PI project wanted by DCCS

[Monty Python]

Today I attended the Patient Safety Committee. The chair (the hospital DCCS) wants to initiate a Process Improvement project to ameliorate one his pet peeves: providers not noticing or properly responding to incidental findings on lab and Xray reports. His case in point: a patient was sent to Xray for suspected AAA, which was confirmed on Xray. Xray report also contained the incidental finding of a small shadowing (nodule?) in the lung left lower lobe. Referring physician either didn't read or properly react to the incidental finding, wound up successfully fixing the AAA, and the pt died two years later from metastatic lung CA.

The DCCS wants a system created to "help the providers properly take note and respond to incidental findings." I'm thinking that's a primary professional responsibility of each provider, especially if the findings/values are properly annotated in the Xray/lab report. (note: I'm not talking about critical values which are called stat to the provider. I'm just talking about non-critical incidental findings).

Does anyone have a good idea (or experience) how this might be addressed at my small community hospital? The lab OIC in attendance says we're hamstrung by CHCS on this, and that any fix from her lane would involve IMD and software revisions. The hospital JCAHO readiness officer (acting chief of QM), who is also an RN, also feels this is a primary responsibility of each provider, and that any PI project would be very convoluted with too many moving parts. Thanks.

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[colbgw02]

This is a stupid idea. I bathe in a tub of incidentalomas all the live long day, and there is no way to standardize or outsource this. It has to be the responsibility of the individual provider, who can synthesize all of the relevant data coming from all the different sources and make an informed decision as to what is necessary and what is not. I say again, this is a stupid idea.

 

[idq1i]

Seconded. Sick and tired of this crap. At which point does the ordering "provider" take responsibility for the results of the ordered test? Maybe if the provider is not educated enough about the reported finding, s/he can pick up the phone and ask the radiologist. Here is the PI project - tracking how many pROVIDERS don't check results of ordered tests, and then figuring out how many of those should actually be credentialed to order the test.

They keep telling me that standards are different in the army. Soon, I'm expecting an order from provider Joe Blow, DFAC (the cafeteria kind) asking for a small bowel series on someone who threw up after eating one of their rat meat tacos.

 

[bricktamland]

I recently attended a radiology economics conference. One of the major themes discussed was the current paradigm shift from "quantity" to "quality." As a subtopic, one the presenters discussed this very issue, that ordering providers routinely fail to follow-up on non-urgent but potentially important findings. His idea was to capitalize on this issue, by devising a way to remind the ordering provider of recommended follow-up for non-urgent findings. By taking on this responsibility, this was one way to prove his radiology group's value (important in the civilian world where there is competition). Now, this guy was a major IT guru, and he created an automated system that would first send out an automated robocall to the ordering provider at the time the recommended study was due. If there was no response, a robocall would then go to the department's chairman. Usually, there was action by this point. But if there was no action after contacting the chairman, a certified letter would then be sent out to the patient. He reported this system resulted in a dramatic improvement in follow-up.

I fundamentally agree that a provider orders a test, that provider should be responsible for acting on the results. Sadly, while this works very well for urgent findings, it works poorly for non-urgent findings. In the civilian world, you can immediately recognize how implementing this system would benefit a radiology group--adding this kind of value might help you preserve your contract with a hospital and fend off the competition. In the military, it's more murky. Does the radiology department (or lab, etc) really want to assume the extra burden and potential liability for assuming this extra duty, especially when the onus should really be on the ordering provider to follow up on these results?

 

[155HE]

I too attended an economics of diagnostic imaging conference last year, and the major theme at that time was also increasing the visibility and "value added" of the radiologist and it's practice. While I absolutely believe that the responsibility for patient management lies with the clinician ordering the tests, I also think that we as radiologists can help.

One idea, which means a few seconds of extra work per study: our dictation software allows us to "code" a report with things like critical value, birads, etc. These codes can then be searched and audited in CHCS. If a code were created for "follow up study recommended"' then an administrative staff member could be tasked with regularly (?weekly) auditing these codes. Subsequently, this admin person could email ordering providers with a reminder to order the follow up test, if indicated. This would require some amount of finessing, but it could be something that radiology could propose before a non-radiologist suggests we do something more cumbersome. This could be one of the "value added" paradigms that the ACR has a hard on for...

