Communication breakdowns and diagnostic errors: a radiology perspective

Design and Perceived Value of a Novel Solution for Asynchronous Communication in Radiology

RATIONALE AND OBJECTIVES

Communication with and within the Radiology Department is typically initiated over phone, face-to-face or general-purpose chat, causing frequent interruptions, additional mental workload, workflow inefficiencies and diagnostic errors. We developed and evaluated a new communication solution that aims to reduce avoidable interruptions caused by technologist-radiologist communication.

MATERIALS AND METHODS

Following an iterative design process with future end users, a scalable web-based software solution, RadConnect, was developed enabling a chat-based communication workflow between a technologist and a radiologist. As a first experimental implementation, technologists can send categorized tickets to a radiology section account. Radiologists receive the tickets in a worklist that is prioritized by urgency. Consented radiologists and technologists performed scripted tasks in 2 hr sessions and completed a structured questionnaire on perceived value and comparison to standard communication modes.

RESULTS

Of 17 participants from three academic European institutes, 65% (11/17) believed they would use RadConnect frequently; 53% (9/17) believed that it reduces phone calls >80%; and 88% (15/17) believed it adds value compared to general-purpose enterprise chat applications.

DISCUSSION

Participants recognized the value of RadConnect especially its categorized tickets, prioritized worklist and role-based interaction model. Inter-institute differences in perceived value of RadConnect may have been caused by technologist-radiologist proximity and communication alternatives in the institutions.

CONCLUSION

Chat-based role-based communication might be a viable mode of communication between technologists and radiologists to reduce avoidable interruptions. Tailoring the chat solution to the needs of and tightly integrated with the radiology workflow is valued by future end users after exposure to the tool in a simulated environment.

Electronic safety-netting tool features considered important by UK general practice staff: an interview and Delphi consensus study

BACKGROUND

The potential of the electronic health record to support safety netting has been recognised and a number of electronic safety-netting (E-SN) tools developed.

AIM

To establish the most important features of E-SN tools.

DESIGN & SETTING

User-experience interviews followed by a Delphi study in a primary care setting in the UK.

METHOD

The user-experience interviews were carried out remotely with primary care staff who had trialled the EMIS E-SN toolkit for suspected cancer. An electronic modified Delphi approach was used, with primary care staff involved in safety netting in any capacity, to measure consensus on tool features.

RESULTS

Thirteen user-experience interviews were carried out and features of E-SN tools seen as important formed the majority of the features included in the Delphi study. Three rounds of Delphi survey were administered. Sixteen responders (64%) completed all three rounds, and 28 out of 44 (64%) features reached consensus. Primary care staff preferred tools that were general in scope.

CONCLUSION

Primary care staff indicated that tools that were not specific to cancer or any other disease, and had features that promoted their flexible, efficient, and integrated use, were important. However, when the important features were discussed with the patient and public involvement (PPI) group, they expressed disappointment that features they believed would make E-SN tools robust and provide a safety net that is difficult to fall through did not reach consensus. The successful adoption of E-SN tools will rely on an evidence base of their effectiveness. Efforts should be made to assess the impact of these tools on patient outcomes.

Natural Language Processing of Radiology Reports to Detect Complications of Ischemic Stroke

BACKGROUND

Abstraction of critical data from unstructured radiologic reports using natural language processing (NLP) is a powerful tool to automate the detection of important clinical features and enhance research efforts. We present a set of NLP approaches to identify critical findings in patients with acute ischemic stroke from radiology reports of computed tomography (CT) and magnetic resonance imaging (MRI).

METHODS

We trained machine learning classifiers to identify categorical outcomes of edema, midline shift (MLS), hemorrhagic transformation, and parenchymal hematoma, as well as rule-based systems (RBS) to identify intraventricular hemorrhage (IVH) and continuous MLS measurements within CT/MRI reports. Using a derivation cohort of 2289 reports from 550 individuals with acute middle cerebral artery territory ischemic strokes, we externally validated our models on reports from a separate institution as well as from patients with ischemic strokes in any vascular territory.

