Do radiologists care about ED reason for scan?

[TeddyBoomBoom]

---

Members don't see this ad.

Maybe a stupid question? 🤷‍♂️

For the record, I’m a board certified ED attending - not rads.

Because of EMR (Epic) I’m finding that many of my CT scans are being ordered with clicky box indications such as “abdominal pain“ or “flank pain”, instead of more specific information.

I kind of feel that in a perfect world it would be better if the radiologist got an indication for a test something like: “Patient well appearing, vital signs unremarkable, has left flank pain with no history of kidney stone, clinical picture not consistent with AAA or dissection, very unlikely ACS, last bowel movement yesterday, no history of diverticulitis or IBD, bloodwork ok, but is presenting with nonspecific lower abdominal pain for one day.”

It would only take about one minute to include this information but it often doesn’t get added, especially if it’s from a nurse or mid-level doing protocol orders

I think part of me always assumes that the radiologists get part of this information from the tech or from chart review, but I am also
aware that some rads basically see the ED doc as a triage nurse, and try to proceed objectively without the ED input. We
have wildly different jobs, so no offense taken or intended.

Serious answers appreciated. As an ER doc that tries (??) to see as much as I can on my own films, I want be as helpful as I can, but not annoying, bc I know you all are super busy also.

tldr: so you care about ED H&P and ED pre-lim wet reads?

 

[brownman23]

A good history is always appreciated. A brief+good history is ideal.

To be frank, the example you gave is too long. "Left flank and lower abdominal pain. Otherwise healthy and stable pt" would get across the same message, but much easier to read.

While radiologists will still stick to our search patterns regardless of history, we certainly look a little closer depending on the history. For example:

• A pt with a Roux-en-y presenting with abdominal pain will make me look me much more closely for an internal hernia, than a presentation of dysuria.
• Knowing the symptoms in a code-stroke workup will make me look closely at the vascular territory that may be affected.

Hope that helps!

 

[SeisK]

The history is the pretest probability, which matters. Faint haziness around a distended GB gets reported very differently depending on the presentation and PMHx.

 

[maxxor]

There is a trend for hospitals to buy these pieces of software which convert the reason for exam from free text to structured indications which are more likely to bill or obtain a high clinical decision support score.

In theory this is “fine” cuz it helps them get paid.

In practice, they often forget to include the original reason for exam. This is a problem because the mapping is not 1-1 and usually far less specific. Sometimes people get frustrated and pick “whatever” to get the exam through and the reason will be completely totally wrong.

If this is what’s going on at your place, ask them to keep your reason for exam attached to the order. If epic people refuse, then make sure it’s in your note. Most of us look. But honestly, most ED notes aren’t written until the patient is ready to leave.

 

[LegendaryBibimbap]

Maybe a stupid question? 🤷‍♂️

For the record, I’m a board certified ED attending - not rads.

Because of EMR (Epic) I’m finding that many of my CT scans are being ordered with clicky box indications such as “abdominal pain“ or “flank pain”, instead of more specific information.

I kind of feel that in a perfect world it would be better if the radiologist got an indication for a test something like: “Patient well appearing, vital signs unremarkable, has left flank pain with no history of kidney stone, clinical picture not consistent with AAA or dissection, very unlikely ACS, last bowel movement yesterday, no history of diverticulitis or IBD, bloodwork ok, but is presenting with nonspecific lower abdominal pain for one day.”

It would only take about one minute to include this information but it often doesn’t get added, especially if it’s from a nurse or mid-level doing protocol orders

I think part of me always assumes that the radiologists get part of this information from the tech or from chart review, but I am also
aware that some rads basically see the ED doc as a triage nurse, and try to proceed objectively without the ED input. We
have wildly different jobs, so no offense taken or intended.

Serious answers appreciated. As an ER doc that tries (??) to see as much as I can on my own films, I want be as helpful as I can, but not annoying, bc I know you all are super busy also.

tldr: so you care about ED H&P and ED pre-lim wet reads?

