The Joint Commission, ACR and Plaintiff’s

Attorneys: New Rules, Standards and Legal

Precedents Mandating Critical Test Result
Management in Radiology

Richard M. Chesbrough, M.D.

President, Radiology Medical Consultants, P.C.
Founder, RADAR Medical Systems, LLC

April 2012 Communication Issues

Sign of the times…

April 2012 Communication Issues

Legal Facts

“Malpractice litigation alleging

radiologic miscommunication is
growing at a faster rate that any other
type of radiologic wrongdoing.”

Berlin, Diagnostic Imaging, Nov. 2007; 31

April 2012 Communication Issues

Legal Facts
 “25% of ACR members report being
involved in at least one malpractice claim
involving failure to communicate…”
Kushner, JACR 2005;2(1):15-21

 Average payment…$1.9 Million Dollars.”

Berlin L., Imaging Economics; Sept, 2005

April 2012 Communication Issues

New ‘buzzword” in healthcare

Critical Test Result Management

“CTRM”

April 2012 Communication Issues

The Paradox of Radiology

 Most advanced imaging technology and

computer skills in the world.

 Yet…still rely on “primitive” phone calls,

answering machines, faxes and loose
pieces of paper for communication of
critical results.
* “One-way” communication.
* Often no permanent documentation

April 2012 Communication Issues

Radiology: We know things that others don’t….

April 2012 Communication Issues

Significant Findings:
How would you handle this?
57 yr old Outpatient: History: “cough”

April 2012 Communication Issues

How would you report?
Communicate results?

 5:30 on a Friday afternoon?

 …and Monday is a holiday?

April 2012 Communication Issues

Actual Cases: Routine Physical

 Susan W. (Head Nurse)

 1997 Physical
 CXR: “Nodule LUL,
needs f/u”
 No follow-up
 Report misfiled
 Ordered by N.P.
 2000 Cough/SOB:
 CXR: 3.5 cm mass
 Settlement: $2.3 Million

April 2012 Communication Issues

What about unexpected
findings: “Incidentalomas?”
CT ABD: ER Patient: “R/O Appendicitis” Saturday 10:30 P.M.
Study “negative” for appendicitis. LLL nodule noted. Patient discharged home (2:30
AM)

Lung Nodule

April 2012 Communication Issues

Retained Sponge
Abdominal X-Ray: “abd. pain”

Retained Sponge

April 2012 Communication Issues

The Problem: No policies ?

 The referring physician is not directly contacted

on urgent or significant findings in up to 60% of
cases. PIAA-ACR Study, 1997

 Almost 20% of radiology departments do not

have an established policy to communicate
findings. PIAA-ACR 1997

 85% of radiology malpractice suits are related

to issues of communication.
Berlin; Imaging Economics, Sept. 2005

April 2012 Communication Issues

The Problem: Referring Doctors ?
Referring Doctors and Radiologist’s advice:
 U. of Maryland Study
 56,083 imaging studies
 1,650 abnormals – needing follow-up
 Docs notified by phone
 153 patients (9.2%) had no f/u
(Over 15 month study period)

Musk; RSNA 2007

April 2012 Communication Issues

The Problem: Patients ?
Patients and advice of doctors:
 2005 AMA Poll:
 2,286 Adults
 “52% chose not to comply with their doctor’s
order for a prescription, diagnostic test or
surgical procedure.”

AmMedNews 10/17/05

April 2012 Communication Issues

The Problem: Recent Study

Communication is prone to errors

 Singh, H. (J.AmMedInformAssoc; 2007;14:459-466)
 190,799 Outpatient visits
 20,680 Imaging studies
 1,017 (0.5%) Abnormal Findings (needing F/U)
 Notification sent via EMR
 45 patients (4.4%) not acknowledged by provider
(lost to F/U)
 Overall: 0.2% (45/20,680) of imaging studies
had abnormal results - not followed up.

April 2012 Communication Issues

Extrapolated to National Population
 National Statistics:
 12 Billion medical test results annually
 Lab, X-ray, Cardiology, etc…
 500 Million of these = Imaging studies
(33,000 rads x 15,000 studies = 500M )
 0.5% “abnormal” = 2.5M
 4.4% Lost to f/u:
= 110,000 per year (300 people/day)

April 2012 Communication Issues

 Going to get worse!

Megatrends: increasing communication failures

 24/7/365 Radiology
 Teleradiology (Remote Reading)
 After-hours “Nighthawk”
 Increasing ER visits ER as “primary care”
 Fewer clinician interactions
(Doctors coming through Radiology Department)

April 2012 Communication Issues

Why Radiologists Don’t Call ?
 Mentality: “Not my job”
 Interrupts workflow
 “Takes too much time”
3-11 minutes: to contact referring physician or their designee
- Personal Communications - Quantum Radiology, 2004
- HFHS Radiology Staff, 2004. WBH Staff, 2006
- Dr. Len Berlin, Rush North Shore Hospital
Average radiology practice:
 @4 calls per day & 7 minutes/call = 28 minutes/day.

 $187,000 lost income for an average size radiology practice

(ACR, 2003: 7 radiologists/avg. group)

 Large Group: (i.e. 42 radiologists) = $1,122,000 lost income

April 2012 Communication Issues

Is calling enough ?