RESULTS

In all data sets, a deep neural network with pretrained biomedical word embeddings (BioClinicalBERT) achieved the highest discrimination performance for binary prediction of edema (area under precision recall curve [AUPRC] > 0.94), MLS (AUPRC > 0.98), hemorrhagic conversion (AUPRC > 0.89), and parenchymal hematoma (AUPRC > 0.76). BioClinicalBERT outperformed lasso regression (p < 0.001) for all outcomes except parenchymal hematoma (p = 0.755). Tailored RBS for IVH and continuous MLS outperformed BioClinicalBERT (p < 0.001) and linear regression, respectively (p < 0.001).

CONCLUSIONS

Our study demonstrates robust performance and external validity of a core NLP tool kit for identifying both categorical and continuous outcomes of ischemic stroke from unstructured radiographic text data. Medically tailored NLP methods have multiple important big data applications, including scalable electronic phenotyping, augmentation of clinical risk prediction models, and facilitation of automatic alert systems in the hospital setting.

Management of Incidental Thyroid Nodules on Chest CT: Using Natural Language Processing to Assess White Paper Adherence and Track Patient Outcomes

OBJECTIVE

The purpose of this study was to develop a natural language processing (NLP) pipeline to identify incidental thyroid nodules (ITNs) meeting criteria for sonographic follow-up and to assess both adherence rates to white paper recommendations and downstream outcomes related to these incidental findings.

METHODS

21583 non-contrast chest CT reports from 2017 and 2018 were retrospectively evaluated to identify reports which included either an explicit recommendation for thyroid ultrasound, a description of a nodule ≥ 1.5 cm, or description of a nodule with suspicious features. Reports from 2018 were used to train an NLP algorithm called fastText for automated identification of such reports. Algorithm performance was then evaluated on the 2017 reports. Next, any patient from 2017 with a report meeting criteria for ultrasound follow-up was further evaluated with manual chart review to determine follow-up adherence rates and nodule-related outcomes.

RESULTS

NLP identified reports with ITNs meeting criteria for sonographic follow-up with an accuracy of 96.5% (95% CI 96.2-96.7) and sensitivity of 92.1% (95% CI 89.8-94.3). In 10006 chest CTs from 2017, ITN follow-up ultrasound was indicated according to white paper criteria in 81 patients (0.8%), explicitly recommended in 46.9% (38/81) of patients, and obtained in less than half of patients in which it was appropriately recommended (17/35, 48.6%).

DISCUSSION

NLP accurately identified chest CT reports meeting criteria for ITN ultrasound follow-up. Radiologist adherence to white paper guidelines and subsequent referrer adherence to radiologist recommendations showed room for improvement.

What Contributes to Diagnostic Error or Delay? A Qualitative Exploration Across Diverse Acute Care Settings in the United States

OBJECTIVES

Diagnostic error and delay is a prevalent and impactful problem. This study was part of a mixed-methods approach to understand the organizational, clinician, and patient factors contributing to diagnostic error and delay among acutely ill patients within a health system, as well as recommendations for the development of tailored, targeted, feasible, and effective interventions.

METHODS

We did a multisite qualitative study using focus group methodology to explore the perspectives of key clinician stakeholders. We used a conceptual framework that characterized diagnostic error and delay as occurring within 1 of 3 stages of the patient's diagnostic journey-critical information gathering, synthesis of key information, and decision making and communication. We developed our moderator guide based on the sociotechnical frameworks previously described by Holden and Singh for understanding noncognitive factors that lead to diagnostic error and delay. Deidentified focus group transcripts were coded in triplicate and to consensus over a series of meetings. A final coded data set was then uploaded into NVivo software. The data were then analyzed to generate overarching themes and categories.

RESULTS

We recruited a total of 64 participants across 4 sites from emergency departments, hospital floor, and intensive care unit settings into 11 focus groups. Clinicians perceive that diverse organizational, communication and coordination, individual clinician, and patient factors interact to impede the process of making timely and accurate diagnoses.

