The Importance of Clinical Health Information at the Point of Radiology Order
The process for formulating radiological imaging interpretations can be improved by giving reading radiologists accurate clinical context during 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. To achieve the highest reliability toward safe patient care, it is essential to promote the inclusion of patient information in radiology orders from all settings: inpatient, emergency department, and ambulatory.
Radiology Claims Review
A 12-year review of The Doctors Company radiology claims that closed between 2010 and 2021 found that a variety of communication failures contributed to adverse outcomes. Communication failure, the second-most common factor contributing to patient injury in diagnostic radiology cases, appeared in 22 percent of the claims. In some of the claims, the radiologists were hampered by inadequate patient information and the rationale behind ordering the radiological studies. It is critical for radiologists to receive information that helps them arrive at interpretations consistent with clinical findings.
Several evidence-based studies have shown that communicating clinical information to radiologists is fundamental to quality radiology interpretations and recommendations. The information communicated must include the patient’s complaints and complete indications for the imaging request.
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 compared with provider notes already documented in the EHR—potentially impacting a radiologist’s optimal exam planning and interpretation.1 In another study, a double-blind randomized controlled trial looked at whether clinical exam findings altered radiological interpretation of ventral hernias on CT. The findings noted the presence and accuracy of clinical information provided to radiologists impacts the diagnosis of abdominal wall hernias in up to 25 percent of cases.2
Studies prove that collecting and reporting a patient’s comprehensive clinical health information at the time of provider ordering positively affect the quality of the radiological interpretation.3 This important handoff of patient information from the ordering provider to the interpreting radiologist can enhance efforts to deliver safer patient care.
The types of pertinent clinical information to be provided by the ordering practitioner include the patient’s surgical history, primary 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 in enhancing the clinical relevance of the final report.
Radiologists are often 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 for radiologists: interpreting studies for multiple hospitals or ambulatory centers, each with its unique EHR system. This requires access to and knowledge of numerous medical record systems.
Radiologists also face a daily problem: The need to access the EHR to search for missing clinical information causes interruptions in the reading process. Depending on the individual’s skill and experience levels, a radiologist 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
Follow these strategies to reduce the potential of a misinterpreted radiology study due to a lack of knowledge of a patient’s clinical information:
- Develop a checklist or protocol of crucial 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 affect their diagnostic process.
- Engage in an education effort to inform referring practitioners 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 practitioner the developed checklist or protocol of necessary information 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 practitioner to re-enter information already in the EHR and reduce efforts by the radiologist to search for important information before 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 absent.
- Integrate radiologists into the healthcare team. If findings are not consistent with clinical information provided by the ordering practitioner, radiologists should initiate a conversation to analyze the situation and determine the next steps in the diagnostic process.
- Audit the frequency of radiology orders in your organization with missing or incomplete patient clinical information. Compare the orders to the information in the patient’s EHR. Identify case examples in which missing clinical information would have been beneficial to interpretation, regardless of whether it would have changed the interpretation. Inform ordering practitioners about consistently missing clinical information and identify those needing additional education.
For questions on radiology safety, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email. We also provide the following resources:
- Study: Diagnostic and Interventional Radiology Closed Claims Study
- Video: Diagnostic Radiology Malpractice Claims Study
- Continuing Medical Education: Diagnostic Radiology: Analysis of Closed Malpractice Claims
- 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
- Cherla DV, Bernardi K, Blair KJ, et al. Importance of the physical exam: double-blind randomized controlled trial of radiologic interpretation of ventral hernias after selective clinical information. Hernia. 2019;23(5):987-994. doi:10.1007/s10029-018-1856-3
- Castillo C, Steffens T, Sim L, Caffery L. The effect of clinical information on radiology reporting: a systematic review. J Med Radiat Sci. 2021;68(1):60-74. doi:10.1002/jmrs.424
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.