If you bother indicating the site of pain or even any billable indication, you're already ahead of 90% of your ER colleagues. We are so used to trash indications right now. For example, the recent trend of putting made up acronyms as the sole indication, which ends up being a useless order of letters that I may or may not try googling to figure out what the hell they're trying to tell me.

 

[Clean7795]

Maybe a stupid question? 🤷‍♂️

For the record, I’m a board certified ED attending - not rads.

Because of EMR (Epic) I’m finding that many of my CT scans are being ordered with clicky box indications such as “abdominal pain“ or “flank pain”, instead of more specific information.

I kind of feel that in a perfect world it would be better if the radiologist got an indication for a test something like: “Patient well appearing, vital signs unremarkable, has left flank pain with no history of kidney stone, clinical picture not consistent with AAA or dissection, very unlikely ACS, last bowel movement yesterday, no history of diverticulitis or IBD, bloodwork ok, but is presenting with nonspecific lower abdominal pain for one day.”

It would only take about one minute to include this information but it often doesn’t get added, especially if it’s from a nurse or mid-level doing protocol orders

I think part of me always assumes that the radiologists get part of this information from the tech or from chart review, but I am also
aware that some rads basically see the ED doc as a triage nurse, and try to proceed objectively without the ED input. We
have wildly different jobs, so no offense taken or intended.

Serious answers appreciated. As an ER doc that tries (??) to see as much as I can on my own films, I want be as helpful as I can, but not annoying, bc I know you all are super busy also.

tldr: so you care about ED H&P and ED pre-lim wet reads?

The radiologist will (probably) look closer in the area of localizing pain symptoms for the abdomen CT or neurologic symptoms for a head CT. Also obviously very helpful for fractures on x-rays.

Just has to be as little as "ruq pain" and any mention of relevant previous surgery.

 

[TeddyBoomBoom]

A good history is always appreciated. A brief+good history is ideal.

[…]

understood and taken to heart!

 

[Ho0v-man]

An ED attending not knowing we need a history to do our job explains so much.

Yes. Literally just tell us where they’re hurting or what the neuro deficit is. It could be better than that. But I’d be thrilled if we could get just this to be the floor.

 

[GadRads]

I think part of me always assumes that the radiologists get part of this information from the tech or from chart review, but I am also
aware that some rads basically see the ED doc as a triage nurse, and try to proceed objectively without the ED input. We
have wildly different jobs, so no offense taken or intended.

Serious answers appreciated. As an ER doc that tries (??) to see as much as I can on my own films, I want be as helpful as I can, but not annoying, bc I know you all are super busy also.

tldr: so you care about ED H&P and ED pre-lim wet reads?

We would look at the chart to get history most of the time, but we cannot because it is sooo busy! Easier to do in academics, but they are getting crushed these days. Try to look at the chart on even 50% of patients when on call and you will get buried by the long list of unread studies and phone calls asking for a read. And not infrequently, when we try to look at the chart, we cannot even locate the information or the notes aren’t even written.

Yes, relevant history is helpful. If a patient has RLQ pain, let us know if there has been an appendectomy. “Stroke”, “stat” or “please scan to mid thigh” are obviously not helpful. I will call an abnormality with more confidence if there is relevant history to support it. I have seen cases where a good history would have saved unnecessary additional tests and imaging and led to early discharge or admission. Referrers who don’t provide a good history are doing a disservice to themselves and their patients.

There are referrers (especially midlevels) who treat imaging as the oracle that answereth all things and minimize the history, physical exam (assuming it is even done) and laboratory data.

 

[guytakingboards]

I think part of me always assumes that the radiologists get part of this information from the tech or from chart review, but I am also
aware that some rads basically see the ED doc as a triage nurse, and try to proceed objectively without the ED input.

You're not the first non-rad to mention something like this, but IMO it's for the most part false to say that rads prefer less history than more. I think it's a relic of back in day when boomer rads had nothing better to do that spend 2hr looking at 1 CT.

One of my best friends from med school who went into medicine once told me "its a puzzle for you guys right? you don't want anything that biases you..." and i just glared at him and called him a *******.

Think of it this way: we are no less a consultant than cards or GI. If you give us a pertinent and relevant history we will be quicker and more specific in our response/report.