CONCLUSIONS

This study highlights the complex sociotechnical system within which individual clinicians operate and the contributions of systems, processes, and institutional factors to diagnostic error and delay.

Verbal Notification of Radiology Results: Are radiologists meeting expectations?

BACKGROUND

Delayed communication of radiographic findings is associated with poor patient outcomes and significant medicolegal risk. Radiologists verbally contact referring practitioners with urgent findings, though practitioner's expectations regarding notification has rarely been examined.

AIM

To assess differences in preferred practice between radiologists and referring practitioners in the verbal communication of urgent radiology findings.

METHODS

For 33 clinical stems, respondents were asked if they would issue (radiologists) or expect to receive (referring practitioners) verbal notification of results or routine written communication only. Surveys were emailed to radiologists and referring practitioners of varying experience at a tertiary referral hospital in Melbourne, Victoria.

RESULTS

A total of 97 survey responses were received. 80 responses were from referring practitioners and 17 from radiologists. Referring practitioners were seen to slightly prefer verbal notification more often than issued by radiologists overall (61%; 95CI 57-66% verbal notification expected versus 58%; 95CI 52-64% issued). More senior referring practitioners with greater than 10 years' experience expected verbal notification more often (67%; 95CI 59-75%), and more senior radiologists issued verbal reports less often (54%; 95CI 39-69%). More junior referring practitioners, for example registrars or fellows, expected notification less often overall (59%; 95CI 43-76%). Subgroup analysis demonstrated statistically significant differences in notification preferences for certain clinical scenarios.

CONCLUSIONS

Overall results show fair correlation between referrer's expectations of verbal notification and the provision of verbal notification by radiologists. However, there were discrepancies in the practice and preferences of more junior and senior practitioners, in addition to in certain clinical scenarios. This article is protected by copyright. All rights reserved.

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions

Handoffs are essential to achieving safe care transitions. In radiology practice, frequent transitions of care responsibility among clinicians, radiologists, and patients occur between moments of care such as determining protocol, imaging, interpreting, and consulting. Continuity of care is maintained across these transitions with handoffs, which are the process of communicating patient information and transferring decision-making responsibility. As a leading cause of medical error, handoffs are a major communication challenge that is exceedingly common in both diagnostic and interventional radiology practice. The frequency of handoffs in radiology underscores the importance of using evidence-based strategies to improve patient safety in the radiology department. In this article, reliability science principles and handoff improvement tools are adapted to provide radiology-focused strategies at individual, team, and organizational levels with the goal of minimizing handoff errors and improving care transitions.

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives

Background

Communication failures involving test results contribute to issues of patient harm and sentinel events. This article aims to synthesise review evidence, practice insights and patient perspectives addressing problems encountered in the communication of diagnostic test results.

Methods

The rapid review identified ten systematic reviews and four narrative reviews. Five practitioner interviews identified insights into interventions and implementation, and a citizen panel with 15 participants explored the patient viewpoint.

Results

The rapid review provided support for the role of technology to ensure effective communication; behavioural interventions such as audit and feedback could be effective in changing clinician behaviour; and point-of-care tests (bedside testing) eliminate the communication breakdown problem altogether. The practice interviews highlighted transparency, and clarifying the lines of responsibility as central to improving test result communication. Enabling better information sharing, implementing adequate planning and utilising technology were also identified in the practice interviews as viable strategies to improve test result communication. The citizen panel highlighted technology as critical to improving communication of test results to both health professionals and patients. Patients also highlighted the importance of having different ways of accessing test results, which is particularly pertinent when ensuring suitability for vulnerable populations.

Conclusions

This paper draws together multiple perspectives on the problem of failures in diagnostic test results communication to inform appropriate interventions. Across the three studies, technology was identified as the most feasible option for closing the loop on test result communication. However, the importance of clear, consistent communication and more streamlined processes were also key elements that emerged.

Review registration

The protocol for the rapid review was registered with PROSPERO CRD42018093316.

