Communicating results: Still a boondoggle

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.

Radiologists know it is imperative that certain imaging findings, particularly those indicating potentially immediate life-threatening conditions, be communicated directly to physicians caring for those patients. Also, any imaging findings that are “potentially” unexpected should be communicated in a less urgent manner, so that their importance, if any, can be ascertained. Such communications need to be clearly documented in the radiology report. As far as I know, such communications must be physician to physician and preferably with one who knows the patient and has the authority to act on the information. Failure to perform these duties can lead to very negative consequences, sooner or later, for the patient’s health and the medico-legal health of any involved physicians.

Well, all that’s very nice and very appropriate, but the systems to support that process really do not exist as far as I know. Of course there are companies that have devised various electronic methods to assist in establishing and verifying such important communication. I know they have supporters and detractors, and I am not writing to judge such offerings currently in the marketplace. I just want to reflect on some of the problems that exist that can confound any electronic solution – although I have a few to suggest, perhaps based on my naivety.

The inherent weaknesses in the system will affect both hospital and private practice settings in different ways. First, consider the creeping indications list. That is, what diagnoses need to be communicated? It seems to be steadily growing. A ruptured abdominal aneurysm is straightforward, but what about a thyroid cyst(s), or a Bosniak type 2 renal cyst, or a deep ulcerated atherosclerotic plaque without intramural blood, or “something” half-way occluding a mainstem bronchus that is probably mucous, but could be a tumor in the wall?

I guess they are all unexpected, but are they significant enough to call another busy physician about? Any of them could be overt disease now or become so in the future. All radiologists must have all the latest thinking about the appropriate work-up, if any, for every finding of this nature at their fingertips. Yes, Google helps, but it does not always lead one to the definitive source of information. On our hospital emergent call list, there is subdural hematoma, but not subarachnoid hemorrhage. Who made that decision? One may feel “safe” if they follow the list, but there is a great deal of discretion (too much?) inherent in the process.

Next, why is it that the radiologist makes and verifies the communication? Certainly for any cases that are urgent clinically the physician requesting the study should have a very high level of interest in the result. In fact, every imaging study performed should be checked by the appropriate physician in every circumstance. Reviewing the result is at least as important as obtaining the study in the first place. Having the radiologist communicate important or unexpected findings is fine, but it must be a 2-way street. What information in the report turns out to be significant to patients is much better known by the physicians directly caring for them, who know something about their history and physical findings, than by a radiologist who often barely gets an indication for the exam.

Sometimes the radiologist does not know whom to talk to about the urgent findings. Maybe you are lucky enough to have an assistant who can spend lots of time looking for the ordering or responsible physician—I’m not that lucky. Every imaging request should provide all relevant contact information for the physician or appropriate designee to receive critical information in a timely fashion,either immediately, or within a practical time frame, depending on the finding. There is no reason that that information should not be standard and a requirement for having a study performed. Responding to a radiologist’s call with “he’s not my patient” or “his doctor is in Tahiti for 3 weeks so call back then” or that “the doctor has gone off service now” or “all the new residents use my name to orderstudies” is not much help. Honestly, though, most people in our hospital try to be helpful in making these contacts, but they are also inconvenienced by the sometimes sloppy process.

Communication of urgent or potentially important imaging findings is anything but a smooth, rapid, reliable, and effective process.I have 2 ideas, which I heard from other radiologists that are really appealing. First, all emergency physicians should have Bluetooth receivers in their ears at all times to get direct calls from radiologists about critical findings. They press a button, listen, and talk. It’sa great opportunity for information exchange. The bedside physician can even do this while the stethoscope is in use or while talking to a patient; just say “excuse me.” These calls can be recorded, as they are now in our emergency department. Second, all reports —imaging and otherwise — should be checked off as reviewed by the physician of record, the one whose name and contact information is on the request, in the electronic medical record. Any reports not checked within a given time should be red-flagged and placed on the front page at sign-in and checked before the user can proceed. Excuse me, if these processes are in use already somewhere. I know there a lot of potential problems/complaints with these ideas, but we have put men on the moon.

I would really welcome other ideas or success stories from you, dear readers, to facilitate getting the end-product of everything else we doto the right person at the right time to optimize our contribution to patient care.