Editorial: Goodbye, Mr. Cox: Time for automated closure of the radiology

By Eliot Siegel, MD
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Dr. Siegel is Chief of Radiology, Baltimore VAMedical Center, and a Professor and the Vice Chairman of the Department of Diagnostic Radiology, University of Maryland, Baltimore, MD. He is also a member of the editorial board of this journal.

Communication of a diagnosis so that it may be beneficially utilized may be altogether as important as the diagnosis itself.
Phillips v. Good Samaritan Hospital, 416 N.E.2d 646 (Ohio App. 1979)

Mr. Cox, our Department Administrator at the Baltimore Veterans Affairs (VA) Medical Center, has announced that he will retire within the next few years. He will be missed greatly for several reasons, not the least of which is his central role as a facilitator, conduit, and information repository for communication of radiology interpretations. Kushner and Lucey, 1 in an excellent recent article in the Journal of the American College of Radiology , discussed the continuing controversy generated by the American College of Radiology (ACR) Guideline for Communication: Diagnostic Radiology, 2 originally issued in 1991. The ACR has responded to criticisms in a constructive manner by creating a study task force and by retaining the services of attorneys to perform a legal review of malpractice cases involving communication issues. The authors of the article emphasized the fact that "there would be liability for communication-related errors even if there had never been a guideline from the ACR." They also identified 4 situations in which courts in malpractice decisions have specified the need for "direct contact" with the responsible clinician (rather than communicating through paper or electronic radiology reports) (Table 1).

Depending on the radiologist's interpretation, these criteria could represent anywhere from a small minority to a majority of abnormal cases. The potential for a medicolegal requirement for "direct" communication in such a large number of cases is both scary and impractical. Kushner and Lucey pointed out that, in addition to "direct" communication and depending on the urgency of the situation, "a text page, facsimile, or e-mail may be appropriate as long as receipt of the communication can somehow be demonstrated and documented, and patient confidentiality be respected…." 1 However, as in the ACR guideline itself, little direction is given as to when these technologies should be used in addition to the report but in lieu of in-person or direct phone communication.

The authors noted that the Physician Insurers Association of America (PIAA) suggests that communication errors in radiology are common. In 1997, a PIAA review found that the most common of these by far was failure by the radiologist to directly contact the referring physician about urgent or significant unexpected findings. 3 The same group found communication issues in 28% of breast cancer claims filed from 1995 to 2002. 4 A review of the medical liability cases reported in Medical Malpractice Verdicts, Settlements, and Experts 5 found 46 communications-related cases. Radiologist defendants were held responsible in 25 of these, usually along with other physicians and with an average settlement of $1.9 million. Seventeen of these cases involved breakdowns in communication between emergency departments and radiology.

The ACR task force made 5 specific recommendations, including a call for "extensive revisions" of the guideline, a summit with other medical organizations to develop ways to reduce communication errors, a more detailed risk management document, and additional education for ACR members.

I believe that the crisis in communication of radiology reports is more acute today than ever before and is worsening, despite the proliferation of computer technologies that once seemed to promise easy solutions. The crisis has been only partially mitigated by improvements in interpretation and report turnaround times, which (ironically) may result in increased expectations by referring clinicians. Other factors precipitating this crisis include a substantial increase in the volume of imaging studies, decreased "in-person" interaction among physicians after implementation of picture archiving and communication systems (PACS) and other information systems, 6 and the increasing importance of imaging studies in routine clinical decision making and patient management.

This crisis of increasing expectations demands that we re-invent the process of communicating radiology reports. Radiology has been stuck in a paradigm of one-way communication of results. We should concentrate on "closing the loop" in a two-way or iterative communication process. Our emphasis has been so focused on the critical issue of reduction in interpretation and report turnaround times that we have neglected the importance of tracking clinician acknowledgment of those reports and their requests for follow-up studies. Given the crucial clinical role of imaging reports in patient care and the potential for litigation, this is a major failing of current PACS functionality.

One objection that radiologists raise against the ACR guideline is that the legal system seems to place an unfair burden of responsibility on the radiologist. Radiology reporting systems should be redesigned to track and then shift a portion of the responsibility for follow-up back to our referring clinicians and simultaneously decrease the risk of adverse action associated with lack of follow-up.

Despite our strong interest and curriculum in imaging informatics at the Veteran's Affairs Medical Center (VAMC), the lack of this software in our information systems has forced us to rely on our greatest analog asset: the estimable Mr. Cox.

Our department policy is that urgent findings (a very small percentage of total reports), such as a significant pneumothorax, are communicated directly by the radiologist to the referring clinician. These cases are also communicated to Mr. Cox, who logs them into a computer database. All other reports that radiologists believe would fall into the 4 categories listed in Table 1 are communicated to Mr. Cox, who quickly tracks down the appropriate referring physician, colleague, or department that will accept responsibility for the results. He enters these cases into the database. He is efficient, professional, friendly, and has the characteristic charm of a Southern gentleman. He knows how to track down clinicians or their designees. He keeps a phone log, including the name of the person with whom he spoke, the time, and the patient. He also follows up on cases in which radiologists have made recommendations, to make sure those studies have been performed within the recommended intervals. He sometimes even reviews radiology reports and calls clinicians with findings without a specific request from the radiologist, because he has an excellent understanding of what is clinically important. These tasks, performed in addition to his other numerous administrative responsibilities, have resulted in major reductions in the number of failures to act promptly or to follow up on significant findings.

It has become increasingly apparent to me that we need to reinvent our thinking and our information systems to create a digital Mr. Cox. The automated system could either provide a pull-down menu or other tool that would allow a radiologist to alert the system when a finding requires either direct or "more direct" communication. This could take the form of a short "sticky note" or brief voice recording or ".wav" file, or the communication could even be generated in structured fashion from a pull-down menu. The software could automatically page or call a referring clinician for urgent findings and request a response. The system would communicate the results in a collegial but informative way and record all details, including when the communication was initiated, who received it, and when it was acknowledged. The system would have the intelligence to try other means of connecting with a referring clinician or, if these failed, to communicate with a clinician's administrative designee. The automated system could even search all reports and, using a natural language-processing algorithm, contact referring clinicians when certain clinical criteria were met or specific keywords were invoked. This could further reduce the possibility of a missed communication in those instances in which the radiologist failed to enter a significant finding into the system. The software also would find cases in which follow-ups were recommended, entered either manually by the radiologist and stored in a follow-up database, or extracted automatically, again by a natural-language processor for reports. Structured reports would, of course, be easiest to use for the system, but these still represent only a tiny minority of reports outside of mammography. "Tickler" notices could be generated as reminders to obtain follow-up reports. The system would also produce a list of cases without acknowledgement of receipt and/or follow-up on imaging recommendations, and these could be followed up manually.

The technologies required to create the digital Mr. Cox are not part of a futuristic fantasy--they already exist. I believe that with strong customer demand and vendor support, these systems could be developed and prototyped fairly rapidly. The remaining challenge would be a cultural and educational one for our referring clinicians.

From my personal perspective, I'm hoping that we can get such technologies working well in advance of the real Mr. Cox's retirement so that we can continue an approach that has been successful in reducing medical errors and in providing better patient care. If it can work well in our environment, with a high percentage of positive findings read by constantly rotating practitioners, I am confident that it will be successful in most diagnostic imaging practices.

Finally, once we have tackled the easy stuff, I would like to see someone build Mr. Cox's trademark Southern charm and grace into the system.

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Editorial: Goodbye, Mr. Cox: Time for automated closure of the radiology.  Appl Radiol. 

June 08, 2005
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