 

[colbgw02]

I recently attended a radiology economics conference. One of the major themes discussed was the current paradigm shift from "quantity" to "quality." As a subtopic, one the presenters discussed this very issue, that ordering providers routinely fail to follow-up on non-urgent but potentially important findings. His idea was to capitalize on this issue, by devising a way to remind the ordering provider of recommended follow-up for non-urgent findings. By taking on this responsibility, this was one way to prove his radiology group's value (important in the civilian world where there is competition). Now, this guy was a major IT guru, and he created an automated system that would first send out an automated robocall to the ordering provider at the time the recommended study was due. If there was no response, a robocall would then go to the department's chairman. Usually, there was action by this point. But if there was no action after contacting the chairman, a certified letter would then be sent out to the patient. He reported this system resulted in a dramatic improvement in follow-up.

I fundamentally agree that a provider orders a test, that provider should be responsible for acting on the results. Sadly, while this works very well for urgent findings, it works poorly for non-urgent findings. In the civilian world, you can immediately recognize how implementing this system would benefit a radiology group--adding this kind of value might help you preserve your contract with a hospital and fend off the competition. In the military, it's more murky. Does the radiology department (or lab, etc) really want to assume the extra burden and potential liability for assuming this extra duty, especially when the onus should really be on the ordering provider to follow up on these results?

At the risk of turning this into a radiology thread...

I have strong feelings about this. Medical imaging is over-utilized in this country. The next radiologist I meet who thinks we do too few studies will be the first one. We don't need to be in the business of automating follow-up imaging so that we do more studies, many of which are unnecessary. Among the radiologists I work with, there seems to be an incessant need to recommend more studies or consultation to whatever service for no particular reason. Sometimes it's even knee jerk, as in at least one person I know always recommends an MRI whenever he reads plain films of the spine. It dilutes the product. And no, you won't get sued for failure to recommend, as there is data out there that shows 0.1% of all radiology lawsuits are a result from such an "oversight".

In light of what I've seen from my colleagues regarding their wholesale inability to recommend judiciously, I find the bolded portion above interesting given its juxtaposition to the subsequently described automated system. In private practice, this sounds like nothing more than a money grab designed to capture more studies that are currently being lost to follow-up. In other words, this system is all about quantity. Furthermore, it's telling to me that, as described at least, the system is designed to go above the head of the ordering provider to his/her boss and then directly to the patient. Has anyone built a brake into this system whereby the ordering provider might have actually considered the radiologist's recommendation and dismissed it after deciding that it was unnecessary and superfluous? Or is the system just going to keep badgering the ordering provider into submission? Will it contact an attorney's office next?

The ordering provider knows (or should know) the patient. He/she knows the full context in which the imaging study was ordered. He/she knows the patient's history and if there are outside studies not available to the radiologist. Accordingly, that provider is best equipped to be the judge of what requires further work-up and what doesn't. Now, I'm all for a system that goes out of its way to point out potentially important things to a provider, but it should stop at that point. Think of it as a glorified, electronic highlighter, but nothing more. We shouldn't be in the business of replacing clinical judgment with reflexive test ordering, because that will just further burden an already bloated system with marginal gains in outcomes.

 

[Homunculus]

this is a slippery slope i wouldn't want to tread on. my only solution would be to have AHLTA highlight in red (like they do with abnormal labs or "emergent" tcons) any radiology study that isn't 100% normal. granted, this may end up with my rads results looking like my CMP's on my patients who all have "elevated" alk phos levels but it's the only way i can think of to show the ordering provider "hey, look at this."

from my own experience as a peds sub specialist who orders more radiology studies than the average bear (and path specimens to boot) this system has a huge potential for unanticipated consequences. for instance-- when a parent/patient sees something highlighted red, or in the case of being printed a giant "H" or "L" next to it, all they know is that it IS NOT NORMAL. and not being normal, well, that must be bad, right? we've all been there.