*Edit: something I definitely think gets taken for granted is that all rads have EMR access. We don't. I read for several small sites (e.g. hospitals, surgical centers, urgent care) where I don't have access to the EMR and have to completely rely on whatever little blurb of information comes across.

In other instances, it's prohibitively painful to log into particular hospitals' EMR. HCA in particular is a solid 1-2min to just access a patient's chart. Log into HCA remote -> 2F in the email -> wait for the remote desktop to load -> load PatientKeeper -> manually enter the patient's MRN -> find the right note. It's just not feasible to do that more than a handful of cases per shift.

 

[vm26]

EPIC is linked with our PACS so at times pretty easy to get some clue of what the general clinical question is. Caveat being more and more pts are getting scanned before there is an EPIC ER note or any indication of why the pt is actually in the ED....Our techs have been trained to help provide additional info which can helpful...At times though we are still stuck with flank pain (side not specified), abdominal pain unspecified etc, and I understand a lot of this is auto-population and billing related...One pet peeve I have in particular is with our US techs who provide us with the same hx for scrotal US-pain (again side not specified).

For a certain subset of pts, hx is semi-useful. These are the frequent fliers that have dozens of prior exams consisting of different modalities and different anatomic areas. I've come to realize that many of these patients suffer from somatization/dysregulation. Likely background of early trauma/neglect/abuse/family dysfunction/poverty, exacerbated by unskillful coping mechanisms such as sugar/obesity, tobacco use, ETOH/drugs etc. Lack of social support, limited education and/or skill-set also contributory...I am not blaming these pts since if I had the same DNA, same parents, same childhood, same education or lack of, I would likely be in the same position.

 

[Cognovi]

Radiologists care so much about the history provided that we will go out of our way to post on our social media networks screenshots of the terrible histories we get.

History changes our diagnostic performance and how we report - our sensitivity of detecting abnormalities that may be pertinent and the specificity of our interpretations when it comes to findings that may be impertinent.

Studies have shown this matters for something as simple as a bone radiograph.

When you are composing a reason for exam, answer two questions:
1) what is going on with the patient
2) what are you concerned about

What's going on with the patient: the symptom, location, duration, any established diagnoses that are relevant, any history of surgery or other major treatment to the area that's relevant. One line is sufficient.

What are you concerned about: what is your provisional/suspected diagnosis, or what diagnosis are you seeking to rule out?

Too often people provide one or the other but not both. 'What's going on' is important if we can think of a diagnosis that you didn't think of that explains the patient's presentation. 'What are you concerned about' is important because we can try to read your mind but sometimes you know more about a certain thing or have a suspicion for something unusual.

Your reason for exam can be shortened and augmented: left flank pain and lower abdominal pain x1 day, otherwise well appearing, evaluate for kidney stone, diverticulitis, epiploic appendagitis

 

[Ho0v-man]

Also “r/o X” is a terrible history. If you say r/o infection on a chest X-ray, I’d still like to know why. Is this because of actual symptoms of an infection or is this a psych clearance or something? This applies to all “r/o” indications. Believe it or not, we know what things to look for when we’re given symptoms.

 

[Neopolymath]

Also “r/o X” is a terrible history. If you say r/o infection on a chest X-ray, I’d still like to know why. Is this because of actual symptoms of an infection or is this a psych clearance or something? This applies to all “r/o” indications. Believe it or not, we know what things to look for when we’re given symptoms.

More importantly it's not billable. Imagine if I messed with the ordering clinicians' pay every time I consulted them. It's insulting outside academia where money apparently is a made up concept.

 

[Ho0v-man]

More importantly it's not billable. Imagine if I messed with the ordering clinicians' pay every time I consulted them. It's insulting outside academia where money apparently is a made up concept.

100%. I’ve felt like I was the only resident who knew that until now! I think if the study is positive for what you’re trying to rule out though.

I used to try to find something billable but I’m done with that now. If admin wants that money then they should talk to the ordering clinicians. I’ll just document “none received” now if they don’t give me anything.

 

[CherryRedDracul]

There is a trend for hospitals to buy these pieces of software which convert the reason for exam from free text to structured indications which are more likely to bill or obtain a high clinical decision support score.