Feasibility and Reliability Testing of Manual Electronic Health Record Reviews as a Tool for Timely Identification of Diagnostic Error in Patients at Risk

BACKGROUND

Although diagnostic error (DE) is a significant problem, it remains challenging for clinicians to identify it reliably and to recognize its contribution to the clinical trajectory of their patients. The purpose of this work was to evaluate the reliability of real-time electronic health record (EHR) reviews using a search strategy for the identification of DE as a contributor to the rapid response team (RRT) activation.

OBJECTIVES

Early and accurate recognition of critical illness is of paramount importance. The objective of this study was to test the feasibility and reliability of prospective, real-time EHR reviews as a means of identification of DE.

METHODS

We conducted this prospective observational study in June 2019 and included consecutive adult patients experiencing their first RRT activation. An EHR search strategy and a standard operating procedure were refined based on the literature and expert clinician inputs. Two physician-investigators independently reviewed eligible patient EHRs for the evidence of DE within 24 hours after RRT activation. In cases of disagreement, a secondary review of the EHR using a taxonomy approach was applied. The reviewers categorized patient experience of DE as Yes/No/Uncertain.

RESULTS

We reviewed 112 patient records. DE was identified in 15% of cases by both reviewers. Kappa agreement with the initial review was 0.23 and with the secondary review 0.65. No evidence of DE was detected in 60% of patients. In 25% of cases, the reviewers could not determine whether DE was present or absent.

CONCLUSION

EHR review is of limited value in the real-time identification of DE in hospitalized patients. Alternative approaches are needed for research and quality improvement efforts in this field.

Evaluating Radiology Result Communication in the Emergency Department

PURPOSE

To assess the pattern of result communication that occurs between radiologists and referring physicians in the emergency department setting.

METHODS

An institutional review board-approved prospective study was performed at a large academic medical center with 24/7 emergency radiology cover. Emergency radiologists logged information regarding all result-reporting communication events that occurred over a 168-hour period.

RESULTS

A total of 286 independent result communication events occurred during the study period, the vast majority of which occurred via telephone (232/286). Emergency radiologists spent 10% of their working time communicating results. Similar amounts of time were spent discussing negative and positive cross-sectional imaging examinations. In a small minority of communication events, additional information was gathered through communication that resulted in a change of interpretation from a normal to an abnormal study.

CONCLUSIONS

Effective and efficient result communication is critical to care delivery in the emergency department setting. Discussion regarding abnormal cases, both in person and over the phone, is encouraged. However, in the emergency setting, time spent on routine direct communication of negative examination results in advance of the final report may lead to increased disruptions, longer turnaround times, and negatively impact patient care. In very few instances, does the additional information gained from the communication event result in a change of interpretation?

Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families

Objective

We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner.

Methods

Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days.

Results

Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period ( P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children’s study results.

Discussion

Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner.

Implications for Practice

With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea.

Test results management and distributed cognition in electronic health record-enabled primary care

Managing abnormal test results in primary care involves coordination across various settings. This study identifies how primary care teams manage test results in a large, computerized healthcare system in order to inform health information technology requirements for test results management and other distributed healthcare services. At five US Veterans Health Administration facilities, we interviewed 37 primary care team members, including 16 primary care providers, 12 registered nurses, and 9 licensed practical nurses. We performed content analysis using a distributed cognition approach, identifying patterns of information transmission across people and artifacts (e.g. electronic health records). Results illustrate challenges (e.g. information overload) as well as strategies used to overcome challenges. Various communication paths were used. Some team members served as intermediaries, processing information before relaying it. Artifacts were used as memory aids. Health information technology should address the risks of distributed work by supporting awareness of team and task status for reliable management of results.

Communicating Radiology Test Results: Are Our Phone Calls Excessive, Just Right, or Not Enough?

RATIONALE AND OBJECTIVES

This study aimed to determine the preferences of radiology and referring provider residents regarding direct communication of radiology test results.

METHODS

This Health Insurance Portability and Accountability Act-compliant quality improvement effort was exempt from institutional review board oversight. An anonymous survey was emailed to 44 radiology residents and 364 referring resident providers who routinely provide or receive direct communication of test results at our quaternary care medical center. The survey focused on the frequency, indication, clinical utility, and methods of direct communication of radiology results. Proportions were compared to chi-square or Fisher exact test.