now imagine for some reason a patient sees something similar to this on their radiology study. will any patient or parent be willing to let the incidentaloma ride?

i kind of view rads and path similarly with this. both are great information, a lot of visual recognition and both with their nonspecific incidental findings that, if not taken into clinical context, can lead to dramatically unnecessary testing. this is where idq hit the nail on the head-- the ECMS or whomever is credentialing everyone to order all those awesome tests needs to be responsible for credentialing those who know how to do it. no PI project in existence can fix incompetence. the next think they will come up with is "i want a PI project to help providers remember to listen to the lungs when someone comes in with a cough." ordering and interpreting labs is such a basic f-ing thing that having a project about it is insane. refer this **** on to risk management to sort out and get the blank checks ready and fire the people that do it for incompetence.

--your friendly neighborhood MR enteroclysis loving caveman

 

[Kilgoretrout 65]

I'd like to see a post-PI analysis of how much network care costs are going to go up when every elevated calcium, ALT, or minimally positive ANA gets sent out to a civilian provider. The local rheumatologist
will recommend the DCCS for a medal.

 

[Gastrapathy]

Set up a dedicated incidentaloma clinic that rads can refer to directly. Staff it with your enemies.


Sent from my iPhone 6 using Tapatalk

 

[DrMetal]

Thanks.

I've heard of places, where the radiologist can book a patient for a repeat scan (in 3-, 6-, 9-months, whatever) to monitor for interval changes, even without the PCM's initial request for such monitoring. Thus, the patient knows about the incidental finding on the day of its presentation, and walks out with an appt for a repeat scan. The Radiologist (not the PCM) makes the the call, as to whether surveillance is needed, and schedules it accordingly. At a later time, patient/PCM can cancel the repeat imaging if they so desire . . . but at least they have scheduled f/u to begin with.

I've also heard of places where the ordering provider can specifically indicate that the patient is not interested in incidental findings, to focus the exam only on the acute pathology of interest (fractured ribs, lower lung opacity, etc etc). Thatway the Radiologist is absolved of any responsibility for incidental findings . . . . .kinda shady

 

[colbgw02]

I've heard of places, where the radiologist can book a patient for a repeat scan (in 3-, 6-, 9-months, whatever) to monitor for interval changes, even without the PCM's initial request for such monitoring. Thus, the patient knows about the incidental finding on the day of its presentation, and walks out with an appt for a repeat scan. The Radiologist (not the PCM) makes the the call, as to whether surveillance is needed, and schedules it accordingly. At a later time, patient/PCM can cancel the repeat imaging if they so desire . . . but at least they have scheduled f/u to begin with.

I've also heard of places where the ordering provider can specifically indicate that the patient is not interested in incidental findings, to focus the exam only on the acute pathology of interest (fractured ribs, lower lung opacity, etc etc). Thatway the Radiologist is absolved of any responsibility for incidental findings . . . . .kinda shady

I don't see how this could work outside of a government setting (and even then it's a bad idea), as it is a clear violation of Stark self-referral laws. The only time a diagnostic radiologist is allowed to do this is in breast imaging, where we are specifically empowered and held responsible for follow-up by MQSA.

 

[DrMetal]

I don't see how this could work outside of a government setting (and even then it's a bad idea), as it is a clear violation of Stark self-referral laws. The only time a diagnostic radiologist is allowed to do this is in breast imaging, where we are specifically empowered and held responsible for follow-up by MQSA.

Is it really a self-referral, if the original test was ordered by the PCM? For instance, if I send a patient to cards, they can book the patient for future 6-month interval follow-ups, because the patient is now 'known' to them, without my prompting. Why not give radiologists the same power? And why are radiologists only allowed to do this with respect to breast imaging? Is the finding of a new pulm nodule--especially in a patient with the right history--not equally concerning? I'm not suggesting that the power be abused, resulting in un-necessary interval scanning . . . but radiologists are doctors too, I would be very ok (even appreciative) of one who uses her judgement to book a patient for necessary surveillance. Of course, I'd discuss it later with the patient. If he's 89-yo and not interested in any futher cancer workup or treatment, I could always cancel it.

