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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: Susan W. (Head Nurse) 1997 Physical CXR: “Nodule LUL, needs f/u” No follow-up Routine Physical 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. 190,799 Outpatient visits (J.AmMedInformAssoc; 2007;14:459-466) 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 Database: (two-way) 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: Problem Feature Ideal CTRM System 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) April 2012 (Physicians) 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 April 2012 Confidential 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