RESULTS

The response rates were 86% (37 of 43) (radiology) and 41% (151 of 364) (referring providers). Approximately half of radiology residents (49% [18 of 37]) thought the frequency of direct verbal communication was excessive, and none (0 of 37) thought more communication was needed. In contrast, only 1.3% (2 of 151; P < .001) of referring providers felt the frequency was excessive, and 24% (36 of 151; P < .001) desired more. The majority (66% [100 of 151]) of referring providers felt phone calls from radiologists often or always added value beyond a timely radiology report, and 59% (44 of 74) felt it is the radiologist's responsibility to call about abnormal findings. Furthermore, 83% (125 of 151) of referring providers preferred to receive a phone call about non-emergent unexpected findings, although preferences varied for various example abnormalities. For outpatients with non-emergent unexpected findings, most providers (90% [64 of 71]) prefer written communication rather than a phone call.

CONCLUSIONS

Referring providers prefer direct communication of radiology results, even for non-urgent unexpected findings, whereas radiology residents prefer less direct communication and are more likely to consider radiologist-to-provider communication superfluous.

Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health Care

PURPOSE

We previously developed electronic triggers to automatically flag records for patients experiencing potential delays in diagnostic evaluation for certain cancers. Because of the unique clinical, logistic, and legal aspects of mammography, this study was conducted to evaluate the effectiveness of a trigger to flag delayed follow-up on mammography.

METHODS

An algorithm was developed to detect delays in follow-up of abnormal mammographic results (>60 days for BI-RADS^® 0, 4, and 5 and >7 months for BI-RADS 3) using clinical data in the electronic health record. Flagged records were then manually reviewed to determine the trigger's performance characteristics (positive and negative predictive value, sensitivity, and specificity). The frequency of delays and patient communication related to abnormal results, reasons for lack of follow-up, and whether patients were subsequently diagnosed with breast cancer were also assessed.

RESULTS

Of 365,686 patients seen between January 1, 2010, and May 31, 2015, the trigger identified 2,129 patients with abnormal findings on mammography, of whom it flagged 552 as having delays in follow-up. From these, review of 400 randomly selected records revealed 283 true delays (positive predictive value, 71%; 95% confidence interval, 66%-75%), including 280 records without any documented plan and three patients with plans that were not adhered to. Transcription and reporting inconsistencies were identified in 27% of externally performed mammographic reports. Only 335 records (84%) contained specific documentation that the patient was informed of the abnormal result.

CONCLUSIONS

Care delays appear to continue despite federal laws requiring patient notification of mammographic results within 30 days. Clinical application of mammography-related triggers could help detect these delays.

Development and Validation of Trigger Algorithms to Identify Delays in Diagnostic Evaluation of Gastroenterological Cancer

BACKGROUND & AIMS

Colorectal cancer (CRC) and hepatocellular cancer (HCC) are common causes of death and morbidity, and patients benefit from early detection. However, delays in follow-up of suspicious findings are common, and methods to efficiently detect such delays are needed. We developed, refined, and tested trigger algorithms that identify patients with delayed follow-up evaluation of findings suspicious of CRC or HCC.

METHODS

We developed and validated two trigger algorithms that detect delays in diagnostic evaluation of CRC and HCC using laboratory, diagnosis, procedure, and referral codes from the Department of Veteran Affairs National Corporate Data Warehouse. The algorithm initially identified patients with positive test results for iron deficiency anemia or fecal immunochemical test (for CRC) and elevated α-fetoprotein results (for HCC). Our algorithm then excluded patients for whom follow-up evaluation was unnecessary, such as patients with a terminal illness or those who had already completed a follow-up evaluation within 60 days. Clinicians reviewed samples of both delayed and nondelayed records, and review data were used to calculate trigger performance.