 

[pgg]

If you think there's something about the way results are reported that makes it easy to overlook incidental findings, you could argue that a system improvement could change that. But good luck getting any structural changes made to CHCS or that abomination AHLTA.

Frankly it sounds like your PI knuckleheads are looking to make work and solve an already solved problem in a way that makes their job look necessary. If doctors aren't following up on abnormal test results, that ought to be picked up by existing peer review. This is why we do OPPEs, right?


You should sic the PI guy on the OPPE guy and maybe they'll consume each other's time instead of yours.

 

[colbgw02]

Is it really a self-referral, if the original test was ordered by the PCM? For instance, if I send a patient to cards, they can book the patient for future 6-month interval follow-ups, because the patient is now 'known' to them, without my prompting.

Yes, it is. The law is very clear on this.

Why not give radiologists the same power?

Because the radiologist doesn't know the entire picture. We also don't have the time or the inclination to develop one.

And why are radiologists only allowed to do this with respect to breast imaging?

Again, radiologists have been mandated to be responsible for the work-up and follow-up of breast lesions. It is a specific exception to self-referral rules codified into federal law by MQSA. That's why breast imaging centers are run much more like clinics than the rest of the radiology department, because it allows the radiologist to speak with the patient and perform a clinical breast exam if necessary. When it comes to screening mammography, it's also a completely different set of circumstances because the patients must be asymptomatic, or else it becomes a diagnostic work-up. The same might work once CT screening for lung cancer in smokers gets ramped up, but again, it's a unique situation because it's a screening population within a specific set of clinical parameters.

Is the finding of a new pulm nodule--especially in a patient with the right history--not equally concerning?

Maybe. That's the point. We, the radiologists, don't know, so we shouldn't be in the business of ordering tests without a full picture.

I'm not suggesting that the power be abused, resulting in un-necessary interval scanning . . . but radiologists are doctors too, I would be very ok (even appreciative) of one who uses her judgement to book a patient for necessary surveillance. Of course, I'd discuss it later with the patient. If he's 89-yo and not interested in any futher cancer workup or treatment, I could always cancel it.

Re: the bolded. Well, that's exactly why self-referral laws exist. I don't believe, or at least I don't want to believe, that most physicians would purposefully game the system, but it happens, a lot. Just recently there was an article showing that knee MRIs are 1/3rd more likely to be 'normal' (read: clinically irrelevant) if they were ordered by someone who owned the magnet (as in an orthopaedic group with their own magnet taking advantage of the Stark loophole). Even if well-intentioned, it's a conflict of interest that we should absolve ourselves of.

Re: the rest. That's great, but in both cases you're having to exercise clinical judgment regarding the need and efficacy of the scan, so all it's really saving you is the logistical work of having to order and arrange the follow-up study. I submit that the system should be set-up in the converse (as it is now), because it should take an act of commission to do these studies - not an act of commission to stop them.

 

[Monty Python]

If you think there's something about the way results are reported that makes it easy to overlook incidental findings, you could argue that a system improvement could change that. But good luck getting any structural changes made to CHCS or that abomination AHLTA.

Frankly it sounds like your PI knuckleheads are looking to make work and solve an already solved problem in a way that makes their job look necessary. If doctors aren't following up on abnormal test results, that ought to be picked up by existing peer review. This is why we do OPPEs, right?


You should sic the PI guy on the OPPE guy and maybe they'll consume each other's time instead of yours.

Just for personal amusement I unofficially ran this by the chief of IMD today, a very capable computer systems and software guru, and also a very practical realist. He agreed it would take revisions to CHCS and/or AHLTA (way way above his authority). He felt it would devolve into medicine-by-committee; he also agreed this is a professional responsibility of the ordering provider to read and appropriately follow-up test results.

 

[bricktamland]

At the risk of turning this into a radiology thread...

