The Tickler File: PACS Application Alerts Radiologists When

Recommended Additional or Follow-up Examinations are Rendered

Mikhail Nekhline, MDSafwan Halabi, MD

Henry Ford Health SystemDepartment of RadiologyDetroit, Michigan, USA

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

Examples of Paper Tickler Files

Reporting and CommunicationAmerican College of Radiology (ACR)

Guidelines on ReportingEffective communication is a critical component

of diagnostic imagingCommitment 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

Radiology ReportClinical 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

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

Radiology Report

Communication ShortcomingsRadiology 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

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

Communication Shortcomings

Electronic Tickler File as a SolutionCreate 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

Electronic Tickler File as a SolutionEnables the radiologist to become an

active participant in the care of patientsEstablishes a closer rapport with the

referring provider and clinical serviceReduces burden on the referring providerOverall goal is to deliver better patient

care and enhance patient safety

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

Electronic Tickler File as a Solution

Malpractice IssuesNegligence 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

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 alertsAlert user when a key word is mentioned in a

radiology reportAlert when follow-up imaging is performed on

a specific patient

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 designatedUser can be alerted when an exam is not

rendered by a certain date or time period

Henry Ford Health System Electronic Tickler File Solution

Alert OptionsAlerts 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

PACS Plug-in Demonstration

Use Case: Abnormal CXR

Illuminate Main Menu

LLL Collapse

Use Case: Abnormal CXR

Set the Alert

Setting the Alert

Setting Alert Options

Set Expiration

Set the Memo

Chose Modality

Chose Alerts

Receiving Alert: Plug-in Inbox

Receiving Alert: E-mail

Time-limited AlertsFollow-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

Receiving Overdue Alert

Time-limited AlertsAlerts 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

Notifying Referring Provider

Send a message to clinician

Forward Alert to Provider

Forward referring providerthe report text and link to the images

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

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

Future Role of AlertsRadiologist 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

Centralized Radiology Call CenterCommunicate 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

Radiologist as Clinical AssetTickler File empowers the radiologist to

actively participate in patient careTransfer 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

References1. ACR Practice Guideline for Communication of Diagnostic Imaging

Findings (Revised 2010)2. Berlin L. Failure of Radiologic Communication: An Increasing

Cause of Malpractice Litigation and Harm to Patients. Appl Rad 2010, Jan-Feb, 17-23

3. Cascade PN and Berlin L. Malpractice Issues in Radiology. AJR 1999;173:1439-1442

4. 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)

5. Berlin L. The Duty to Communicate. AJR 2011;197 W9626. 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

CorrespondenceMailing address: Henry Ford HospitalDepartment of Radiology, K32799 West Grand BoulevardDetroit, MI 48202-2689

E-mail: Mikhail Nekhline: mikhailn@rad.hfh.eduSafwan Halabi: safwanh@rad.hfh.edu