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Mikhail Nekhline, MD Safwan Halabi, MD Henry Ford Health System Department of Radiology

The Tickler File: PACS Application Alerts Radiologists When Recommended Additional or Follow-up Examinations are Rendered. Mikhail Nekhline, MD Safwan Halabi, MD Henry Ford Health System Department of Radiology Detroit, Michigan, USA. What is a Tickler File?.

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Mikhail Nekhline, MD Safwan Halabi, MD Henry Ford Health System Department of Radiology

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  1. The Tickler File: PACS Application Alerts Radiologists When Recommended Additional or Follow-up Examinations are Rendered Mikhail Nekhline, MD Safwan Halabi, MD Henry Ford Health System Department of Radiology Detroit, Michigan, USA

  2. What is a Tickler File? • Ordering provider: A file/list that is maintained to alert health care providers if and when a follow-up examination is recommended for their patient • Radiologist: A file/list that is maintained to follow-up imaging recommendations and patient outcomes

  3. Examples of Paper Tickler Files

  4. Reporting and Communication • American College of Radiology (ACR) Guidelines on Reporting • Effective communication is a critical component of diagnostic imaging • Commitment and reciprocal duty of information exchange between the ordering provider and radiologist • Emphasizes the importance of suggesting additional or follow-up studies when appropriate • Mandates the necessity to review all available pertinent previous reports and images

  5. Radiology Report • Clinical document that communicates the imaging interpretation and recommendation of the radiologist • Clinical document that serves to guide patient care • Patient’s document that resides in the permanent medical record • Legal document for medical malpractice liability

  6. Radiology Report • Cleary written and/or verbally communicated to avoid ambiguity • Includes comparison and correlation to prior imaging when available • Includes recommendation for appropriate additional or follow-up examination • Final signed report with interpretation and recommendation delivered to the referring provider or clinical service

  7. Communication Shortcomings • Radiology reports and communications are not received by the responsible parties • Significant delay between image acquisition and image interpretation • Prior imaging is not available at the time of interpretation for comparison

  8. Communication Shortcomings • Referring provider assumes that other health care personnel will follow-up with the radiology recommendations • Referring provider may misinterpret the clinical significance of the imaging interpretation and/or follow-up imaging recommendations • Patient transferred care to a different facility, was lost to follow-up or was non-compliant with follow-up recommendations

  9. Electronic Tickler File as a Solution • Create exam follow-up lists and alerts electronically at the time of image interpretation and recommendations • Ability to track all subsequent patient imaging to ensure that recommendations were acted upon • Provide feedback to the radiologist in regards to follow-up imaging results and patient outcome

  10. Electronic Tickler File as a Solution • Enables the radiologist to become an active participant in the care of patients • Establishes a closer rapport with the referring provider and clinical service • Reduces burden on the referring provider • Overall goal is to deliver better patient care and enhance patient safety

  11. Electronic Tickler File as a Solution • Prevent duplicate imaging exams ordered from different providers • Guide patient care and close the loop to the ordering provider and patient • Radiologist interpreting the follow-up exam will be in a better position to answer the clinical question raised on the initial exam • Limits malpractice claims

  12. Malpractice Issues • Negligence of hospital employees to deliver a message or act upon it does not protect the radiologist from a medical malpractice claim • Failure to review prior exams for comparison or correlation may be considered as negligence • Failure to act on recommended studies may be considered a breach of duty by both the referring clinician and the radiologist

  13. Henry Ford Health System Electronic Tickler File Solution • Illuminate plug-in (Softek Solutions, Inc.,Kansas City, KS) developed for iSite Radiology PACS (Philips, Foster City, CA) • Advanced search and data mining plug-in with functionality to create exam alerts • Alert user when a key word is mentioned in a radiology report • Alert when follow-up imaging is performed on a specific patient

  14. Henry Ford Health System Electronic Tickler File Solution • PACS plug-in allows a radiologist to track a patient when follow-up imaging is recommended • Follow-up alerts can be filtered by specific imaging modality • Alert expiration date can be designated • User can be alerted when an exam is not rendered by a certain date or time period