I have strong feelings about this. Medical imaging is over-utilized in this country. The next radiologist I meet who thinks we do too few studies will be the first one. We don't need to be in the business of automating follow-up imaging so that we do more studies, many of which are unnecessary. Among the radiologists I work with, there seems to be an incessant need to recommend more studies or consultation to whatever service for no particular reason. Sometimes it's even knee jerk, as in at least one person I know always recommends an MRI whenever he reads plain films of the spine. It dilutes the product. And no, you won't get sued for failure to recommend, as there is data out there that shows 0.1% of all radiology lawsuits are a result from such an "oversight".

In light of what I've seen from my colleagues regarding their wholesale inability to recommend judiciously, I find the bolded portion above interesting given its juxtaposition to the subsequently described automated system. In private practice, this sounds like nothing more than a money grab designed to capture more studies that are currently being lost to follow-up. In other words, this system is all about quantity. Furthermore, it's telling to me that, as described at least, the system is designed to go above the head of the ordering provider to his/her boss and then directly to the patient. Has anyone built a brake into this system whereby the ordering provider might have actually considered the radiologist's recommendation and dismissed it after deciding that it was unnecessary and superfluous? Or is the system just going to keep badgering the ordering provider into submission? Will it contact an attorney's office next?

The ordering provider knows (or should know) the patient. He/she knows the full context in which the imaging study was ordered. He/she knows the patient's history and if there are outside studies not available to the radiologist. Accordingly, that provider is best equipped to be the judge of what requires further work-up and what doesn't. Now, I'm all for a system that goes out of its way to point out potentially important things to a provider, but it should stop at that point. Think of it as a glorified, electronic highlighter, but nothing more. We shouldn't be in the business of replacing clinical judgment with reflexive test ordering, because that will just further burden an already bloated system with marginal gains in outcomes.

Excessive recommendations for follow-up imaging can be the unfortunate byproduct of a defensive medicine mindset and/or a self-referral ("money-grab") mindset. But still, there are plenty of cases where these "incidentalomas" do turn out to be something serious, as described in the OPs post, where the lung nodule because a metastatic cancer. If there is a system in place that significantly improves follow-up, perhaps a substantial amount of morbidity and mortality might be prevented. We can argure about who's responsibility it should be to act on these recommendations, but ultimately, our patient's well-being should be at the forefront of that discussion. Is the radiologist who conceived this follow-up system really after more money, or did he step up to the plate and figure out a way to do the best thing for the patient?

I'm not sure what the right answer is, since it's a complicated topic. I think it's an idea worthy of evaluation though.

Another issue that was brought up was clinical competence when ordering tests. Well, that went out the window when the Navy (not sure about Army or Air Force) decided to open the flood gates and let nurse practitioners, chiropractors, physical therapists, and just about anyone and their pet dog order advanced imaging tests. Sadly, imaging has become the substitute for a physical exam. Here is a real example of an order request for an MRI from one of our non-physician practitioners:

"35 y/o male c/c shoulder/back pain for 5+ years. Pt states no
traum a to affected areas. referral. Denies trauma, however as ___ he
carried lo ts of heavy equipment in left arm. , received P.T. And pain
resolved , however has positional numbness that goes from lower chest to
back of left scapula. O nly occurs with sitting. and occurs every time he
sits, Not with activity , laying down or standing. Has not gotten worse
but not better either. Hard to s it for any period of time . Describes as
an area big as a broom stick , bores from from of low chest radiates back
and forth to scapula on left . Only at r est and sitting , can run ,PT
without any problems. Has FROM to shoulder.Pleas e auth for a MRI of
thoracic area including cheat and left shoulder"

I sent this request back and asked this person to re-submit with a working diagnosis, such as "r/o cervical disk herniation, r/o thoracic outlet, etc." This person could not come up with anything. I also tried in vain to explain that an MRI of the "thoracic area including the chest and left shoulder" does not exist. I'm still confused about the broom stick analogy. This same person actually once asked me, "what does the word 'lesion' mean?"

