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Improving Imaging Quality and safety with e-communication Ronald Arenson, MD.

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Presentation on theme: "Improving Imaging Quality and safety with e-communication Ronald Arenson, MD."— Presentation transcript:

1 Improving Imaging Quality and safety with e-communication Ronald Arenson, MD

2 Magnitude of the Safety Problem 22% Americans claim family member suffered mistake - Commonwealth Fund22% Americans claim family member suffered mistake - Commonwealth Fund Medical errors cause 44, ,000 deaths / year in US - IOMMedical errors cause 44, ,000 deaths / year in US - IOM Eighth leading cause of death ahead of vehicle accidents and breast cancer - AHRQEighth leading cause of death ahead of vehicle accidents and breast cancer - AHRQ 2% of admissions experience medication errors costing $2 billion / yr - IOM2% of admissions experience medication errors costing $2 billion / yr - IOM Preventable medical mistakes cost $ billion / year - IOMPreventable medical mistakes cost $ billion / year - IOM Second only to med errors, patient falls occur in 2-4% of patients and 2- 6% result in significant injury - JCAHOSecond only to med errors, patient falls occur in 2-4% of patients and 2- 6% result in significant injury - JCAHO

3 Patient Care depends on Imaging We perform procedures on many patients each day (500,000 procedures per year at UCSF)We perform procedures on many patients each day (500,000 procedures per year at UCSF) CT and MR have become extensions of the physical examinationCT and MR have become extensions of the physical examination Triage roleTriage role Acute versus chronicAcute versus chronic Surgical versus medicalSurgical versus medical

4 Perfect Aims to Avoid Safety Problems Patient mis-IDPatient mis-ID Equipment - failureEquipment - failure Reading - misinterpretReading - misinterpret Fall - patient fallFall - patient fall Environment - spillEnvironment - spill CommunicationCommunication Test - wrong exam / complication / excess radiationTest - wrong exam / complication / excess radiation AllergyAllergy Injection - wrong material / dose / extravasationsInjection - wrong material / dose / extravasations Metal - in magnetMetal - in magnet Side - wrong sideSide - wrong side

5 E-Communication What is it?What is it? Computer-based, non-paper, non-FAX communicationComputer-based, non-paper, non-FAX communication ComponentsComponents Web services or Service Oriented ArchitectureWeb services or Service Oriented Architecture EMR note – official medical recordEMR note – official medical record Secure Secure SMS (Short Messaging Service) = Text message (with security)SMS (Short Messaging Service) = Text message (with security) “Full duplex” – acknowledgement or verification“Full duplex” – acknowledgement or verification

6 Information business Medical Care and Radiology in particular in the information businessMedical Care and Radiology in particular in the information business Access to and integration with EMRAccess to and integration with EMR Two major points of communicationTwo major points of communication Study requests – order entry (clinical indication) – to be discussed by Keith Dreyer, MDStudy requests – order entry (clinical indication) – to be discussed by Keith Dreyer, MD Access to EMR for context, labs, medsAccess to EMR for context, labs, meds Reporting results – get results to our referring MDsReporting results – get results to our referring MDs Make sure we have the correct target individualMake sure we have the correct target individual Bob Wachter, MD: “Cannot do Quality and Safety without IT”Bob Wachter, MD: “Cannot do Quality and Safety without IT”

7 Other communication challenges Protocoling – electronic, standardizationProtocoling – electronic, standardization Messages to technologists – RISMessages to technologists – RIS Patient interactionsPatient interactions Medication / laboratory conflictsMedication / laboratory conflicts Sending reports to patientsSending reports to patients Management reporting: mining for quality and safetyManagement reporting: mining for quality and safety QA “tagging”QA “tagging” Computer Aided Diagnosis – will not be covered in this talkComputer Aided Diagnosis – will not be covered in this talk Mammography, High-res chest CT, skeletal bone age, diabetic retinopathyMammography, High-res chest CT, skeletal bone age, diabetic retinopathy

8 Patient Misidentification Performing a procedure on the wrong patientPerforming a procedure on the wrong patient Giving the wrong patient injections / drugsGiving the wrong patient injections / drugs Technologist placing the wrong patient identifiers on imagesTechnologist placing the wrong patient identifiers on images Transcriptionist mixing up patientsTranscriptionist mixing up patients Radiologist reading images for the wrong patientRadiologist reading images for the wrong patient RIS/PACS/transcription or voice recognition integration avoids most of theseRIS/PACS/transcription or voice recognition integration avoids most of these