RESULTS

We applied the algorithm for CRC to 245,158 patients seen from January 1, 2013, through December 31, 2013 and identified 1073 patients with delayed follow up. In a review of 400 randomly selected records, we found that our algorithm identified patients with delayed follow-up with a positive predictive value of 56.0% (95% CI, 51.0%-61.0%). We applied the algorithm for HCC to 333,828 patients seen from January 1, 2011 through December 31, 2014, and identified 130 patients with delayed follow-up. During manual review of all 130 records, we found that our algorithm identified patients with delayed follow-up with a positive predictive value of 82.3% (95% CI, 74.4%-88.2%). When we extrapolated the findings to all patients with abnormal results, the algorithm identified patients with delayed follow-up evaluation for CRC with 68.6% sensitivity (95% CI, 65.4%-71.6%) and 81.1% specificity (95% CI, 79.5%-82.6%); it identified patients with delayed follow-up evaluation for HCC with 89.1% sensitivity (95% CI, 81.8%-93.8%) and 96.5% specificity (95% CI, 94.8%-97.7%). Compared to nonselective methods, use of the algorithm reduced the number of records required for review to identify a delay by more than 99%.

CONCLUSIONS

Using data from the Veterans Affairs electronic health record database, we developed an algorithm that greatly reduces the number of record reviews necessary to identify delays in follow-up evaluations for patients with suspected CRC or HCC. This approach offers a more efficient method to identify delayed diagnostic evaluation of gastroenterological cancers.

The fate of radiology report recommendations at a pediatric medical center

BACKGROUND

The American College of Radiology (ACR) practice parameters for communication dictate that follow-up recommendations be suggested when appropriate. Radiologists assume that referring physicians read their reports and heed their advice. In reality, recommendations might not be carried out or even acknowledged.

OBJECTIVE

We aimed to determine the proportion of imaging recommendations that are acknowledged and acted upon.

MATERIALS AND METHODS

We conducted a retrospective review of all consecutive radiology reports containing "recommend" in the impression at a single academic children's hospital over a 1-month period. We documented point of care (emergency department, inpatient, outpatient), study type, recommendation wording, and communication method (report only or direct verbal). We reviewed medical records to ascertain whether the recommendations were acknowledged or executed. We used chi-square tests to evaluate associations between variables. P<0.05 was considered significant.

RESULTS

We reviewed 526 reports and excluded 73. We included the remaining 453 reports, from 370 unique patients (201 male, 169 female). Inpatients comprised most reports (n=223), followed by emergency department (ED) patients (n=118) and outpatients (n=112). Among these reports, 69% (n=313) of recommendations were executed. Of the 140 recommendations not carried out, 14% were acknowledged in clinical notes. Compliance correlated with point of care (ED>inpatient>outpatient; P=0.001) but not with additional verbal communication (P=0.33), study type (radiograph vs. other; P=0.35) or type of follow-up recommendation (follow-up imaging vs. other; P=0.99).

CONCLUSION

Nearly one-third of radiology report follow-up recommendations are not executed. Recommendations are most commonly neglected for outpatient imaging reports. The radiology community should take steps to improve recommendation adherence.

Assigning responsibility to close the loop on radiology test results

Failure to follow-up on test results represents a serious breakdown point in the diagnostic process which can lead to missed or delayed diagnoses and patient harm. Amidst discussions to ensure fail-safe test result follow-up, an important, yet under-discussed question emerges: how do we determine who is ultimately responsible for initiating follow-up action on the tests that are ordered? This seemingly simple question belies its true complexity. Although many of these complexities are also applicable to other diagnostic specialities, the field of medical imaging provides an ideal context to discuss the challenges of attributing responsibility of test result follow-up. In this review, we summarize several key concepts and challenges in the context of critical results, wet reads, and incidental findings to stimulate further discussion on responsibility issues in radiology. These discussions could help establish reliable closed-loop communication to ensure that every test result is sent, received, acknowledged and acted upon without failure.

Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcomes

OBJECTIVE

The overall purpose was to understand the effects of handoff protocols using meta-analytic approaches.

BACKGROUND

Standardized protocols have been required by the Joint Commission, but meta-analytic integration of handoff protocol research has not been conducted.