  15. Alert Options • Alerts can be received by the radiologist and other providers via different electronic methods including: plug-in inbox, e-mail, text message, and pager • Alerts may contain the follow-up imaging report or a link to the report

  16. PACS Plug-in Demonstration

  17. Use Case: Abnormal CXR

  18. Use Case: Abnormal CXR Illuminate Main Menu LLL Collapse

  19. Setting the Alert Set the Alert

  20. Setting Alert Options Set Expiration Chose Modality Set the Memo Chose Alerts

  21. Receiving Alert: Plug-in Inbox

  22. Receiving Alert: E-mail

  23. Time-limited Alerts • Follow-ups can be time-limited by creation of alert expiration to ensure patient care loop closure • Alert expiration depends on the inherent nature of the suspected process, level of suspicion and radiologist preference • If no imaging of the selected modality is obtained within the allotted time period, the overdue alert notice is generated

  24. Receiving Overdue Alert

  25. Time-limited Alerts • Alerts can be forwarded to the patient’s provider as a reminder that the recommended follow-up examination has not been rendered • Currently, only users of the Illuminate PACS plug-in can receive the alert • Radiologist acts as the “Tickler” for the referring physician

  26. Notifying Referring Provider Send a message to clinician

  27. Forward Alert to Provider Forward referring provider the report text and link to the images

  28. Benefits of the Electronic Tickler File • Convenient method to electronically track follow-up recommendations at the time of interpretation • Redundant alerts can be set via various communication methods (e-mail, pager, SMS) • Alerts can be forwarded to the health care team (clinician, medical director, case worker) • Interesting studies can be tagged and archived to create a teaching file or for research purposes

  29. Benefits of the Electronic Tickler File • Allows radiologists to read the reports and view the images of their recommended follow-up exams • Evaluates accuracy of the radiologist’s initial interpretation and validity of follow-up recommendations • Delivers feedback about the patient to the radiologist • Exposes the radiologist to the radiologic course of a disease process

  30. Future Role of Alerts • Radiologist actively participating in care of the patient redefines role of radiology in clinical medicine • Establish call center to centrally handle all communication between the radiologist, referring physician and patient • Enhance radiology trainee education with the ability track the outcomes of their interpretations and patient outcomes

  31. Centralized Radiology Call Center • Communicate critical results, unexpected findings, and missed follow-up exams to the referring physician • Reduce burden on the radiologist to track down the referring physician and maintain a central Tickler File • Document and audit all communication between the radiologist and referring provider

  32. Radiologist as Clinical Asset • Tickler File empowers the radiologist to actively participate in patient care • Transfer burden of Tickler File maintenance from the ordering provider to the radiologist • Reduce malpractice risk for the hospital and the radiologist by closing the communication loop • Add value to the radiology group to avoid risk of radiology service outsourcing

  33. References • ACR Practice Guideline for Communication of Diagnostic Imaging Findings (Revised 2010) • Berlin L. Failure of Radiologic Communication: An Increasing Cause of Malpractice Litigation and Harm to Patients. Appl Rad 2010, Jan-Feb, 17-23 • Cascade PN and Berlin L. Malpractice Issues in Radiology. AJR 1999;173:1439-1442 • Chesbrough R. Critical Results: Communication Management in Radiology. http://imaging-radiation-oncology.advanceweb.com/features/article-3/critical-results-communication-management-in-radiology.aspx (posted 4/6/2010, accessed 10/1/2011) • Berlin L. The Duty to Communicate. AJR 2011;197 W962 • Towbin AJ, Hall S, Moskovitz J, Johnson ND, Donnelly LF. Creating a Comprehensive Customer Service Program to Help Convey Critical and Acute Results of Radiology Studies. AJR 2011;196:W48-W51

  34. Correspondence Mailing address: Henry Ford Hospital Department of Radiology, K3 2799 West Grand Boulevard Detroit, MI 48202-2689 E-mail: Mikhail Nekhline: mikhailn@rad.hfh.edu Safwan Halabi: safwanh@rad.hfh.edu

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