9 Selecting Proper Patient ID

10 Barcode or RFID Solution Patient ID bracelets with either barcodes or RFIDPatient ID bracelets with either barcodes or RFID Readers associated with imaging equipment to choose from patient worklistsReaders associated with imaging equipment to choose from patient worklists Portable readers for portable exams using CR which provide patient ID to plates to be read by scannersPortable readers for portable exams using CR which provide patient ID to plates to be read by scanners

11 Tech worklist

12 Select search by MRN

13 Barcode removes other patients

14 Appropriate Examination Electronic Order Entry systems - CPOEElectronic Order Entry systems - CPOE Speed transmission to RadiologySpeed transmission to Radiology May provide more patient historyMay provide more patient history May improve physician and patient satisfactionMay improve physician and patient satisfaction Standardized order sets very helpfulStandardized order sets very helpful Can include decision-support tools that improve appropriatenessCan include decision-support tools that improve appropriateness Decision-support order entry for Radiology will be in a separate presentationDecision-support order entry for Radiology will be in a separate presentation

15 Reporting Communication issues Unexpected acute findings or new neoplastic diagnosisUnexpected acute findings or new neoplastic diagnosis ACR standard for “direct” communicationACR standard for “direct” communication “Wet readings” – wet read module“Wet readings” – wet read module Resident interpretations at nightResident interpretations at night Accuracy and audit trailAccuracy and audit trail Outside priors and curbside consults for outside studiesOutside priors and curbside consults for outside studies Poorly constructed reports – mixing up right and left, confusing abbreviationsPoorly constructed reports – mixing up right and left, confusing abbreviations Smart reports – voice recognitionSmart reports – voice recognition Structured reportingStructured reporting Misunderstood report findings – standard terminology like Radlex and reference informationMisunderstood report findings – standard terminology like Radlex and reference information Reporting and tracking sub-critical findingsReporting and tracking sub-critical findings Alex Rybkin, MD, project at SFGHAlex Rybkin, MD, project at SFGH

16 Wet Read Module Add-on to PACSAdd-on to PACS Provides immediate preliminary interpretations to ED, ICUs, othersProvides immediate preliminary interpretations to ED, ICUs, others Uses PACS displays and PDAsUses PACS displays and PDAs Built-in feedback to referring MDs and QA for attending changes after resident interpretationsBuilt-in feedback to referring MDs and QA for attending changes after resident interpretations Wyatt Tellis, Kathy Andriole, J Digit Imaging Jun;17(2):80-6. Epub 2004 Mar 25 Wyatt Tellis, Kathy Andriole, J Digit Imaging Dec;18(4):316-25

17 Entering wet-read

18 Entering QA review

19 PDA GUI Wet-Read Alert Wet-Read & Full Report Display ED Patient ListRIS Query Panel

20 Reporting errors

21 Safely Performed Patient Safety is a major concern for all but Radiology particularly vulnerable becausePatient Safety is a major concern for all but Radiology particularly vulnerable because we perform a very large number of procedures dailywe perform a very large number of procedures daily we are not very familiar with our patientswe are not very familiar with our patients there are many steps involved in the process of carethere are many steps involved in the process of care we utilize drugs, contrast, radiation, needles, catheters, and other devices that can cause harmwe utilize drugs, contrast, radiation, needles, catheters, and other devices that can cause harm Radiation exposure especially in CT now a major concernRadiation exposure especially in CT now a major concern Variation in dose for same examinationVariation in dose for same examination Large number of CT exams especially in childrenLarge number of CT exams especially in children

22 Protocoling

23 Protocol GUI

24 Scanned Requisition

25 Radiation monitoring Now important to capture radiation exposure from each exam (available from newer CTs / DR)Now important to capture radiation exposure from each exam (available from newer CTs / DR) Should accumulate dose for each patientShould accumulate dose for each patient Should share the accumulated dose with other organizationsShould share the accumulated dose with other organizations National repository?National repository? Requires sharing data with other institutionsRequires sharing data with other institutions RSNA contract with the NIBIBRSNA contract with the NIBIB

26 Communicating Urgent Findings Radiologists expected to immediately communicate with referring MDs for urgent and unexpected findingsRadiologists expected to immediately communicate with referring MDs for urgent and unexpected findings Sometimes difficult to reach referring MDs and sometimes their staff do not effectively communicate with themSometimes difficult to reach referring MDs and sometimes their staff do not effectively communicate with them Subcritical findings also a problemSubcritical findings also a problem Non-calcified nodule on CT, recommend f/uNon-calcified nodule on CT, recommend f/u Commercial systems such as VA View Alert and Vocada’s VoiceLink attempt to assist in process and documentationCommercial systems such as VA View Alert and Vocada’s VoiceLink attempt to assist in process and documentation Shifts responsibility away from RadiologyShifts responsibility away from Radiology