It's not a mystery where all this excessive imaging comes from. . . . and supposedly an influx of these non-physician providers are going to reduce health care costs. . . .

 

[idq1i]

I have an incredibly low threshold for rejecting/kicking back any of this nonsense that's not CPG, with quotes from guidelines. No chiropractor is going to order an MRI here

 

[DrMetal]

Re: the bolded. Well, that's exactly why self-referral laws exist. I don't believe, or at least I don't want to believe, that most physicians would purposefully game the system, but it happens, a lot. Just recently there was an article showing that knee MRIs are 1/3rd more likely to be 'normal' (read: clinically irrelevant) if they were ordered by someone who owned the magnet (as in an orthopaedic group with their own magnet

Aww hell, I quit.

 

[IgD]

The radiologist should write an AHLTA note documenting the abnormal finding and then CC the ordering provider as a co-signer.

 

[colbgw02]

The radiologist should write an AHLTA note documenting the abnormal finding and then CC the ordering provider as a co-signer.

Are you trolling or making a joke?

If serious, this is such a wasteful and, frankly, dumb idea. First of all, radiology reports already show up in AHLTA. There's a reason why millions of dollars of IT money are spent to make sure that the PACS/dictation software talks to CHCS/AHLTA. Second of all, who in the hell has enough time in their day to write anywhere between 30 to 120 (service dependent) notes on top of what they're already doing?

 

[Homunculus]

The radiologist should write an AHLTA note documenting the abnormal finding and then CC the ordering provider as a co-signer.

it should already show up under "new results" in AHLTA for the ordering provider. which to make it go away requires it to be "sign/remove"d

if you start doing this with chest films, the lab is going to have to start doing them as well. the only think I can reasonably see is to have the radiology result highlight in red (like a lab) and set the criteria for it being highlighted as *anything* not 100% normal. this is not a radiologist's job, nor should it be. i'd prefer they have time to do more of my UGI's and MRE's, lol.

--your friendly neighborhood new result clearing caveman

 

[Homunculus]

You should sic the PI guy on the OPPE guy and maybe they'll consume each other's time instead of yours.

there's your real PI project.

--your friendly neighborhood watch the carnage from the sidelines caveman

 

[bustbones26]

Today I attended the Patient Safety Committee. The chair (the hospital DCCS) wants to initiate a Process Improvement project to ameliorate one his pet peeves: providers not noticing or properly responding to incidental findings on lab and Xray reports. His case in point: a patient was sent to Xray for suspected AAA, which was confirmed on Xray. Xray report also contained the incidental finding of a small shadowing (nodule?) in the lung left lower lobe. Referring physician either didn't read or properly react to the incidental finding, wound up successfully fixing the AAA, and the pt died two years later from metastatic lung CA.

The DCCS wants a system created to "help the providers properly take note and respond to incidental findings." I'm thinking that's a primary professional responsibility of each provider, especially if the findings/values are properly annotated in the Xray/lab report. (note: I'm not talking about critical values which are called stat to the provider. I'm just talking about non-critical incidental findings).

Does anyone have a good idea (or experience) how this might be addressed at my small community hospital? The lab OIC in attendance says we're hamstrung by CHCS on this, and that any fix from her lane would involve IMD and software revisions. The hospital JCAHO readiness officer (acting chief of QM), who is also an RN, also feels this is a primary responsibility of each provider, and that any PI project would be very convoluted with too many moving parts. Thanks.

Hey, your DCCS needs to do something to get a bronze star?

 

[deuist]

One of issues with having the ordering doc take responsibility comes with overnight radiographs from the emergency department. What happens when I order a chest X-ray for chest pain and the next day the radiologist reads an abnormal nodule? I never get a call or report sent to me. That puts me at risk for following up on all studies well after the patient has left my care and hopefully will never see me again. On the rare occasion I get a read back in time in the ED, I will tell the patient, but I am also not sure how much the patient is going to follow up. I do refer everyone back to their PCM and hope that the primary can catch any abnormal next-day reads. Having a system as described above with follow up ordering scheduled in advance definitely makes sense to me. If federal laws prevent radiologists from making those appointments, I would at least like PCM's to have a method for easy ordering.