In theory this is “fine” cuz it helps them get paid.

In practice, they often forget to include the original reason for exam. This is a problem because the mapping is not 1-1 and usually far less specific. Sometimes people get frustrated and pick “whatever” to get the exam through and the reason will be completely totally wrong.

If this is what’s going on at your place, ask them to keep your reason for exam attached to the order. If epic people refuse, then make sure it’s in your note. Most of us look. But honestly, most ED notes aren’t written until the patient is ready to leave.

My God. Thank you for clarifying something I've had questions about for years and none of my attendings knew.

I'd get indications like "Dudley-Klingenstein syndrome" and would be puzzled how that even came to be. Wtf even is that?? The indications are sometimes so horribly wrong that a radiologist can completely miss the mark without the real clinical information at hand.

It's criminal.

 

[Cognovi]

My God. Thank you for clarifying something I've had questions about for years and none of my attendings knew.

I'd get indications like "Dudley-Klingenstein syndrome" and would be puzzled how that even came to be. Wtf even is that?? The indications are sometimes so horribly wrong that a radiologist can completely miss the mark without the real clinical information at hand.

It's criminal.

I don't know that structured indications makes it necessarily worse.

All inpatient and ED imaging requests at my institution have unstructured indications and no need to assign an ICD code. They're dog water. Often populated by a surgical intern with instructions for a particular protocol with no communication of the underlying clinical context to even validate that protocol is appropriate or to inform the interpretation.

 

[maxxor]

I don't know that structured indications makes it necessarily worse.

All inpatient and ED imaging requests at my institution have unstructured indications and no need to assign an ICD code. They're dog water. Often populated by a surgical intern with instructions for a particular protocol with no communication of the underlying clinical context to even validate that protocol is appropriate or to inform the interpretation.

They are worse when

1. They are unbillable
2. They delete the original reason for exam and replace with the new thing
3. They are clearly mismatched and create chart-lore which eventually leads to people demanding addendums...

It's a decent idea, but often the execution is very poor.

 

[Cognovi]

I've started more aggressively epic messaging the inpatient/ED provider asking them to give me more context when I read a study that has a useless indication. One reason for exam I saw recently was just "yes". If you try to save time by giving no history, I'm not going to let it happen. Unfortunately sometimes their shift has changed so it passes the burden to the next person but hopefully this will alter behavior eventually.

I hear what you are saying about the chart lore. The problem with the structured indication is that providers will pick a diagnosis when they *suspect* or just *want to rule out* the diagnosis but they do not actually have the diagnosis. When in reality, assigning an ICD 10 code means the patient has that thing, including to billers/payers. That's why there are symptom/sign ICD 10 codes, not just diseases.

 

[LegendaryBibimbap]

I get indications like "eval" and the ER hasn't even put in a note yet. No wonder they're being replaced by midlevels

 

[scortegagna]

Yes, of course we care. It makes a world of difference.

 

[maxxor]

I get indications like "eval" and the ER hasn't even put in a note yet. No wonder they're being replaced by midlevels

To be fair to the ER docs, the midlevels don’t have notes either when I open ER cases.

It’s just too many patients and too many juggled priorities. Documentation is last

 

[CherryRedDracul]

They are worse when

1. They are unbillable
2. They delete the original reason for exam and replace with the new thing
3. They are clearly mismatched and create chart-lore which eventually leads to people demanding addendums...

It's a decent idea, but often the execution is very poor.

This is exactly how it is at my place. I've quite literally had trainees make incorrect interpretations on outpatient examinations because they relied on the completely incorrect structured indications.

 

[maxxor]

I literally just opened an exam

Structured / whatever replaced indication: Anal Carcinoma, initial workup

Actual indication: Rectal carcinoma

And no the ordering isn’t dumb. It’s a med onc who’s note indeed says “rectal carcinoma”.

That’s the danger of these things. They replace what the person wrote with something else and you have no idea.

 

[GadRads]

That’s why I give broad differentials. Sometimes I get phone calls from the referring who then finally provides a better history/indication over the phone.