensive Easy to use 100% reliable Enterprise-wide Generate “Active” alerts

(Distinct from EMR – “passive alerts”)


Features & Benefits: Ideal CTRM System

Problem Feature Benefit__ Communication failure “Closed-loop” No lost results

Time Sensitive Activates in seconds Urgent results

“Lost” Patients F/U tracking No lost F/U’s

Different locations Web-based Access anywhere

Expensive Nominal fee No cost to users

(Hospital) (Physicians)


CTRM: Provider Benefits

Improved Patient Outcomes Record of Notification

Significant & Unexpected findings Follow-Up recommendations Permanent Record

Medicolegal Benefits Decreased Liability Decrease Malpractice Premiums

Confidential


“The Single biggest problem in communication is the illusion that it has taken place…”

- George Bernard Shaw


www.radarmed.com

Richard M. Chesbrough, M.D.

Founder, RADAR Medical Systems

(248) 514-9742

www.radarmed.com


Documents

Richard M. Chesbrough, M.D. President, Radiology Medical Consultants, P.C