 

[IlDestriero]

I've heard of places, where the radiologist can book a patient for a repeat scan (in 3-, 6-, 9-months, whatever) to monitor for interval changes, even without the PCM's initial request for such monitoring. Thus, the patient knows about the incidental finding on the day of its presentation, and walks out with an appt for a repeat scan. The Radiologist (not the PCM) makes the the call, as to whether surveillance is needed, and schedules it accordingly. At a later time, patient/PCM can cancel the repeat imaging if they so desire . . . but at least they have scheduled f/u to begin with.

I've also heard of places where the ordering provider can specifically indicate that the patient is not interested in incidental findings, to focus the exam only on the acute pathology of interest (fractured ribs, lower lung opacity, etc etc). Thatway the Radiologist is absolved of any responsibility for incidental findings . . . . .kinda shady

I think the radiologist is absolved either way. Someone orders a study. They do it and report back in a timely manner, calling etc. for urgent things. That's job done for them. If the ordering attending fails to read the report or act on it's findings, that's on them. This is exactly why I refuse to order labs or change MRI/ct/etc orders for the convenience of the patient. "Sorry, I can't order/change that for you, your primary physician will have to do that.". I'm not taking responsibility for things I'm never going to follow up on.

 

[idq1i]

One of issues with having the ordering doc take responsibility comes with overnight radiographs from the emergency department. What happens when I order a chest X-ray for chest pain and the next day the radiologist reads an abnormal nodule? I never get a call or report sent to me. That puts me at risk for following up on all studies well after the patient has left my care and hopefully will never see me again. On the rare occasion I get a read back in time in the ED, I will tell the patient, but I am also not sure how much the patient is going to follow up. I do refer everyone back to their PCM and hope that the primary can catch any abnormal next-day reads. Having a system as described above with follow up ordering scheduled in advance definitely makes sense to me. If federal laws prevent radiologists from making those appointments, I would at least like PCM's to have a method for easy ordering.

All your new reports come up as New Results in CHCS. It's ultimately your responsibility to review the results. It's impractical for us to call you with every result on a patient, or to look through god-awful alhta to see which of the 75 providers has seen the patient, and to try to get a hold of them. Trust me, we are plenty busy in the morning, and it's not with coffee drinking.

In a sense I feel your pain, but I don't really see any other way.

 

[bricktamland]

I'm probably crazy but as a radiologist I actually do spend the time each morning to sift through the AHLTA notes for the weekend and overnight plain film studies in which I find abnormalities. If the providers staffing our immediate care clinic missed the diagnosis, I walk down the hall and inform them in person (even when it's a case of pneumonia that was misdiagnosed but treated with antibiotics anyway). If it's an incidental finding like a pulmonary nodule, I generally don't trust the immediate care provider to act on those types of things and thus I will dig into CHCS and find out who the designated PCM is for that patient. I then send out an email to the PCM and cc the ordering provider.

I'm at a fairly small command so it's not a horrible burden to do these things, but it is very inefficient. I feel it's in the patient's best interest and I also think the ER/immediate care providers should receive feedback.

It does surprise me though that there seems to be a sense in the ER or in the urgent/immediate care clinics that after the patient is discharged, there is no obligation to follow up on anything. Maybe I have a false perception of how things really operate. But in mind I picture the ER physicians logging into CHCS, opening up the "New Results," and then reflexively holding down the delete key. Hopefully that's not the case and just a bad stereotype I've manufactured.

It would be nice if a system could be devised that could benefit both parties (and the patient, too). However, military medicine is incredibly inflexible and unwilling to adopt any innovative IT solutions. . . . just look at how long CHCS has persisted.

 

[orbitsurgMD]

So let's suppose we agree it is the professional responsibility of the primary receiving physician (i.e. the doctor who ordered the study) to do something about incidental findings. How do you make it possible for a busy specialist who has ordered a study for one reason to not forget to refer the patient back to the primary to follow up on an incidental finding in a study, the workup for which may be outside the scope of his practice.

