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The Tickler File: PACS Application Alerts Radiologists When Recommended Additional or Follow-up Examinations are Rendered Mikhail Nekhline, MD Safwan Halabi,

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Presentation on theme: "The Tickler File: PACS Application Alerts Radiologists When Recommended Additional or Follow-up Examinations are Rendered Mikhail Nekhline, MD Safwan Halabi,"— Presentation transcript:

1 The Tickler File: PACS Application Alerts Radiologists When Recommended Additional or Follow-up Examinations are Rendered Mikhail Nekhline, MD Safwan Halabi, MD Henry Ford Health System Department of Radiology Detroit, Michigan, USA

2 What is a Tickler File? Ordering provider: A file/list that is maintained to alert health care providers if and when a follow-up examination is recommended for their patient Radiologist: A file/list that is maintained to follow-up imaging recommendations and patient outcomes

3 Examples of Paper Tickler Files

4 Reporting and Communication American College of Radiology (ACR) Guidelines on Reporting Effective communication is a critical component of diagnostic imaging Commitment and reciprocal duty of information exchange between the ordering provider and radiologist Emphasizes the importance of suggesting additional or follow-up studies when appropriate Mandates the necessity to review all available pertinent previous reports and images

5 Radiology Report Clinical document that communicates the imaging interpretation and recommendation of the radiologist Clinical document that serves to guide patient care Patient’s document that resides in the permanent medical record Legal document for medical malpractice liability

6 Cleary written and/or verbally communicated to avoid ambiguity Includes comparison and correlation to prior imaging when available Includes recommendation for appropriate additional or follow-up examination Final signed report with interpretation and recommendation delivered to the referring provider or clinical service Radiology Report

7 Communication Shortcomings Radiology reports and communications are not received by the responsible parties Significant delay between image acquisition and image interpretation Prior imaging is not available at the time of interpretation for comparison

8 Referring provider assumes that other health care personnel will follow-up with the radiology recommendations Referring provider may misinterpret the clinical significance of the imaging interpretation and/or follow-up imaging recommendations Patient transferred care to a different facility, was lost to follow-up or was non-compliant with follow-up recommendations Communication Shortcomings

9 Electronic Tickler File as a Solution Create exam follow-up lists and alerts electronically at the time of image interpretation and recommendations Ability to track all subsequent patient imaging to ensure that recommendations were acted upon Provide feedback to the radiologist in regards to follow-up imaging results and patient outcome

10 Electronic Tickler File as a Solution Enables the radiologist to become an active participant in the care of patients Establishes a closer rapport with the referring provider and clinical service Reduces burden on the referring provider Overall goal is to deliver better patient care and enhance patient safety

11 Prevent duplicate imaging exams ordered from different providers Guide patient care and close the loop to the ordering provider and patient Radiologist interpreting the follow-up exam will be in a better position to answer the clinical question raised on the initial exam Limits malpractice claims Electronic Tickler File as a Solution

12 Malpractice Issues Negligence of hospital employees to deliver a message or act upon it does not protect the radiologist from a medical malpractice claim Failure to review prior exams for comparison or correlation may be considered as negligence Failure to act on recommended studies may be considered a breach of duty by both the referring clinician and the radiologist

13 Henry Ford Health System Electronic Tickler File Solution Illuminate plug-in (Softek Solutions, Inc.,Kansas City, KS) developed for iSite Radiology PACS (Philips, Foster City, CA) Advanced search and data mining plug-in with functionality to create exam alerts Alert user when a key word is mentioned in a radiology report Alert when follow-up imaging is performed on a specific patient

14 PACS plug-in allows a radiologist to track a patient when follow-up imaging is recommended Follow-up alerts can be filtered by specific imaging modality Alert expiration date can be designated User can be alerted when an exam is not rendered by a certain date or time period Henry Ford Health System Electronic Tickler File Solution

15 Alert Options Alerts can be received by the radiologist and other providers via different electronic methods including: plug-in inbox, , text message, and pager Alerts may contain the follow-up imaging report or a link to the report

16 PACS Plug-in Demonstration

17 Use Case: Abnormal CXR

18 Illuminate Main Menu LLL Collapse Use Case: Abnormal CXR

19 Set the Alert Setting the Alert

20 Setting Alert Options Set Expiration Set the Memo Chose Modality Chose Alerts

21 Receiving Alert: Plug-in Inbox

22 Receiving Alert:

23 Time-limited Alerts Follow-ups can be time-limited by creation of alert expiration to ensure patient care loop closure Alert expiration depends on the inherent nature of the suspected process, level of suspicion and radiologist preference If no imaging of the selected modality is obtained within the allotted time period, the overdue alert notice is generated

24 Receiving Overdue Alert

25 Time-limited Alerts Alerts can be forwarded to the patient’s provider as a reminder that the recommended follow-up examination has not been rendered Currently, only users of the Illuminate PACS plug- in can receive the alert Radiologist acts as the “Tickler” for the referring physician

26 Notifying Referring Provider Send a message to clinician

27 Forward Alert to Provider Forward referring provider the report text and link to the images

28 Benefits of the Electronic Tickler File Convenient method to electronically track follow- up recommendations at the time of interpretation Redundant alerts can be set via various communication methods ( , pager, SMS) Alerts can be forwarded to the health care team (clinician, medical director, case worker) Interesting studies can be tagged and archived to create a teaching file or for research purposes

29 Benefits of the Electronic Tickler File Allows radiologists to read the reports and view the images of their recommended follow-up exams Evaluates accuracy of the radiologist’s initial interpretation and validity of follow-up recommendations Delivers feedback about the patient to the radiologist Exposes the radiologist to the radiologic course of a disease process

30 Future Role of Alerts Radiologist actively participating in care of the patient redefines role of radiology in clinical medicine Establish call center to centrally handle all communication between the radiologist, referring physician and patient Enhance radiology trainee education with the ability track the outcomes of their interpretations and patient outcomes

31 Centralized Radiology Call Center Communicate critical results, unexpected findings, and missed follow-up exams to the referring physician Reduce burden on the radiologist to track down the referring physician and maintain a central Tickler File Document and audit all communication between the radiologist and referring provider

32 Radiologist as Clinical Asset Tickler File empowers the radiologist to actively participate in patient care Transfer burden of Tickler File maintenance from the ordering provider to the radiologist Reduce malpractice risk for the hospital and the radiologist by closing the communication loop Add value to the radiology group to avoid risk of radiology service outsourcing

33 References 1. ACR Practice Guideline for Communication of Diagnostic Imaging Findings (Revised 2010) 2. Berlin L. Failure of Radiologic Communication: An Increasing Cause of Malpractice Litigation and Harm to Patients. Appl Rad 2010, Jan-Feb, Cascade PN and Berlin L. Malpractice Issues in Radiology. AJR 1999;173: Chesbrough R. Critical Results: Communication Management in Radiology. 3/critical-results-communication-management-in-radiology.aspx (posted 4/6/2010, accessed 10/1/2011) 5. Berlin L. The Duty to Communicate. AJR 2011;197 W Towbin AJ, Hall S, Moskovitz J, Johnson ND, Donnelly LF. Creating a Comprehensive Customer Service Program to Help Convey Critical and Acute Results of Radiology Studies. AJR 2011;196:W48-W51

34 Correspondence Mailing address: Henry Ford Hospital Department of Radiology, K West Grand Boulevard Detroit, MI Mikhail Nekhline: Safwan Halabi:


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