OPEN INNOVATION Researching a New Paradigm Chesbrough 2006 and Nokia IBM.
Richard M. Chesbrough, M.D. President, Radiology Medical Consultants, P.C.
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Transcript of Richard M. Chesbrough, M.D. President, Radiology Medical Consultants, P.C.
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April 2012 Communication Issues
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
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April 2012 Communication Issues
Sign of the times…
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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
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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
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April 2012 Communication Issues
New ‘buzzword” in healthcare
Critical Test Result Management
“CTRM”
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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
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April 2012 Communication Issues
Radiology: We know things that others don’t….
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April 2012 Communication Issues
Significant Findings: How would you handle this?57 yr old Outpatient: History: “cough”
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April 2012 Communication Issues
How would you report?Communicate results?
5:30 on a Friday afternoon?
…and Monday is a holiday?
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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
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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
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April 2012 Communication Issues
Retained SpongeAbdominal X-Ray: “abd. pain”
Retained Sponge
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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
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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
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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
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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.
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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)
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April 2012 Communication Issues
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)
Going to get worse!
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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
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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)
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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.”
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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.”
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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...”
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April 2012 Communication Issues
Legal Precedent * the future ?
Stanley v. McCarver92 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
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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.
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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
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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…
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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
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April 2012 Communication Issues
New Alternatives:
American College of RadiologyStandards 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)
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April 2012 Communication Issues
HELP ?
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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)
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April 2012 Communication Issues
Ideal CTRM Solution
Inexpensive Easy to use 100% reliable Enterprise-wide Generate “Active” alerts
(Distinct from EMR – “passive alerts”)
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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)
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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
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April 2012 Communication Issues
“The Single biggest problem in communication is the illusion that it has taken place…”
- George Bernard Shaw
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April 2012 Communication Issues
www.radarmed.com
Richard M. Chesbrough, M.D.
Founder, RADAR Medical Systems
(248) 514-9742
www.radarmed.com
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April 2012 Communication Issues