One way would be to always copy diagnostic and lab testing results to the patient's primary. Another way would be to mail a copy of the report to the patient. Maybe both.

 

[deuist]

I didn't know that "New Results" was even an option in CHCS. I'll have to give it a try on my next shift.

 

[idq1i]

I didn't know that "New Results" was even an option in CHCS. I'll have to give it a try on my next shift.

PHY, RNR.

 

[Doctor Bob]

But in mind I picture the ER physicians logging into CHCS, opening up the "New Results," and then reflexively holding down the delete key. Hopefully that's not the case and just a bad stereotype I've manufactured.

Not at all.
I don't even open "New Results"

 

[colbgw02]

I didn't know that "New Results" was even an option in CHCS. I'll have to give it a try on my next shift.

This is kind of baffling to me. I realize that, as an ED doc, CHCS isn't really your thing, but I've never even heard of another military doc not at least aware of this function.

As an aside, our ED at my residency had at least a temporary policy of ordering all imaging studies under a single provider. It didn't matter if he was working at the time or not. In fact, they continued to do it after this provider deployed. I always imagined there would eventually be some bad outcome where there was a lot of fingerpointing about who was responsible for following up on a study, but I never saw it happen. From a radiologist's perspective, this seems like a horrible policy, because it circumvents the system's default setting of sending results to the ostensibly responsible provider. It also always made it a real pain to figure out to whom we were supposed to talk in the event of critical findings.

 

[deuist]

This is kind of baffling to me. I realize that, as an ED doc, CHCS isn't really your thing, but I've never even heard of another military doc not at least aware of this function.

I check individual patient results through RCR --> LAB for labs and use PACS for imaging.

 

[colbgw02]

I check individual patient results through RCR --> LAB for labs and use PACS for imaging.

Clearly there are other ways of finding results that you're specifically looking for. I was just surprised that someone could be familiar with CHCS, but not this particular function. Don't you get that message that says something like "you have new results"?

 

[idq1i]

This is kind of baffling to me. I realize that, as an ED doc, CHCS isn't really your thing, but I've never even heard of another military doc not at least aware of this function.

As an aside, our ED at my residency had at least a temporary policy of ordering all imaging studies under a single provider. It didn't matter if he was working at the time or not. In fact, they continued to do it after this provider deployed. I always imagined there would eventually be some bad outcome where there was a lot of fingerpointing about who was responsible for following up on a study, but I never saw it happen. From a radiologist's perspective, this seems like a horrible policy, because it circumvents the system's default setting of sending results to the ostensibly responsible provider. It also always made it a real pain to figure out to whom we were supposed to talk in the event of critical findings.

For the most part, in my ER (aka urgent cc), most studies are ordered to placate the patient. So not caring about results seems unsurprising.

 

[deuist]

Clearly there are other ways of finding results that you're specifically looking for. I was just surprised that someone could be familiar with CHCS, but not this particular function. Don't you get that message that says something like "you have new results"?

I get that message all the time. I wouldn't say that I'm familiar with CHCS. I've never been trained on it. All I go by are the screens in front of me.

 

[Ziehl-Neelsen]

As an aside, our ED at my residency had at least a temporary policy of ordering all imaging studies under a single provider. It didn't matter if he was working at the time or not. In fact, they continued to do it after this provider deployed. I always imagined there would eventually be some bad outcome where there was a lot of fingerpointing about who was responsible for following up on a study, but I never saw it happen. From a radiologist's perspective, this seems like a horrible policy, because it circumvents the system's default setting of sending results to the ostensibly responsible provider. It also always made it a real pain to figure out to whom we were supposed to talk in the event of critical findings.

You must have trained at SAMMC.

 

[colbgw02]

You must have trained at SAMMC.

Negatory.

 

[Homunculus]

You must have trained at SAMMC.

sounds like maybe the good idea fairy may have PCS'd around to more than one ED

--your friendly neighborhood do they make a good idea fairy zapper caveman