 Documentation ?
(who, what, when, how?)
“If it’s not documented it didn’t happen…”

 Permanent Record ?
(5 years from date of dictation)

April 2012 Communication Issues

Legal Precedent
 Merriman v. Toothaker
515 P.2d 509 (Wash App 1973)
 Cervical spine fracture
 4-day delay - Permanent neurologic injury
 Court: “Because of the serious
implications… “personal contact”
was required to insure prompt action.”

April 2012 Communication Issues

Legal Precedent
 Phillips v. Good Samaritan Hospital
416 NE 2d 646 (OH APP 1979)
 “Radiologists who provide indirect medical care
cannot escape liability by doing no more than relaying
information through ordinary hospital channels.”

 “The communication of the diagnosis… may be

altogether as important as the diagnosis itself.”

April 2012 Communication Issues

Legal Precedent
 Corteau v. Dodd
773 SW2d 436 (Ark 1989)
 Malpositioned Endotracheal tube
 Routine report sent. No phone call
 Patient suffered additional injuries

 Court: “When a patient is in peril… it does him

little good if the [radiologist] has discovered his
condition, unless the [radiologist]…informs the
patient, or those responsible for his care...”

April 2012 Communication Issues

Legal Precedent * the future ?

 Stanley v. McCarver
92 P3d 849 (Ariz 2004)
 Pre-employment CXR
 Radiologist: “possible lung cancer”
 Report sent to Employer (nursing home)

 Patient not informed. (Dx’d CANCER -10 months later)

 Patient expires
 Radiologist and nursing home sued

 Nursing home declares bankruptcy

April 2012 Communication Issues

Legal Precedent
 Stanley v. McCarver (cont.)
 Trial Court:
Dismissed case against radiologist.
Plaintiff appealed
 Appellate Court :
“If there is no referring physician, or the referring
physician is unavailable, the duty to inform the
patient shifts to the radiologist.” [italics added]
 Arizona Supreme Court :
Duty to inform is up to jury; case-by-case basis.
April 2012 Communication Issues
Joint Commission:
Joint Commission on Accreditation of
Healthcare Organizations
(Now – Joint Commission)

National Patient Safety Goals

No. 2: “Improve Effectiveness of
Communication Among
Caregivers.”
2A. Critical Test Results
2C. Measure Performance

April 2012 Communication Issues

JC: Communication Focus

 59% of hospitals were in compliance

with the Joint Commission national
patient safety goal #2 in 2008

 64% were compliant in 2007

….Problem not going away…

April 2012 Communication Issues

ACR Standards:
American College of Radiology: Standards of Practice: 2008

“Significant Unexpected Findings: “

[Radiologist must] “…communicate the findings to the referring
physician… in a manner that reasonably insures receipt of the
findings.”

(Requires “Direct communication”)

 In Person
 By Telephone

“In radiology…[traditional reporting] or putting the

report into the RIS or EMR is inadequate.”
Chang P, Diagnostic Imaging, Oct. 2007; 40

April 2012 Communication Issues

New Alternatives:
American College of Radiology
Standards of Practice, effective Oct. 1, 2005
Communication of Findings, Section 5C:

New communications authorized:

“Other forms of [reporting] that provide documentation of receipt…to
demonstrate that the communication has been delivered and
acknowledged.”
 Text pager

 Facsimile (Fax)

 Voice messaging

 “Non-traditional approaches” (Email, PDA, Web)

April 2012 Communication Issues

HELP ?

April 2012 Communication Issues

Ideal CTRM Solution
 Time Sensitive
 Acknowledgement receipt (two-way)
 Database:
 Tracking of results
 Permanent Storage
 Reminder notifications
(i.e. 3, 6, 12 month F/U)
 Ability to generate data
 Audit Trail
 Searchable database
 Compliance Reports (Joint Commission)

April 2012 Communication Issues

Ideal CTRM Solution
 Inexpensive
 Easy to use
 100% reliable
 Enterprise-wide
 Generate “Active” alerts
(Distinct from EMR – “passive alerts”)

April 2012 Communication Issues

Features & Benefits: Ideal CTRM System

Problem Feature Benefit__

 Communication failure “Closed-loop” No lost results

 Time Sensitive Activates in seconds Urgent results

 “Lost” Patients F/U tracking No lost F/U’s

 Different locations Web-based Access anywhere

 Expensive Nominal fee No cost to users

(Hospital) (Physicians)

April 2012 Communication Issues

CTRM: Provider Benefits
Improved Patient Outcomes
 Record of Notification
 Significant & Unexpected findings
 Follow-Up recommendations
 Permanent Record

Medicolegal Benefits
 Decreased Liability
 Decrease Malpractice Premiums

Confidential
April 2012 Communication Issues
“The Single biggest problem in communication
is the illusion that it has taken place…”
- George Bernard Shaw

April 2012 Communication Issues

www.radarmed.com

Richard M. Chesbrough, M.D.

Founder, RADAR Medical Systems

(248) 514-9742
www.radarmed.com

April 2012 Communication Issues

April 2012 Communication Issues