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Richard M. Chesbrough, M.D. President, Radiology Medical Consultants, P.C.

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. Sign of the times….

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Richard M. Chesbrough, M.D. President, Radiology Medical Consultants, P.C.

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  1. 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 Communication Issues

  2. Sign of the times… Communication Issues

  3. 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 Communication Issues

  4. 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 Communication Issues

  5. New ‘buzzword” in healthcare Critical Test Result Management “CTRM” Communication Issues

  6. 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 Communication Issues

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

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

  9. How would you report?Communicate results? • 5:30 on a Friday afternoon? • …and Monday is a holiday? Communication Issues

  10. 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 Communication Issues

  11. 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 Communication Issues

  12. Retained SpongeAbdominal X-Ray: “abd. pain” Retained Sponge Communication Issues

  13. 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 Communication Issues

  14. 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 Communication Issues

  15. 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 Communication Issues

  16. 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. Communication Issues

  17. 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) Communication Issues

  18. Megatrends: increasing communication failures Going to get worse! • 24/7/365 Radiology • Teleradiology (Remote Reading) • After-hours “Nighthawk” • Increasing ER visitsER as “primary care” • Fewer clinician interactions (Doctors coming through Radiology Department) Communication Issues

  19. 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 Communication Issues

  20. 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) Communication Issues

  21. 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.” Communication Issues

  22. 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.” Communication Issues

  23. 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...” Communication Issues

  24. 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 Communication Issues

  25. 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. Communication Issues

  26. 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 Communication Issues

  27. 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… Communication Issues

  28. 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 Communication Issues

  29. 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) Communication Issues

  30. HELP ? Communication Issues

  31. 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) Communication Issues

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

  33. 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) Communication Issues

  34. 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 Communication Issues

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

  36. www.radarmed.com Richard M. Chesbrough, M.D. Founder, RADAR Medical Systems (248) 514-9742 www.radarmed.com Communication Issues

  37. Communication Issues

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