27

28 Referring MD Miscommunication Poor clinical history on requestPoor clinical history on request No indication of reason for ordering procedureNo indication of reason for ordering procedure Selection of the wrong type of procedure or the wrong sideSelection of the wrong type of procedure or the wrong side Be sure someone talks with the patient before proceedingBe sure someone talks with the patient before proceeding Inadequate preparation of the patient for a procedureInadequate preparation of the patient for a procedure Not reading reports carefully / no proper follow-upNot reading reports carefully / no proper follow-up

29 Communications with other institutions In the United States, few “closed” systems, e.g. Kaiser, VAIn the United States, few “closed” systems, e.g. Kaiser, VA Typical community environmentTypical community environment Hospitals and physicians separate entitiesHospitals and physicians separate entities Incomplete or fractional EMRIncomplete or fractional EMR Challenge of identifying patients across separate institutions and enterprisesChallenge of identifying patients across separate institutions and enterprises This issue includes inpatient versus outpatientThis issue includes inpatient versus outpatient Challenge of identifying the “relevant” clinicianChallenge of identifying the “relevant” clinician

30 Management Reporting Quality and Safety require careful monitoringQuality and Safety require careful monitoring Effective management reporting is essential for this monitoringEffective management reporting is essential for this monitoring “Dashboard” concepts can be useful in Radiology for high level view“Dashboard” concepts can be useful in Radiology for high level view

31 Report Turn-around Times October - Median Hours

32 RSNA efforts Integrating the Health Care Enterprise (IHE)Integrating the Health Care Enterprise (IHE) Structured ReportingStructured Reporting Radlex vocabularyRadlex vocabulary NIBIB Image Sharing ContractNIBIB Image Sharing Contract Radiation reportingRadiation reporting

33 Integrating the Healthcare Enterprise

34 IHE for Merger of Exams / Reports

35 IHE for Processed Images

36 IHE and Shared Context Effective integration of separate systems requires sharing context for patient, exam, and event statusEffective integration of separate systems requires sharing context for patient, exam, and event status Most systems support patient ID (MRN) but do not currently support beyond that levelMost systems support patient ID (MRN) but do not currently support beyond that level Radiation exposure is now an IHE profileRadiation exposure is now an IHE profile

37 Structured Reporting and Lexicons Structured reportingStructured reporting Can improve on the quality of communication with referring MDCan improve on the quality of communication with referring MD Facilitates retrieval by findings / diagnosisFacilitates retrieval by findings / diagnosis Provides opportunity to measure accuracyProvides opportunity to measure accuracy LexiconsLexicons BIRADS from ACRBIRADS from ACR RadLex from RSNARadLex from RSNA RSNA now launching structured reporting projectRSNA now launching structured reporting project Best practice Radiology templateBest practice Radiology template

38 RadLex by RSNA Standardized lexiconStandardized lexicon Ontology for radiology terminologyOntology for radiology terminology By subspecialtyBy subspecialty ProceduresProcedures Playbook – specific protocols rather than just CPTPlaybook – specific protocols rather than just CPT FindingsFindings Structured report and searchable termsStructured report and searchable terms

39 Image sharing project NIBIB sponsored contract with the RSNANIBIB sponsored contract with the RSNA Six institutions sub-contractedSix institutions sub-contracted Patients control who has accessPatients control who has access Avoids HIPAA issuesAvoids HIPAA issues Uses IHE standards for image transmissionUses IHE standards for image transmission Facilitates availability of patients’ prior images when in a new institutionFacilitates availability of patients’ prior images when in a new institution Technique applicable to other types of dataTechnique applicable to other types of data Accumulated radiation dose Other clinical information Research data and images

40 Hospital/Imaging Center Edge Device Clearinghouse Patient Identity Source Register Document Set [ITI- 4] Pid=RSNA+2 nd Factor Document Source PACS RIS PHR Document Registry PIX Manager RSNA ID Map Report DB Temp Image Storage Document Repository Document Consumer

41 Conclusions Variety of possible patient safety problems in RadiologyVariety of possible patient safety problems in Radiology Quality and Safety in Radiology can be greatly enhanced by the application of information technologyQuality and Safety in Radiology can be greatly enhanced by the application of information technology Further development and deployment of IHE are key to achieving these gains in Safety and QualityFurther development and deployment of IHE are key to achieving these gains in Safety and Quality


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