METHOD

The primary outcomes investigated were handoff information passed during transitions of care, patient outcomes, provider outcomes, and organizational outcomes. Sources included Medline, SAGE, Embase, PsycINFO, and PubMed, searched from the earliest date available through March 30th, 2015. Initially 4,556 articles were identified, with 4,520 removed. This process left a final set of 36 articles, all which included pre-/postintervention designs implemented in live clinical/hospital settings. We also conducted a moderation analysis based on the number of items contained in each protocol to understand if the length of a protocol led to systematic changes in effect sizes of the outcome variables.

RESULTS

Meta-analyses were conducted on 34,527 pre- and 30,072 postintervention data points. Results indicate positive effects on all four outcomes: handoff information (g = .71, 95% confidence interval [CI] [.63, .79]), patient outcomes (g = .53, 95% CI [.41, .65]), provider outcomes (g = .51, 95% CI [.41, .60]), and organizational outcomes (g = .29, 95% CI [.23, .35]). We found protocols to be effective, but there is significant publication bias and heterogeneity in the literature. Due to publication bias, we further searched the gray literature through greylit.org and found another 347 articles, although none were relevant to this research. Our moderation analysis demonstrates that for handoff information, protocols using 12 or more items led to a significantly higher proportion of information passed compared with protocols using 11 or fewer items. Further, there were numerous negative outcomes found throughout this meta-analysis, with trends demonstrating that protocols can increase the time for handover and the rate of errors of omission.

CONCLUSIONS

These results demonstrate that handoff protocols tend to improve results on multiple levels, including handoff information passed and patient, provider, and organizational outcomes. These findings come with the caveat that publication bias exists in the literature on handoffs. Instances where protocols can lead to negative outcomes are also discussed.

APPLICATION

Significant effects were found for protocols across provider types, regardless of expertise or area of clinical focus. It also appears that more thorough protocols lead to more information being passed, especially when those protocols consist of 12 or more items. Given these findings, publication bias is an apparent feature of this literature base. Recommendations to reduce the apparent publication bias in the field include changing the way articles are screened and published.

Patient Portals as a Means of Information and Communication Technology Support to Patient- Centric Care Coordination - the Missing Evidence and the Challenges of Evaluation. A joint contribution of IMIA WG EVAL and EFMI WG EVAL

OBJECTIVES

To review the potential contribution of Information and Communication Technology (ICT) to enable patient-centric and coordinated care, and in particular to explore the role of patient portals as a developing ICT tool, to assess the available evidence, and to describe the evaluation challenges.

METHODS

Reviews of IMIA, EFMI, and other initiatives, together with literature reviews.

RESULTS

We present the progression from care coordination to care integration, and from patient-centric to person-centric approaches. We describe the different roles of ICT as an enabler of the effective presentation of information as and when needed. We focus on the patient's role as a co-producer of health as well as the focus and purpose of care. We discuss the need for changing organisational processes as well as the current mixed evidence regarding patient portals as a logical tool, and the reasons for this dichotomy, together with the evaluation principles supported by theoretical frameworks so as to yield robust evidence.

CONCLUSIONS

There is expressed commitment to coordinated care and to putting the patient in the centre. However to achieve this, new interactive patient portals will be needed to enable peer communication by all stakeholders including patients and professionals. Few portals capable of this exist to date. The evaluation of these portals as enablers of system change, rather than as simple windows into electronic records, is at an early stage and novel evaluation approaches are needed.

Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings

Purpose To develop an electronic health record (EHR)-based trigger algorithm to identify delays in follow-up of patients with imaging results that are suggestive of lung cancer and to validate this trigger on retrospective data. Materials and Methods The local institutional review board approved the study. A "trigger" algorithm was developed to automate the detection of delays in diagnostic evaluation of chest computed tomographic (CT) images and conventional radiographs that were electronically flagged by reviewing radiologists as being "suspicious for malignancy." The trigger algorithm was developed through literature review and expert input. It included patients who were alive and 40-70 years old, and it excluded instances in which appropriate timely follow-up (defined as occurring within 30 days) was detected (eg, pulmonary visit) or when follow-up was unnecessary (eg, in patients with a terminal illness). The algorithm was iteratively applied to a retrospective test cohort in an EHR data warehouse at a large Veterans Affairs facility, and manual record reviews were used to validate each individual criterion. The final algorithm aimed at detecting an absence of timely follow-up was retrospectively applied to an independent validation cohort to determine the positive predictive value (PPV). Trigger performance, time to follow-up, reasons for lack of follow-up, and cancer outcomes were analyzed and reported by using descriptive statistics. Results The trigger algorithm was retrospectively applied to the records of 89 168 patients seen between January 1, 2009, and December 31, 2009. Of 538 records with an imaging report that was flagged as suspicious for malignancy, 131 were identified by the trigger as being high risk for delayed diagnostic evaluation. Manual chart reviews confirmed a true absence of follow-up in 75 cases (trigger PPV of 57.3% for detecting evaluation delays), of which four received a diagnosis of primary lung cancer within the subsequent 2 years. Conclusion EHR-based triggers can be used to identify patients with suspicious imaging findings in whom follow-up diagnostic evaluation was delayed. (©) RSNA, 2015.

Lack of timely follow-up of abnormal imaging results and radiologists' recommendations

PURPOSE

Abnormal imaging results may not always lead to timely follow-up. We tested whether certain aspects of communication in radiology reports influence the response of the referring providers, and hence follow-up on abnormal findings.

METHODS

We focused on 2 communication-related items that we hypothesized could affect follow-up: expressions of doubt in the radiology report, and recommendations for further imaging. After institutional review board approval, we conducted a retrospective review of 250 outpatient radiology reports from a multispecialty ambulatory clinic of a tertiary-care Veterans Affairs facility. The selected studies included 92 cases confirmed to lack timely follow-up (ie, further tests or consultations, treatment, and/or communication to the patient within 4 weeks), as determined in a previous study. An additional 158 cases with documented timely follow-up served as controls. Doubt in the narrative was measured by the presence of key phrases (eg, "unable to exclude," "cannot exclude," "cannot rule out," "possibly," and "unlikely"), in the absence of which we used reviewer interpretation. A physician blinded to follow-up outcomes collected the data.

RESULTS

Patients whose reports contained recommendations for further imaging were more likely to have been lost to follow-up at 4 weeks compared with patients without such recommendations (P = .01). Language in the report suggestive of doubt did not affect the timeliness of follow-up (P = .59).

CONCLUSIONS

Abnormal imaging results with recommendations for additional imaging may be more vulnerable to lack of timely follow-up. Additional safeguards, such as tracking systems, should be developed to prevent failure to follow up on such results.

Breakdowns in communication of radiological findings: an ethical and medico-legal conundrum

Communication problems in diagnostic testing have increased in both number and importance in recent years. The medical and legal impact of failure of communication is dramatic. Over the past decades, the courts have expanded and strengthened the duty imposed on radiologists to timely communicate radiologic abnormalities to referring physicians and perhaps the patients themselves in certain situations. The need to communicate these findings goes beyond strict legal requirements: there is a moral imperative as well. The Code of Medical Ethics of the American Medical Association points out that "Ethical values and legal principles are usually closely related, but ethical obligations typically exceed legal duties." Thus, from the perspective of the law, radiologists are required to communicate important unexpected findings to referring physicians in a timely fashion, or alternatively to the patients themselves. From a moral perspective, radiologists should want to effect such communications. Practice standards, moral values, and ethical statements from professional medical societies call for full disclosure of medical errors to patients affected by them. Surveys of radiologists and non-radiologic physicians reveal that only few would divulge all aspects of the error to the patient. In order to encourage physicians to disclose errors to patients and assist in protecting them in some manner if malpractice litigation follows, more than 35 states have passed laws that do not allow a physician's admission of an error and apologetic statements to be revealed in the courtroom. Whether such disclosure increases or decreases the likelihood of a medical malpractice lawsuit is unclear, but ethical and moral considerations enjoin physicians to disclose errors and offer apologies.