The Importance of Clinical Health Information at the Point of Radiology Order

Lisa M. McCorkle, MSN, MBA, Senior Patient Safety Risk Manager, The Doctors Company

The process for formulating radiological imaging interpretations can be improved by giving reading radiologists accurate clinical context at the time of order entry. Having ready access to clinical context helps radiologists eliminate assumptions and better positions them to apply their skills and expertise in rendering final interpretive reports.

It is not uncommon, however, for radiologists to receive inadequate patient information that potentially compromises their diagnostic decision-making abilities and accuracy. Promoting the inclusion of patient information—to inpatient, emergency department, and ambulatory radiology environments—is essential for the highest reliability effort toward safe patient care.

In The Doctors Company Diagnostic and Interventional Radiology Closed Claim Study, we found a variety of communication failures that contribute to adverse outcomes. Communication failure was the second-most common factor that contributed to patient injury in diagnostic radiology’s diagnosis-related cases, appearing in 18 percent of those claims. In some of these claims, the radiologists were hampered by inadequate information about patients and the rationale behind ordering their radiological studies. It is important for radiologists to receive information that helps them arrive at interpretations that are consistent with clinical findings.

Several evidence-based studies over time have shown that communication of clinical information to the radiologist—including patient complaints and indications for the imaging request—is required for a quality radiology interpretation process and for making recommendations. A 2018 study looked at more than 300 orders for MRI and CT exams and found that requisition indications were incomplete 81 percent of the time when compared with provider notes already documented in the electronic health record (EHR)—potentially impacting a radiologist’s optimal exam planning and interpretation.1 Other studies noted that 72 percent of the time radiologists needed more clinical information than they received, and 87 percent felt that additional clinical information could change or modify the final report.2

The types of pertinent clinical information to be provided by the ordering physician include the patient’s surgical history, major medical conditions, relevant family history, social history (such as drugs, alcohol, or smoking), working diagnosis, signs and symptoms, and questions to be answered. Although there is no standardized protocol, the American College of Radiology’s ACR Practice Parameter for Communication of Diagnostic Imaging Findings notes that such information can assist the reading radiologist to enhance the clinical relevance of the final report.

Challenges

Many times, radiologists are unaware that a patient’s clinical health information is missing when preparing to interpret a study and dictate a report. A challenge for radiologists can be searching for important information (for example, accessing an EHR requires a system user sign-on, password, and training to maneuver to the patient clinical information) while balancing the pressure to keep pace with a large volume of assigned studies. Another challenge facing radiologists is interpreting studies for multiple hospitals or ambulatory centers, each with its unique EHR system. This results in the need to have access to and knowledge of multiple medical record systems.

Radiologists are faced with a daily conundrum: Their desire to obtain complete clinical context of the reason for an imaging study can interrupt the reading process due to the need to track down clinical information in an EHR. Depending on skill and experience levels, radiologists may voluntarily—and inadvertently—assume the risk of a potentially inaccurate study interpretation by not taking the time to search for clinical health information not provided at the time of order entry.

Risk Mitigation Strategies

Strategies to reduce the potential of a misinterpreted radiology study due to lack of knowledge of a patient’s clinical information include the following:

  • Develop a checklist or protocol of important clinical information needed at the time of the order. The checklist may be individualized by diagnostic modality if necessary and include information that would benefit radiologists and could impact their diagnostic process.
  • Engage in an education effort to inform referring providers from inpatient, emergency department, and ambulatory locations of the evidenced-based benefits of providing the pertinent or even critical patient information needed for interpretation and reporting of imaging studies. Offer the ordering provider the developed checklist or protocol of information needed at the time of the order.
  • Validate and provide ongoing monitoring of radiologists’ access to and knowledge of maneuverability in the EHRs of facilities that originate orders.
  • Investigate the digital capabilities of EHRs or other third-party software in using data extraction technology or artificial intelligence to mine information (e.g., clinical health history, family history, surgical history, social history, and current symptoms and complaints) and report information missing at the time of the radiology order. These system capabilities minimize the need for the referring provider to re-enter information that is already in the EHR and efforts by the radiologist to search for important information prior to interpreting and reporting on the resulting study.
  • Encourage radiology technologists to look for and validate the presence of patient clinical information needed at the time of the order. Direct them to collect the information or alert the radiologist if it is not present.
  • Integrate radiologists into the healthcare team. If findings are not consistent with clinical information provided by the ordering physician, radiologists should initiate a conversation to analyze the situation and determine next steps in the diagnostic process.
  • Audit the frequency of radiology orders in your organization that have missing or incomplete patient clinical information. Compare the orders to the information in the patient’s EHR. Identify individual case examples in which missing clinical information would have been beneficial to interpretation, regardless of whether it would have changed the interpretation. Inform ordering providers about consistently missing clinical information and identify those who may need additional education.

The collection and reporting of a patient’s comprehensive clinical health picture at the time of provider ordering is proven in evidenced-based studies to have a positive impact on the quality of the radiological interpretation. This important handoff of patient information from ordering provider to interpreting radiologist can enhance efforts to deliver safer patient care.

For questions on radiology safety, contact the Department of Patient Safety and Risk Management at patientsafety@thedoctors.com or (800) 421-2368. We also provide the following resources:


References

  1. Lacson R, Laroya R, Wang A, et al. Integrity of clinical information in computerized order requisitions for diagnostic imaging. J Am Med Inform Assoc. 2018;25(12):1651-1656. doi:10.1093/jamia/ocy133
  2. Boonn WW, Langlotz CP. Radiologist use of and perceived need for patient data access. J Digit Imaging. 2009;22(4):357-362. doi:10.1007/s10278-008-9115-2

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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