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. Radiology Report
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

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. Communication Shortcomings
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

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. Electronic Tickler File as a Solution
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

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. Henry Ford Health System Electronic Tickler File Solution
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

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. Use Case: Abnormal CXR
Illuminate Main Menu
LLL Collapse

19. Setting the Alert
Set the Alert

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

21. Receiving Alert: Plug-in Inbox

22. Receiving Alert: E-mail

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
ACR Practice Guideline for Communication of Diagnostic Imaging Findings (Revised 2010)
Berlin L. Failure of Radiologic Communication: An Increasing Cause of Malpractice Litigation and Harm to Patients. Appl Rad 2010, Jan-Feb, 17-23
Cascade PN and Berlin L. Malpractice Issues in Radiology. AJR 1999;173:
Chesbrough R. Critical Results: Communication Management in Radiology. (posted 4/6/2010, accessed 10/1/2011)
Berlin L. The Duty to Communicate. AJR 2011;197 W962
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, K3
2799 West Grand Boulevard
Detroit, MI
Mikhail Nekhline:
Safwan Halabi: